Simple solution, radical change
Caring for older people in emergency departments is one of the biggest challenges facing hospitals, not only because of the number of patients involved, but also because of the wide range of long-term conditions they have
Caring for older people in emergency departments (EDs) is one of the biggest challenges facing hospitals, not only because of the number of patients involved, but also because of the wide range of long-term conditions they have.
The solution does not need to be intricate. According to a report by the Commission on Improving Urgent Care for Older People, the opposite is true.
The commission was set up by the NHS Confederation in March 2015 and comprises staff from across the health and other care sectors, including the RCN. Its report, published in January, concludes that care for older people should be ‘simpler’ and ‘more straightforward’.
Series of visit
Commission chair Mark Newbold says that the report’s conclusion was reached after commission members carried out a series of visits to innovative areas in England and Wales.
‘Radical change does not need to be complex, but should strip back complexities,’ he says. ‘We have talked too much in the past about integrating the providers of services and not enough about integrating care around people.’
Dr Newbold says the report has implications for hospitals and the community, and the examples it highlights provide a ‘compelling case’ for action. ‘I have been privileged to see how much transformational practice exists. The challenge is to ensure it happens at sufficient scale,’ he says.
To this end, the commission has set out three principles for the NHS to follow:
- Care should be driven by each person’s needs and goals.
- Care co-ordination should involve offering a single point of contact to guide patients through the system.
- Proactive and preventive care should be prioritised to keep people well.
One hospital seeking to apply these principles is Sheffield Teaching Hospitals NHS Foundation Trust. In the past, the trust struggled with delayed discharges, but this has changed since it introduced ‘discharge to assess’. Under this system patients’ needs are no longer being assessed in hospital, but are assessed at home by an active recovery team made up of nurses, physiotherapists and occupational therapists.
Consultant geriatrician Tom Downes says: ‘Home assessments make sense because they are in familiar environments, rather than the unfamiliar setting of a hospital.’
In 2013/14, almost 3.7 million visits to emergency departments were by people over 65, with one in ten by someone over 90:
- The over-75s have an average of three long-term conditions.
- The over-65s account for more than half of all bed days and four in ten day cases.
- Average length of stay after an emergency admission for a patient aged 85 or over is 11 days – nearly twice the national average.
Improved discharge times
Over the past 12 months, 7,000 people have benefited from the initiative, with patients being discharged home in an average of 1.1 days instead of 5.5, as was the case before. Because the active recovery team has a more accurate picture of patients’ needs, the initiative has also ensured that fewer intensive care packages have needed arranging.
Another initiative, involving North East London NHS Foundation Trust and the local ambulance service, is helping to keep older people at home after a fall. Those who fall but do not appear to have hip fractures are assessed at home by a nurse and paramedic, who can provide treatment and arrange the provision of necessary equipment such as walking frames, or community care packages.
Many of the programmes highlighted in the commission’s report involve community services. In Hertfordshire, for example, a multidisciplinary team of clinicians has been set up to provide a rapid response service for care home residents who fall ill, accompanied by a system of regular ‘ward rounds’ in the homes by local GPs.
The report also cites several schemes that help people navigate the system, including a care co-ordination project, run by Age UK, in Cornwall. This uses co-ordinators who work with vulnerable older people, the NHS and the care system to develop shared care plans.
Halving of admissions
Evaluation of the project, which started in 2012 and has now been adopted in nine sites, shows that it has halved admissions. British Geriatrics Society older people’s nurses and allied health professionals group chair Jane Buswell says that input from the community is going to be vital if the workload on emergency departments is to be eased.
‘There will always be times when older people will need to be admitted to hospital,’ she says. ‘But if we get care right and properly support people in care homes and those who are frail, living in the community, we could really reduce the pressures.’
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