Improving transitions from hospital to home.

Abstract

❛The success of out-of-hospital care will partly be judged by its ability to offer older people a quality dimension to their life experience.❜ The imperative of making integrated care a reality is widely accepted. However, yet again, there is evidence that some patients do not transition between hospitals and community settings in an effective manner (Ungoed-Thomas, 2015), with some NHS Trusts experiencing delayed discharges in excess of 100 days. During the year ending March 2015, the University Hospital Southampton NHS Foundation Trust had 207 patients who waited 4 weeks or longer after having been declared fit for discharge (Ungoed-Thomas, 2015). While only a minority of patients experience long delays when medically fit for discharge, the need to improve transition arrangements was the basis of the recent National Institute for Health and Care Excellence (NICE) (2015) guidance. The NICE guideline rightly recommends that those with social care needs should have a care plan that addresses all aspects of their life. The care plan should include agreed preferences relating to their care needs and information exchange, so that care decisions are always person-centred and respectful, with the involvement of the individual and his/her family and/or carer as appropriate. Importantly, the care plan should incorporate agreed decisions relating to advance care plans and end-of-life care. Indeed, it is possible that the very old or very frail do not want to be admitted to hospital at all, having expressed their desire to have a dignified death in their current home. However, if a hospital admission is appropriate, the NICE guideline emphasises coordination between the hospital-based and community-based multidisciplinary teams so that there is a seamless approach across the services. Good record-keeping of assessments, treatments (prescribed and non-prescribed medications), and progress toward discharge are essential to ensure the timely transfer back to the patient’s current home or an alternative. NICE recommends the use of discharge protocols that include good information-sharing arrangements between health and social care providers, as well as between patients and their families. Knowing the preferred place of death of those at the end of life provides community nursing services the opportunity to enable a dignified death in the preferred setting, utilising generic and specialist palliative care services. The NICE guideline recommends that such patients should be followed up within 24 hours of hospital discharge so that ongoing care plans can be agreed and carers given practical support. Other hospital discharges will relate to ongoing care and re-enablement, and again, the importance of a follow up within 24–72 hours of discharge is emphasised so that the care delivery meets expectations and unnecessary readmissions are avoided. The increasing social isolation and loneliness of older people may exacerbate their vulnerability. Identifying local resources such as ‘Contact the Elderly’ (www.contact-the-elderly. org.uk/) for those aged over 75 years and living alone may be one strategy to reduce the experience of loneliness. It offers connectivity with a social group with whom to share conversations and develop new friendships. The success of out-of-hospital care will partly be judged by its ability to offer older people a quality dimension to their life experience, because no advanced society should condone life extension without a reasonable quality of life. Community nurses, as advocates of their clients, should be at the forefront of promoting a high quality of life for all those receiving nursing at home. BJCN