NHS restoration and recovery – addressing the capacity challenge across an ICS

Case study Virtual ward, Partnerships 29th Jul 2020

Many positive changes have come out of the NHS response to COVID-19. As our health and care systems address the complex challenge of a backlog of elective cases, the approach of Winter and further COVID-19 surges, what can be done to balance these competing demands on systems with limited capacity?

This article considers some timely, grounded and cost-effective options for the sustainable recovery and delivery of core NHS services while retaining the ability to respond to COVID-19.

Getting the right balance between, delivering a Recovery Plan, providing ‘normal’ NHS services and maintaining capacity for local surges in COVID-19 cases.To respond to the challenges in demand, additional capacity and resources are required, combined with new ways of working.

• Expanding the provision of home-based care will free up hospital capacity to help address these pressures, increasing the ability to deliver ‘ordinary’ health and care services.
• Home-based care has the additional advantage of reducing the risk of cross infection between COVID-19 positive and other patients
• Technology – the use of video consultations and remote monitoring are positive changes in models of care delivery which can be further developed to maximise efficiency and resources.

At Norfolk and Norwich University Hospitals NHS Foundation Trust patients have left hospital early and been safely treated at home – at half the cost of remaining in hospital

 How can the NHS provide for the pent-up demand for health and care services that have been delayed due to the COVID-19 outbreak?

NHS providers and commissioners need to take steps to provide timely and cost-effective care in excess of ‘pre-COVID-19’ capacity. Actions which could be ready for Winter 2020/21 include:

Optimising inpatient beds promoting safe, effective, efficient patient flow from hospital to home.

• Delivering models of Early Supported Discharge. Moving patients out of the acute setting sooner to complete care at home instead of in hospital.

  • Early supported discharge delivers not only step-down capacity but also effectively step-through capacity. Patients go home at D minus 4 or before, that would have stayed in hospital beds. This is also the case for bridging packages of care. Patients often go home after their discharge day (e.g. D plus 4) whereas a bridging service is able to rapidly move the patient home by providing care on their discharge day.

• Better planning of the route into and out of hospital. Prehabilitation (before surgery) and rehabilitation (post-surgery) reduces the length of stay in hospital and improves outcomes.
• Continue the joint working between NHS and private healthcare to enable changes to be implemented quickly.
• Value for money. Flexible capacity based on the patient at home is more cost efficient than capital spending on less flexible new ward building.

Patients are being rapidly discharged from hospital with a higher level of complexity.

At Imperial College Healthcare NHS Trust early supported discharge patients regained independence and avoided the need for hospital readmission through the use of a multi-disciplinary community team.

 Many of the changes to discharge practices, brought in to manage the peak in COVID-19 cases, are being retained for the long-term. As the number of patients discharged to community care returns to pre-COVID levels, appropriate care must be available for patients with longer termand more complex needs.

To address these needs a range of factors should be considered:

  • Care services delivered by multi-disciplinary teams can respond quickly to changes in patient’s acuity (step up and step down).
  • More complex patients require a workforce which has the capability of managing acute care at home. This is significantly different to care traditionally delivered by District Nurses and Community Nurses.
  • Technology enabled remote patient monitoring helps to support patients with a higher level of acuity.
  • A focus on quality and safety must be retained post discharge from hospital.
  • Promote physical and emotional wellbeing. Meeting extra demand for mental health services as a result of the societal and economic impacts of lockdown.
  • Utilise tried and tested models for out of hospital services that are quick to deploy, scalable and ready to meet complex patient needs. Ready for Winter.

As services normalise, how can the positive changes that have taken place as a result of the pandemic be retained?

NHS Hospital Trusts have been working hard with their community partners to improve the integration of services so that patients have a quicker and smoother transfer to the care they need at home, or close to home.

The independent sector has played a significant role in supporting the NHS across all parts of the healthcare system in responding to COVID 19. The relationship between the two sectors has radically changed during this period with great examples of partnership. It is important to ‘lock-in’ these changes for the next phase of the pandemic response and once service provision normalises.
• The 2-hour discharge pathway is a positive step, however, gaps are already emerging as former reasons for delay reappear and delayed discharge lists grow – this demonstrates a need for a quick reaction service to add to existing community capacity
• The rapid adoption of technology should be retained and built on. Mobile patient records, virtual MDT, remote monitoring and analytics of data from wearables should be encouraged
• Lock-in the attitude that there are ‘no acceptable delays in patient discharge. Meaningful measures will allow this to be tracked in acute and community settings.

What is the impact of delayed transfers from hospital to home?

