Framework for maximising the use of care homes and use of therapy-led units for patients medically fit for discharge
NHS England and NHS Improvement have produced a Best Practice Framework to support sustainability and transformation partnerships (STPs) and their provider organisations. This is in recognition of the pressure that can build in the system, with ensuing threats to patient safety, during the winter months.
The framework aims to address two models and the implementation approach that needs to be taken by STPs and their provider organisations. These models aim to:
- maximise the appropriate use of care homes by identifying and supporting care homes at risk of closure, and using surveillance to monitor capacity and patient flow across the care sector
- identify and care for the cohort of patients, in Therapy-Led Units who are medically fit for discharge, and therefore contributing to the stranded patient and Delayed Transfers Of Care (DTOC) metrics in hospitals, with the right therapeutic conditions and appropriate staffing models.
WebEx presentations to support implementation
In January 2018, we are hosting a number of presentations with a range of professionals and organisations to further raise awareness of the best practice winter framework. If you would like to join any of the WebEx presentations below, please email firstname.lastname@example.org, indicating which presentation(s) you would like joining details for.
|Criteria-Led Discharge||Jane Robinson, Clinical Improvement Project Lead, NHS Improvement.
Liz Lees-Deutsch, Consultant Nurse in Acute Medicine at the Heartlands Hospital.
|16 January 2018||2:00pm – 2.30pm|
|Flu programme||Kenny Gibson, Head of Public Health Commissioning. (London),SRO for Homelessness, NHS England.||17 January 2018||11:30am – 12:00 midday|
|End PJ paralysis and the power of language||Prof Brian Dolan, Director of Health Service 360, Honorary Professor of Leadership in Healthcare, University of Salford, Manchester, Visiting Professor of Nursing, Oxford Institute of Nursing, Midwifery & Allied Health Research (OxINMAHR), Oxford.||22 January 2018||11:00am – 12:00 midday|
|Therapy-Led Units||Dr Joanne Fillingham, Clinical Director Allied Health Professions (AHPs), Deputy Chief Allied Health Professions Officer.
Prof Brian Dolan, Director of Health Service 360, Honorary Professor of Leadership in Healthcare, University of Salford, Manchester, Visiting Professor of Nursing, Oxford Institute of Nursing, Midwifery & Allied Health Research (OxINMAHR), Oxford.
|23 January 2018||4:00pm – 4:30pm|
|Other ways to Value Patients’ Time (Home First and Hospital Avoidance)||Liz Sargeant, OBE MCSP, Clinical Lead Health and Social Care Integration and AHPs. Emergency Care Improvement Programme.||25 January 2018||12:00 midday – 12:30pm|
This section provides a short series of case studies to provide real-life examples of how nursing and care staff help lead the way in improving services during winter. They provide examples of practice to reduce delayed transfers of care, as well as optimising pathways for patients who are medically ready for discharge.
Case study one
Operational Models to optimise care of patients who are Medically Fit for Discharge (MFFD)
Organisation: Worcestershire Acute Hospitals NHS Trust – Evergreen Ward
Description: Understanding the problem
The hospital was keen to open a winter pressures ward with a difference hence the therapy leadership role for a medically fit for discharge ward (MFFD). The vision for the ward was that all staff were to:
- promote independence at all times with all tasks including getting patients dressed in their own clothes and for them to be sat out for meals times as a minimum.
- focus on discharge planning at all times with a aim of home first.
Solution: Aims and objective
The initiative for the trust was to have extra capacity for the winter but with a clearer purpose than being extra beds. The aim was for the ward to have a 72 hour length of stay for patients waiting for community services and to provide rehabilitation to increase and/or maintain independence.
Method and approach:
- Small team of substantive posts RN/HCA Small team of substantive posts
- Secured funding for a ward based Occupational Therapists and Occupational Therapy assistant
- Band 3 Physio assistant
- Full time ANP and consultant support when required
- 40 per cent less patients are discharges via inpatient rehab
- Three times more people are discharges home with no increase in formal care
- Average LOS is 5 days
Key learning points:
- Allied Health Professions (AHPs) are essential to have a positive impact on flow
- Integrated multidisciplinary team working is essential
- All staff are able to working new ways and help other team members enjoy ‘rehabilitation’
Plans for spread:
Kings fund ‘Harnessing the value of AHPs’ conference presentation. Since then they have had multiple meetings set up to work with other services who are doing something similar or are looking to do something similar.
