Community Network

Facilitating early supported discharge for older patients: Bristol Community Health's 'in-reach' service

two hands on a walking stick

10 / 11 / 2015

Older people often remain in hospital for too long when their needs could be better met in the community. 

Bristol Community Health’s in-reach service allows staff from the rapid response team to actively ‘pull’ patients from acute wards and arrange for their care in community services.

Key learning

  • Older people with complex needs often experience unnecessarily long hospital stays when they would be better off being treated in the community.
  • Bristol Community Health has established an ‘in-reach’ service, so that team members can actively ‘pull’ patients out of short-stay wards and into community services.
  • They estimate that the scheme saves an average of £132,000 per quarter, based on a saving of three bed days per patient.
  • The success hinges on multi-disciplinary team working, communication, proactive clinical risk-taking and effective collaboration across acute and community service boundaries.

What the organisation faced

In Bristol, and beyond, the NHS is contending with changes in the demographics and disease profiles of its patients. When frail older people with complex conditions are admitted to hospital they can experience longer stays due to difficulties in putting in place support for them in the community. The local acute trusts in Bristol have experienced a large reduction in acute hospital beds in recent years, putting extensive pressure on these resources.

Bristol Community Health has previously established a REACT (Rapid Assessment Emergency Care Team), based in the emergency departments of the Bristol Royal Infirmary and Southmead Hospitals.

This team acts to prevent admissions wherever possible. Acute hospital stays are expensive and it is widely agreed that patients should be treated in the community wherever this is clinically appropriate. As a result the service has been extended to ensure that those who are admitted can be discharged into the community as soon as possible.

What the organisation did

Bristol Community Health established a new in-reach service, as an addition to the existing REACT service. This allows REACT team members to actively ‘pull’ patients from short stay wards and into existing community services.

The team identifies older patients who are suitable for early supported discharge within five days of admission. They may come from the Older Persons Assessment Unit (OPAU), Medical Admissions Unit (MAU) or Surgical/Trauma Assessment Unit (STAU). These units make up a total of 85 beds.

The team often follow up patients who have already been involved with the rapid response teams in the community prior to their admission, or following a REACT assessment in the emergency department. They aim to assess and refer them back to community teams where appropriate, to prevent prolonged admissions. These patients are given a comprehensive geriatric assessment, ensuring all their problems are identified, prioritised and addressed.

The service relies on multi-disciplinary team working, with effective communication and proactive clinical risk taking. Staff also need a working knowledge of the community service capacity available, particularly in the rapid response teams, as well as the ability to work collaboratively across the traditional boundaries of acute and community care.

Staff attend daily morning board rounds to identify suitable patients, complete timely assessments and communicate with the ward coordinator to update them on potential discharges. If necessary, they are able to refer patients to step down beds at South Bristol Community Hospital for short term intensive rehabilitation of up to seven days, prior to discharge home with rapid response teams.

The in-reach team are led by advanced practitioners, supported by nurses, physiotherapists and occupational therapists from the rapid response team, working on a rotational basis. This ensures staff have expert knowledge of the ability and skill mix within the rapid response team to manage clinically complex patients, allowing them to plan safe and effective treatment alternatives in the community.

Results and benefits

From the beginning of April 2015 to the end of June 2015 the in-reach team have facilitated 110 discharges; with 82 patients supported by RRT and 10 patients discharged to a step down bed at South Bristol Community Hospital. A further 18 patients were discharged to other services.

  • Estimated average saving in bed days per patient - 3
  • Cost of bed day (approx.) - £400
  • Bed cost savings made in total (based on 110 discharges) per quarter - £132,000
These costings are based on an average saving of three bed days per patient, however estimated discharge dates can be subjective and therefore bed day savings are difficult to calculate accurately.

Of the patients discharged it was perceived that some may have required longer than three additional bed days if support was not available on discharge and that support offered by the rapid response team may also reduce rates of re-admission; however this perception is anecdotal rather than proven at present.

Overcoming obstacles 

The scheme is limited when it comes to out of area patients, as the team is currently only able to assess and provide support on discharge for patients registered with a Bristol GP. Due to the locations of the hospitals the team routinely encounter patients from South Gloucestershire and North Somerset who would potentially be suitable for this service, but are currently ineligible.

There are some issues around the perception amongst clinical staff of what the rapid response team can manage in the community, with understanding of this varying across different wards. This is improving with time and experience and plans are in place to further raise awareness through informal education sessions and case-by-case discussions at an advanced level.

The rapid response team fully support the in-reach service and are able to be flexible with capacity across the city to accommodate the facilitated discharges. However the needs of these patients need to be balanced against referrals from the community for prevention-of-admission services.  

There are limitations in the availability of rapid step down beds at South Bristol Community Hospital.

There have been some issues with discharge planning, particularly the ability to restart packages of care quickly, arrange medications and secure transport.

Takeaway tips

  • Actions speak louder than words. Some schemes will succeed and some will fail, you still need to be brave and try things.
  • There are no quick wins - change takes time and there may be ‘false dawns’. 
  • You need to be prepared to continually ‘tinker’ to get things right.

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