By the HN Advisory Board
Professor Matthew Cooke,
Emergency Department Clinician
Dr Steven Laitner,
GP and Public Health Consultant
Introduction
The months of managing Covid-19 have further highlighted the need to further improve the safety, and timeliness of hospital discharge processes. With capacity constraints, priority is shifting to making a reality of the long-held aspiration that more of the NHS care is delivered at home, whether by hospital outreach, or by increasing capacity and capability in the community. However, establishing a safe and effective ‘early supported discharge’ process has been a challenge with which the NHS has wrestled for decades. Every transfer of care creates well-documented patient safety risks; but every delayed discharge also carries risk.
In order to facilitate effective patient transitions back to their home environment, or maintain them at home and prevent hospitalisation, collaboration between primary and secondary care must become the priority. This can be enhanced by digital processes that enable new operating models. The HN Advisory Board have considered the topic of ‘Hospital at Home’ and share perspectives from both secondary and primary care.
Secondary Care: Professor Matthew Cooke (Emergency Department Clinician)
Transferring care from hospital to community has become a complex process of clinical handover to a person often unknown to the hospital team and is often perceived as risky. But this risk must be balanced against the risks of staying in hospital (e.g. deconditioning, healthcare associated infections (HCAIs)) and the disadvantages of not being in a familiar home environment (reduced mobility, reduced mental stimulation, disorientation).
One key challenge is giving the referring clinician the confidence to know their patient will be safely monitored upon discharge, or if not, admitted. If a clinician is unfamiliar with the community team or the virtual ward team, they will be less willing to expedite early discharge. To prevent this, it is crucial that the person/team responsible for helping a patient’s transition home collaborates with the secondary care team to learn about the patient’s condition and develop a clear shared care plan. It is also important for the hospital to realise that the community team may have a deeper understanding of the patient’s support and ability when at home.
When developing a smooth early discharge, or admission prevention process, the first consideration is how early a patient will be sent home. At the highest level, a patient may be sent home with very active treatment requirements – what we often think of as the ‘Hospital at Home’ model.
Patients with less active treatment needs may move into the virtual ward, where the care plan is largely self-administered (with a degree of supervision) and monitoring can be performed remotely as low levels of clinical oversight is required. This cohort of patients can be greatly extended from traditional models by using appropriate remote clinical coaching and support to activate more patients for a safe early return to home. Shifting to a system where patient and carer are supported to be as independent as possible is better for the patient and more efficient for the NHS.
While effective communication between care teams is vital, there are at least six key considerations for an early discharge process:
Success of early discharge systems depends on establishing mechanisms to take decisions earlier so post-hospital preparation can happen as soon as possible. Sometimes this might be practical in avoiding an admission via a well co-designed Same-Day Emergency Care (SDEC) pathway, but when admitted for inpatient care the discharge process should start the day after admission; clear plans and target dates often accelerate the process. More importantly is the move to a culture of ‘what is stopping you going home for your care’ as opposed to ‘when will you be ready’. In addition, the patient might not necessarily have reached pre-admissions levels of function, but if they continue to have the right care and support at home, this should not preclude a timely supported discharge. To effectively prepare a care plan, the information flow about the patient must be in place and accessible to the clinical team responsible for the patient at home. This means defining any prescribed monitoring within parameters and relevant escalation.
Once the infrastructure to share the information is established, the governance structure must also be clearly articulated. There are many different governance structures across secondary, primary, community and private care. Therefore, as these different organisations interact, they must develop and agree upon a clear governance structure detailing who is responsible for the patient at each phase of the earlier supported discharge process.
To successfully get any model in place, a senior clinician is needed to act as a champion for establishing and improving the process. This enthusiast can help their team overcome any initial obstacles or concerns and address the challenges head-on. This champion may be in any part of the pathway but will usually need fellow champions in other parts of the pathway to their own.
In the digitally enabled care models possible today, the continuity of care across the secondary and primary care interface means that these champions can envision and implement much more ambitious pathways, starting much earlier in active care, but also by effective clinical coaching so patients can self-administer shared care plans.
Primary Care: Dr Steven Laitner (GP and Public Health Consultant)
It has often been described like a brick wall between hospital care and primary care. This brick wall impedes movement between both sides; in primary care, it can be challenging to get quick access to specialist advice and care for your patient and in the hospital, it can be equally challenging to discharge the patient back into primary care with timely care and support in the community. Often these two worlds operate entirely separately. We need to work toward sharing knowledge and expertise between primary care and secondary care – this must include the patient and their carer throughout the process.