Case study two
Organisation: Nottingham Universities NHS Hospital Trust (NUH)– B49 Community Ward
Description: Understanding the problem
2.7 million additional hospital bed days occur for older patients no longer in need of acute treatment once in hospital (UK National Audit Office NAO-report, 2016). The Department of Health (DH,2000) cites that two thirds of acute hospital beds are occupied by people aged 65 and over, indicating an increased number of frail older people in receipt of acute care from previous years.
Evidence also suggests that older people can quickly lose mobility and the ability to do everyday tasks such as bathing and dressing and could lose up to 5 per cent of muscle strength for every day of a hospital stay. This can lead to a diminishing desire to self-care or complete other aspects of daily routine (Killick, 2004), and results in older people leaving hospital more functionally dependent than preadmission.
Focus on service improvements and new ways of working that deliver care to older people within hospital settings is therefore essential to contribute to overall systems of increased NHS efficiencies and health outcomes for people.
Within NUH we have recognised that the Health Care of Older People (HCOP) Specialty within the Medicine division at NUH consistently has a large number of medically safe for transfer patients that remain in our care longer than necessary. This is normally due to delays in transfer of care to our community or social care partners. These patients do not necessarily require the level of acute care provided by our base HCOP wards.
The community ward B49 was established to co-locate appropriate patients from this cohort in order to deliver care in a more appropriate manner. This is provided by a therapy led team and aims to focus on re-ablement and expedited discharge.
Solution: Aims and objective
The community ward B49’s aims were set up as:
- To provide ongoing care with a re-ablement focus whilst awaiting discharge, to prevent deconditioning, and to strive towards stepping down of care needs on discharge by improving function. This supports our wider #endpjparalysis work.
- To expedite discharges through a focussed approach using board rounds, internal escalation processes and existing links to community and social care services.
Benefits were outlined to be:
- Patients will receive therapy led care with a focus on re-ablement. This will be a more appropriate level of care and will match the patient’s needs. This may also allow for step downs in packages of care and better outcomes for non-acute patients.
- Patients will be cared for by staff with a focus on expedited discharge. Close liaison with the supported transfer of care (STOC) team within NUH and robust escalation processes will ensure as efficient discharge as possible and reduced length of stay (LOS).
Method and approach:
This change was initially trialled between January to April 2017 on a previously acute HCOP ward. The change required a different work force model to incorporate and reflect the anticipated reduced medical needs of the patient and the therapy led approach.
Workforce: The workforce was therefore reduced from an acute nursing and medical model to safely care for 23 in-patient beds on the ward following discussion with Medical colleagues.
The standard operating procedure reflected the new medical cover of patients remaining under the care of the parent Consultant team from their original base ward and in case of escalation back following medical deterioration. A rotating Trust grade doctor was assigned to the ward to complete jobs which include updating medicines and discharge summaries for home and reviewing medically unwell patients.
The Registered nursing ratio was reduced from the acute ward establishment and the number of nursing auxiliary posts were increased to reflect the re-ablement approach to support patients with activities of daily living.
The therapy cover to the ward remained as previous, as it was anticipated that the re-ablement approach would be ward led and not reliant on therapy staff only and it was anticipated that there would be reduced need for acute therapy assessments.
To support the delivery of re-ablement focussed care the ward manager post was trialled as a therapy lead.
The Support and Administration team on the ward remained static, with the discharge coordinator role central to expediting discharges.
Communication: Regular forums were made available for staff to discuss concerns with the Senior leadership team which included the assistant general manager for HCOP, matron and ward manager.
Ward Criteria: A criteria was established to ensure appropriate patients were identified for the new ward. The ward manager would routinely use NUH bed management systems to then screen and select patients.
Post-trial period, the ward was made substantive based on successful outcomes of expedited discharges and moves towards a re-ablement approach.
