Fife Good Practice Example - Choice Policy
Summary of Initiative
Our joint initiative was to facilitate discharge for a group of older people who had remained in hospital beds for a number of months following multidisciplinary assessments and who had been described as fit for discharge.(transitional clients/patients.)
We initially targeted a ward in a Community Hospital which hosted two groups of people one described as Long Term Hospital Care patients and a group described as transitional i.e. waiting a place in a care setting.
Our Aims and Objectives: -
- Target those who had been classed as a delayed discharge for the greatest period of time - discounting the X codes
- User (patient) and Carer involvement
- Reassurance to all regarding interim placements
- A robust process in keeping with the Joint Discharge Policy.
- Ensure evidence of decisions taken
- Provide a positive role model to ward and hospital staff involved in Hospital Discharges
- Ensure front line staff did not have to deal with possible conflicts when having to offer day to day personal care
At the beginning of 2005 we began discussing a joint initiative at a Fife wide meeting about delayed discharges when we were seeing evidence of a large percentage of people with delays of about a year in clusters on wards where different outcomes of care were being planned for and the people identified as being able to move into a care setting were not making choices of care homes and with their family were beginning to compare their own situation to those on the ward identified as needing to remain in the hospital environment. We initially targeted a hospital where there had been the lengthiest of delays. The feedback from Social work and Nursing staff identified that patients and family were being asked to accept places in care settings which they had put down as a choice for and these places of choice were being refused. Some people had refused up to three appropriate local resource offers over a number of months.
Annie Briggs Discharge support Nurse and Susan Ott Team Leader Older People's service met to discuss the Jointly agreed discharge policy and compare this to the information we had on the individuals on the ward selected.
We ensured staff involved in working with this group of people understood that we would be undertaking this work and the reasons for this. We ensured that the locality Manager for the hospital concerned understood the benefits to them of freeing up beds which they could then use for others needing to come in to hospital from the community or from acute hospital settings.
We agreed our respective roles and recognised that on behalf of the hospital services Annie had responsibility for conveying the medical and nursing opinions and the patient fitness for discharge to the patient and family and with this in mind it is Annie who convenes a meeting with the patient and family. The meeting is led by Annie and Susan takes those involved through the steps which Social Workers had covered in respect of assessments and information on choices etc. We jointly referred to the Joint Discharge document and ensured family and patients had copies of this document along with printed information about moving on from hospital and a list of care settings with vacancies.
We were clear about what information had already been conveyed to patients and families and ensured we could evidence decisions which had been taken and the reason for this. We ensured that everyone involved understood the benefits of not remaining in a hospital environment if this was not needed. This included lack of privacy, lack of personal belongings for the patient, a less inflexible routine, preventing others from accessing a scarce resource, greater risk of hospital acquired infection and compared this to the benefits of moving in to a care setting where people do have their own private space, there are more social opportunities for people to become involved in, they can have more of their own belongings about them and there are less medical routines than on a hospital ward. The Locality General Manager was aware we were planning this piece of work.
We identified times and a suitable venue and invited patients and family to individual meetings and discussed the reasons for the meeting and opened the meeting to exploring why people were still in hospital. We were able to explore fears and offer reassurance and we were able to ensure in some cases that family understood and supported the older adults wish to move in to a care setting.
We tried to handle these meetings in a sensitive manner ensuring alternative care settings were considered first and by keeping communication open between all involved. We did set time frameworks for expected move from hospital.
Costs have not been calculated but in the ward which was first targeted we now have a regular flow through of patients which means more people are accessing the beds from acute to those in the community because patients are not getting stuck. In turn this ensures flow from acute to these transitional beds which also has a considerable cost saving.
We didn't need to use any high tech info, simply clear communication skills and evidence based decision making.
At a strategic level this initiative was supported at a Senior Level in that the Council's own resources were asked to take people on an interim basis and the contracting section for the council identified private resources who would accept people on an interim basis.
Results
Initially from an 8 bedded ward there were 4 people appropriate to remain there and 4 people refusing to leave some of whom had been there for more than a year.
All 4 of those identified as appropriate to leave were offered either interim places with a reassurance of being kept on the list for their first choice of home or were offered a place which they found acceptable. There were negotiations with a private resource to take an older woman's budgie as well as herself.
One person was subsequently transferred to a first choice of resource whilst the other 3 settled in to the resource which they moved to.
All of these people moved out of hospital within one month of the meetings taking place.
There is no longer a culture of being able to remain in hospital on this ward and this particular ward setting continues to be proactive if there is concern that a patient may be at risk of becoming stuck and ward staff, AHP and Social workers are more positive about taking what seemed to them to be tough decisions to discharge older adults who were frail and vulnerable in to care settings in the community.
In the wider but still local area it is now recognised that Annie Briggs and Susan Ott do keep an overview of patients and local staff are working in a more positive fashion to ensure timely discharges.
Where people do become stuck they are identified at a Fife wide meeting and jointly this process swings into action. Currently, when ever this end part of the process for discharging people needs to be implemented we have been successful in enabling discharge from hospital.
From people originally waiting for over a year our longest delay on this ward has been markedly reduced.
Structure
From feedback to the Fife wide meeting all those involved in discharge planning from hospital have seen the benefits of close co-operation between agencies and this has filtered out across the area. There are a number of small initiatives now looking at better communication and involvement of patients along with patient pathways and there is a sense of more ownership of these processes.
Contact Details
Susan Ott, Team Leader for Social Work Hospital Discharge Team for Older People Services, Castlehill, Cupar, KY15 4HA
Annie Briggs, Discharge Support Nurse, Whytemans Brae Hospital, Kirkcaldy, KY1 2ND