By Susan Adams, CHS Healthcare Manager, south of England
We are all extremely familiar with delayed discharges (DTOC) as a vital sign of how a hospital and the surrounding health system is performing. In addition to DTOC, another measure has been introduced whose apparent simplicity belies the ambition it holds for care of the elderly.
NHS England states Trusts must reduce the number of continuing healthcare screenings and full assessments taking place in an acute location. There is a wealth of evidence to show how rapidly older people’s capacity declines in hospital. Ten days of bed rest leads to a 14 per cent reduction in leg and hip strength and a 12 per cent reduction in aerobic capacity. Muscle strength in hospital can decline by as much as five per cent per day. This inevitably impacts on their ability to perform key tasks: one study found that people over the age of 70 in hospital declined by 12 per cent in the function bathing, eating, moving around and going to the toilet.
Therefore, by assessing an older person in an acute setting, we are measuring their capacity at the time when it is likely to be at its lowest level. There is also the ‘double whammy’ that by keeping them in hospital awaiting an assessment, we are causing their capacity to diminish further. In so doing, the risk is they will go from hospital to long term care, rather than having a prospect of recovering sufficiently to return to their own home.
A hospital based assessment is only appropriate for the small minority of patients with very complex health needs that are unlikely to change very much over time. But the large majority of those currently having hospital based assessments are in the ‘frail elderly’ category, which is recognised as being a continuum, with potential for both improvement and deterioration.
We have seen this in practice in the service we provide in Gloucestershire, where we have worked since 2014, developing what we do from simple hospital discharge support and co-ordination to a full discharge to assess (D2A) pathway. Working with up to 50 patients each month, we have many examples of individuals who are able to return to their own home after a period of reablement in their D2A placement. Without the D2A pathway, many patients would have gone straight from hospital to long term care.
Examples include a 96-year-old man: after a hospital admission, he required a Sara Stedy to transfer and was very fearful of falling. Two weeks of physiotherapy followed by a rehabilitation placement enabled him to return to his level of mobility before hospital admission and return to his own home. A 94-year-old woman who was admitted to hospital with sepsis moving into a nursing D2A bed with a high level of confusion and was dependent upon a hoist for all transfers. Twice weekly physiotherapy sessions have enabled her to move to step transfers with frame and she is now in a community rehabilitation bed with the plan for a return home.
For some people, a long term care placement is the best and safest option. But it is recognised that too many elderly people go into long term care after an episode in hospital when they had the potential, with time and support, to return to their own home. Of course, moving older people out of hospital for assessment and reablement will significantly improve DTOC rates. But a systems based view must not diminish the principle behind this measure: by assessing out of hospital, we are giving elderly, frail individuals their best possible chance of returning to their own home and that is a goal we must strive to achieve.