The new ways of working and the ward remit has achieved a good profile and sits within the HCOP Speciality where it is recognised for its purpose. The Medicine bed managers now identify patients appropriate for the ward which releases the ward manager time to develop the new ward and culture alongside the other responsibilities of manging an in-patient ward at NUH. Recruitment has been underway to recruit to establishment and training will be developed to help educate staff to deliver re-ablement focussed care.
In this instance the transition of a therapy band 7 to ward manager has been successful with support from the Medicine Division and Therapy Department working collaboratively. A training programme was established to upskill on pertinent governance and process issues that are required to ensure safe management of a ward.
Through working within the Division and amongst Ward Sisters and Matrons new relationships have been established which has also supported the success and transition of the unique role of a therapy ward manager managing an in-patient ward.
Alongside the new work of the ward, NUH has championed the #endpjparalysis work and has created publicity and promotion around the Trusts commitment to this. The new community ward has been included within this publicity due to its efforts at a re-ablement approach. The community Ward B49 Team are committed to the #end pjparalysis initiative and there is strong emphasis upon getting out of bed and dressed, as well as accessing the dining room and bathrooms as much as possible. The team have held bay exercise groups as well as starting on goals for patients that have been identified waiting for community rehabilitation.
As part of this, the ward has had high profile visits from sir Bruce Keogh, NHSI SAFER team, Sky News, local BBC news and Professor Brian Dolan and written a piece for the NHS Fab website contributed towards Cares events and worked closely with the Patient Public Involvement group to consider future ways of working and is due to attend the NHS Fab Awards ceremony this November. The ward and the therapy lead role has also received interest from other Trusts and services across the UK with visits and teleconferences to share the work achieved and interest from Nottingham University Research fellows to trial a self-medications project.
At time of the pilot period review it was acknowledged that the ward discharge rate had increased. With examples of discharge rates reaching double digits on occasions. There was also a trend since the introduction of the ward of higher than average discharges across the HCOP speciality.
The ward has also been acknowledged for expediting discharges and creating flow by being exemplar in its use of SAFER principals.
The impact of the re-ablement approach continues to be measured as it is slowly begins to shape the ward culture and has had positive patient stories recorded due to this approach.
Having a, established and experienced therapy lead for the ward has enabled closer focus upon expediting the delayed discharges and focus upon flow and capacity within the ward to assist the Trust on a daily basis.
Quality metrics have not deteriorated as a result of the change in leadership and ward function, in fact a number of areas have seen improvement e.g late observations reduced, staff sickness reduced from 7.4 per cent to 1.4 per cent.
Key learning points:
- Collaborative cross professional working to establish new ways of working and create new ward model
- Therapy in-patient ward manager role
- On- going scope and opportunities
- Realistic opportunities to shape patient and family expectations of acute NHS services and bed usage
Plans for spread:
As highlighted the community ward has received recognition from within NUH as well as national interest from other therapy departments and clinical leads who are interested in establishing similar models of care. There has also been interest from different Divisions within NUH as to the success of a non nurse lead for a clinical area.
Case study three
Organisation: Yeovil District Hospital – Intermediate Care in Cookson’s Nursing Home
Description: understanding the problem
Patient flow was not providing the right length of stay and often the best outcomes for patients were not achieved.
Solution – Aims and objective
The overall aims of this collaboration was to:
- Improve patient flow at Yeovil District Hospital
- Reduce unnecessary length of hospital stay
- Enable reablement in an appropriate environment
- Maximise patient clinical outcomes
- Reduce on-going costs of care.
Method and approach
Rablement Team (Cooksons Court)
Somerset Care and Yeovil District Hospital work in partnership to provide rehabilitation and reablement in a modern, homely nursing home, Cooksons Court. Hear about what this means for patients, the hospital and the NHS.
The Reablement Therapy Team consists of Physiotherapists, Occupational Therapists and Rehabilitation Assistants who work at the Reablement Centre, based at Cooksons Court Nursing Home.
Having a base at Cooksons Court, allows the therapy team to offer a more supportive 24hour rehabilitation programme to aid the facilitation of the patients journey to their normal place of residence. This is for the patients that need a short term high intensity rehabilitation period in order to achieve their goals to return home safely and to prevent future admissions into care provider services.