In order to respond to the demands of Covid-19, we must seek real-time flow of information, expertise, advice and support. While demolishing brick walls is an important first step, there are many more challenges to overcome.
Here are some questions that primary care must consider as we work to develop an appropriate timely discharge process:
We need to work towards developing an equilateral triangle of communication connecting the GP, hospital specialist and the patient. The patient should be able to get timely access to primary and secondary care expertise, regardless of where they are located. The more barriers we put up in movement of knowledge and communication, the more problems we create. We should be striving toward a model whereby a patient is only in a hospital bed when they need a therapeutic intervention (e.g. invasive ventilation or an operation), but if they only require monitoring or specialist advice – they should be at home if at all possible. Digital advances mean that this type of care model is now deliverable, and it is our culture, practices and governance that need to catch-up.
Historically there has been a limit on communication between primary care and the patient, however since the emergence of Covid-19, these barriers have mostly been removed and patients can contact their surgery with more ease. To facilitate this communication, we are beginning to witness better infrastructure to allow for text-based communication between the GP and the patient. What is less frequent is asynchronous communication platforms between the GP and hospital specialist, although the NHS Advice and Guidance system and private providers such as Consultant Connect are supporting this more and more. However, there is still one party not included — the patient. Shared decision making is fundamental to an effective outcome. As we progress toward a timely discharge model – information infrastructure that allows this level of communication will be key to ensuring clear and managed information flow. One idea would be a platform which allows the patient to post information that both the primary care and secondary clinician can view and the appropriate individual can respond (with the communication visible to all three members). To enhance this process, a care navigator could oversee the conversation and allocate a task to a particular care provider.
Many primary care providers will be concerned about managing demand if easier lines of communication are opened up with the patient, however the more you empower and support the patient through more regular communication, the less likely people are to call in a crisis.
To successfully develop an early discharge model, or admission avoidance model, we should start by determining who are the most suitable patients that will benefit the greatest from a model of care where there is ongoing support as required from a specialist, GP and care navigator. To trial the proposed form of communication above, we should possibly focus on people with multimorbidity, complex needs with a high risk of admission. Once we identify the right patients, we need to work toward developing a managed communication pathway and encourage primary and secondary care to tear down the brick wall in an effort to work with the patient toward a swift recovery out of hospital.
Conclusions
HN has already demonstrated that proactive case management, patient empowerment and care navigation can effectively work together and reduce unplanned hospital care. This model can be extended to help successfully establish an early supported discharge process, or effective SDEC pathway, that transitions into the virtual ward. As primary and secondary care work toward developing a more coherent shared model, there is an opportunity for HN to facilitate the dialogue between these two groups of clinicians and the patients. There is the ability to use modern technology to further inform these discussions with self-monitored parameters with appropriate support. The common goal is to establish a mechanism whereby a patient is in hospital only when they need to be – any monitoring or support that can be provided outside of the hospital should be conducted within the comfort of a patient’s home. We can deliver a much-improved model of care with ‘NHS at Home’ if we support and fully integrate patients in the care processes and care plan delivery.
With their experience of primary and secondary care, the HN Advisory Board have also seen that patients are invariably keen to go home. Empowering patients creates a culture where the patient and their carer(s), can challenge clinicians and question delays in their discharge. Why am I still in hospital? Couldn’t this care be done in my home? What would it take to get me home today?
This is all possible now…what is stopping us?
About HN
HN is a healthcare company that delivers AI guided case-finding, remote monitoring, clinical coaching and virtual ward solutions to the NHS.
Since our UK launch in 2015, we have developed into an award-winning NHS partner and, from March 2020, have been supported by the NHS Innovation Accelerator to scale nationally.
We provide practical applications of population health management, going beyond just identifying high-cost, high-need patients and actually intervening to support them to improve their health outcomes and reduce their care consumption. hn-company.co.uk
About Professor Matthew Cooke
Matthew was formerly the urgent and emergency care ‘tsar’ for the UK Government, most known for his introduction of the four-hour target. He is also an experienced A&E physician, featuring twice on HSJ’s annual “top 100 clinical leaders”. His leadership roles have included National Director for NHS 111 and Chief Clinical Officer at Capgemini. @MatthewCooke
About Dr Steven Laitner
Steven is an influential and experienced GP, population health expert and clinical leader. He has a strong background in public health and clinical leadership. Steven practices as a part-time GP and as a freelance health consultant with his own consultancy company, Programmes for Health, supporting a range of healthcare commissioning and provider organisations. @SteveLaitner
For further information, please contact Angela Bambridge.