Home Again: Discharge and Recovery – the Integrated Way

2000 patients and 20000 bed days later… (or goodbye to delayed transfers of care aka DToC!)

My last WIHSC blog in October 2015 told of a new service in South Kent stopping delayed transfers of care (DToC) by giving all the support needed (assessment, drugs, transport, home care) through specially trained teams of nurse-supervised Personal Nursing Assistants who get people out of hospital as soon as they are declared fit for discharge. It was a very new service that has really taken off since then with 9 hospitals in Kent and Essex now taking part. The upshot is that 2000 patients have had between them 20,000 days supported at home who would otherwise have been languishing unnecessarily in hospital beds. The most important outcome is patient well-being and satisfaction, but I am sure you can do the sums in terms of savings in the cost of bed days to the NHS. This number of patients is of course way in excess of the total number of people experiencing delayed transfers of care in the whole of Wales…

Similar in style to the Buurtzog Home Nursing  service in Holland, the nurse-led partnership operating in Kent and Essex has gone into hospitals and brought out people experiencing DToCs who should be in their own home. Specially trained Personnal Nursing Assistants (PNAs), working with their ‘Guardian Nurse’, care for each patient in their own home for up to 5 days (or up to 6 weeks for non weight-bearing people). Real time information and communication is managed through the PNAs iPads and iPhones. 61% of patients don’t need any further health, or social care packages once they have had their 5 days support and continue with their own lives after the team have finished. Even those who go on to have a social care package really appreciate the home from hospital recovery service ( 99% positive Friends and Family score for all participants ). Some patients do go back into hospital; however, on average, there is a less than 5 % re-admission rate – which is quite a result.

What next?

Well, one of the Trusts is talking about Hospital At Home, with healthcare delivery at home under the clinical control of hospital consultants. Imagine not having to build more hospital beds yet being able to treat more elective patients, or people with specific conditions. Instead of a 4 day stay in hospital, one day for the operating procedure then 3 days recovery in a hospital bed, your recovery would happen at home with all the convenience of your home environment, but with constant nursing and Physio supervision by the Home Hospital team who would use remote telemonitoring, iPads and iPhones connecting the patient to the hospital 24×7. This could be the new way of caring for patients without the risk of hospital acquired infections, nutrition or hydration worries. What a revolution it could be?

Coming to a hospital near you , soon, I hope….

Written by Justin Jewitt, External Professor


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