All team members will aid patients with their individualised programme, which include exercises, functional tasks and personal goals of tasks that are key to the patients’ health and wellbeing.
- 15 per cent reduction in the total number of beds the Trust occupies
- Reduction in the Length of Stay
- 95 per cent of people were discharged home from Cooksons Court
- 42 per cent of patients required a reduction in their predicted home care packages upon discharge
- £1.6 million savings in ongoing care costs
Key learning points:
- Working with other agencies has a significant impact in the sustainability and shared agenda
- 7 day therapy services
Case study four
Organisation: Birmingham Cross City CCG and Birmingham Council
Birmingham Cross City CCG and Birmingham Council have worked closely over recent years to align processes, and improve their approach to quality, monitoring and assurance in nursing homes. This has included to date:
- Regular data and information sharing meetings are held, involving CQC, Healthwatch, Safeguarding, CSU and all Birmingham and Solihull CCGs. This has led to the development of a Joint Quality Assurance Framework (JQAF) which includes:
- a Quality Assurance Framework tool (QAF) update annually
- escalation and management process for poor performance
- monitoring process for nursing homes
- a provider self-assessment questionnaire strengthened with health inserts (e.g. capture of harms such as pressure ulcers, falls, deaths, infection control)
- the development of a Joint Social Care & Funded Nursing Care (FNC) specification
- joint provider market consultation for FNC and CHC specifications
- collaborative working on pricing mechanism for CHC
- implementation of a system for reporting of serious incidents to CCGs, and reporting of true safeguards to Safeguarding in local authority, which commenced in May 2017.
- Provision of education and training, and regular care home managers’ meetings
This work has contributed to an increase by 10 per cent of care homes in the good category to over 67 per cent of CQC in comparison to 2 other CCG areas whose ratings have either deteriorated or remained static at either 50 per cent or 28 per cent in the good category.
Case study five
Organisation: South Warwickshire Foundation Trust – Castle Brook Transitional Unit
Description: understanding the problem
There is increasing pressure on acute hospitals to improve patient flow and to reduce the amount of detrimental hospital bed days for patients. £820 million is the estimate of the gross cost to the NHS of older patients in hospital beds who are no longer in need of acute treatment and 1.15 million bed days are lost to reported delayed transfers of care in acute hospitals during 2015 (up 31 per cent since 2013) (National Picture; National Audit Office 2016).
Evidence has also shown that the elderly population can lose 5 per cent of muscle strength per day in a hospital bed, therefore leading to reduced mobility, stamina and the ability to care for themselves and remain independent and in their own homes.
Following a whole system point prevalence audit on every patient in the trust at one point in time, it was highlighted that there were medically fit patients in South Warwickshire Foundation Trust acute hospital beds because they weren’t able to manage at home and weren’t yet safe to receive care or therapy in their own homes. This cohort of patients typically needed support at night or in between care calls but no longer required their ongoing therapy to be provided within a 24 hour nursed environment.
Solution – aims and objective
The overall aims of Castle Brook Therapy Unit are to:
- Increase independence and daily living skills.
- Avoid the loss of confidence or ability that is associated with spending too long in hospital.
- Reduce unnecessary hospital delays; once a person is medically fit they should be discharged as soon as possible with sufficient support in place to meet their short term needs.
- Reduce costly long term health and social care provision where people can be safely supported with less intervention in their lives.
- Ensure people receive a period of recovery away from the acute hospital to enable an accurate assessment of their health and social care needs.
- Make sure patients are supported to return home if possible, or in a homely setting whenever appropriate, for as long as possible.
- Make sure that decisions about a long term support are made out of hospital and ensure people, if appropriate have access to therapeutic and Reablement services to ensure they reach their optimum potential.
Method and approach
Discharge to Assess (D2A) comprises three pathways and is designed to move care closer to home and reduce unnecessarily prolonged acute hospital stay. It is a multi-agency approach between the Local Authority, South Warwickshire NHS Foundation Trust (SWFT) and South Warwickshire CCG.
Initially, as part of the D2A programme, SWFT purchased nursing home placements and provided therapy into the nursing homes, however the constant turnover was difficult for them and they could only accept one new patient per day. A transitional unit was then set up in the acute hospital to prepare for winter pressures, however the environment and location was not ideal to promote the proposed therapeutic model.