At the James Paget University Hospitals NHS Foundation Trust patients have been discharged as soon as they are medically fit with ‘care bridging’, resulting in a median saving of five bed days per patient.

 Measures for 2020 are not available since the first part of the calendar year however in 2019 almost 60,000 NHS beds were ‘blocked’ every month by delayed transfers of care.

Patients are spending unnecessary nights in a hospital bed because of delays in services which would provide their care at home, or in another setting. Delayed discharge also results in deconditioning for patients, increased risk of infection and ultimately an increased cost of care.

What can be done?

Early supported discharge services and virtual wards offer a scalable way to provide patients with the care they need at home, instead of in hospital – a ‘Hospital at Home’. These services fill in the gap until established community services are available or offer types of home-based care not provided locally. Where already operated by the NHS and their partner organisations these services offer a safe and cost-effective option for patients who welcome the opportunity of an early return to the familiar surroundings of home.

What is Hospital at Home?

Hospital at Home provides a comprehensive ‘secondary care at home’ service, for example: IV therapies, wound care (including) negative pressure therapy, rehabilitation and bridging packages of care. The service recognises the needs of individual patients and considers diversity of the population with respect to cultural needs.

Our Hospital at Home service complements existing services integrating with NHS and local authority community provision. It responds quickly to allow medically stable patients to leave hospital or avoid admission, improving flow and releasing inpatient bed capacity.

• Clinical responsibility remains with patient’s consultant/GP, unless otherwise agreed. Interventions are prescribed by the accountable consultant/GP and delivered at home by the HomeLink Healthcare multi-disciplinary team
• The multi-disciplinary teams comprise of highly skilled and well-trained registered nurses, physiotherapists, occupational therapists and healthcare assistants
• A mobile electronic patient record (EPR) allows all staff involved in a patient’s care to access the care plan and care record in the field via a mobile app
• Telehealth devices can be used to monitor the patient’s vital signs between care visits (24/7)
• All patients have their holistic needs assessed prior to discharge and a clinical baseline established and Care Plan developed. At each visit patient needs are reassessed, changes monitored and recorded in the EPR. Home visits are conducted according to patient needs, including both nursing and therapy observations.
• For each patient flags and indicators for escalation are agreed and contained in the Care Plan identifying when additional medical review or escalation is required. When indicated by clinical need a multi-disciplinary team review will also be undertaken.

NNUH at Home, a hospital at home service created in partnership between HomeLink Healthcare and Norfolk and Norwich University Hospitals NHS Foundation Trust has saved over 5,000 bed days, with 100% patient satisfaction’, resulting in a median saving of five bed days per patient.

 

HomeLink Healthcare supports the delivery of core NHS and care services during the pandemic and beyond HomeLink Healthcare is an independent sector organisation partnering with the NHS to deliver home-based care to patients who would otherwise be in hospital, a Hospital at Home. We enable this with our safe, high quality and caring service, supported by technology and our skilled staff, delivering care at the right time in the right place. We are supporting the NHS with a flexible, responsive and agile approach to changing care needs during the COVID-19 pandemic and beyond.

Providing home-based care for patients reduced hospital bed nights and avoided admissions, lowering demand on stretched resources and risk of cross infection. We are continuing to work alongside our NHS partners to maximise the utilisation of inpatient beds by caring for patients at home as soon as they are medically suitable for our services.

HomeLink Healthcare are experts in designing, mobilising and delivering Hospital at Home Services. Find out more about the process of commissioning HomeLink Healthcare to set up a Hospital at Home service.

Get in touch

To speak to a member of our team about virtual wards, call us on (020) 3137 5370 or contact us.  You can tell us about your situation, and we can tell you more about our experience of Hospital at Home and how we might be able to help you.

“You did everything exceptionally and allowed me to leave hospital six weeks earlier than planned because of the service you provided.

THANK YOU!!”

Patient feedback

“I am so grateful to have been referred to HomeLink Healthcare, they have really helped me get back on my feet. If I had stayed in the hospital I would not have achieved everything I have done”

Patient feedback

“I want to thank you from the bottom of my heart, and let you know that the work you do makes a true difference to people’s lives and wellbeing.”

Dr Vassiliki Bravis Consultant, Imperial College London

“Exceptional, amazing service with highly qualified staff. I felt confident at all times that staff knew how to deal with my picc line and my four times-a-day antibiotics was made easier by such lovely caring and compassionate staff”

Patient feedback

“The visiting therapist took her time with me, was always providing encouragement and without that I wouldn’t be at the point I am today.”

Patient feedback

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