SWFT contracted and collaborated with Warwickshire Care Services (WCS) to create a therapy led Transitional Unit within Castle Brook, a modern and technologically advanced care home. The 13 bedded units’ NHS therapy team consists of the Therapy Lead, whom is an Occupational Therapist by background, a rotational Physiotherapist, rotational Occupational Therapist, a part time Physiotherapy Assistant and a part time Occupational Therapy Assistant. A Band 4 Therapy Assistant Practitioner has also recently been recruited.
Warwickshire Care Services team consists of a Lead Enabler and Enablers that have received extra reablement training to ensure they continue the rehabilitation philosophy whilst therapists are not on site.
Daily handovers between SWFT and WCS allow for effective communication and enhance the integration between the teams. Furthermore a weekly MDT is held, in which a Social Worker and Age UK representative attend. GP’s visit three times weekly and see patients that have been highlighted by the therapy team and district nurses visit as and when required.
The use of technology has played a major part in the speed of admission. As part of the admission process the Therapy Lead meets and screens the patient in the acute hospital, explains the service and gains written consent. It is important that the patient understands that the transfer into the unit is part of their on going treatment, and they remain the responsibility of South Warwickshire FT. A trusted assessment is then completed online with baseline information and care plans created for the patient. This is then electronically forwarded to the lead within the unit for joint agreement that the patient is suitable. This prevents any delay with the home needing to visit the patient on the ward.
Having the unit based with a care home allows for a less institutionalised and more therapy enriched environment, facilitating the successful transition of the patients from the acute hospital to the community and to their normal place of residence. Patients receive both one to one and group therapy sessions and are encouraged to recreate a routine similar to their own at home.
Part of the criteria requires that patients are motivated and engaged with therapy and have the ability to improve and to return to their own place of residence within a 21day period. Therefore it is a short stay, low level rehabilitation unit that focuses on planning for safe discharge and reducing the amount of care or support services required on discharge and in the future.
Bed pressures in the hospital have resulted in a room designated for extra capacity being filled. This room had been previously been used as a therapy space.
Bed pressures have also resulted in a need to work closely with the acute therapy teams to adjust the criteria to aid patient flow at times of high pressure. Criteria has been flexed to now allow for one patient requiring assistance of two to mobilise to be on the unit at any one time. Also patients awaiting community teams capacity or social services packages have been accepted.
Some challenges have occurred due to difference in policies and procedures between SWFT and WCS care homes and therefore has required some negotiation and problem solving from both parties.
- 1,870 hospital bed stays saved between April and October 2017.
- Average length of stay, year to date is 14.3 days.
- 89 per cent of patients discharged to their usual place of residence. (9% readmission to hospital and 2% discharged to care home).
- 83 per cent of patients return home self-medicating.
- 96 per cent reduction in patients with night needs on discharge.
- 100 per cent of patients likely to recommend the service to family and friends (September 2017).
- 100 per cent of patients improving in at least one aspect of the Therapy Outcome Measure (TOM).
- 93 per cent of patients have improved in the Elderly Mobility Score (EMS).
- Vast Majority of patients being discharged with a reduction in predicted care packages on point of transfer to Castle Brook.
- A number of patient’s have returned home independently and without any care support on discharge.
Key learning points
- Allied Health Professions (AHPs) are essential to have a positive impact on flow.
- Integrated multidisciplinary team working is essential.
- Therapy Led service allows for all patient contact to have therapeutic benefit.
- Providing rehabilitation in a more homely environment has a positive impact.
- Working in partnership with care home staff is essential and allows for more holistic assessment and intervention.
Plans for spread
- Therapists and managers from other trusts have visited in order to showcase and to share learning from the service.
- New Band 4 Therapy Assistant Practitioner role has been recruited to and so development of this position and responsibilities has begun.
- Plans to utilise the trusted assessment and technology available in the home more to enable a successful and enhanced 24hour rehabilitation service. – SWFT staff to complete daily carer handovers on the system to discuss goals and plan therapy sessions.
Find out more about the framework to support winter pressures by emailing email@example.com.