Hospital Discharge – Meeting the challenge, improving outcomes

1. Hospital Discharge – Meeting the challenge, improving outcomes Philippa Russell E-mail: prussell@ncb.org.uk Ref: SCOC Hospital Discharge Leeds Sept 10 2015

2. ‘From the pond to the sea?’ Understanding the carers’ perspective on hospital discharge.

3. Demographic change – a challenge for the NHS and social care • 5.4 million carers in England • Number of people over 65 with care needs projected to grow from 2.5 million in 2010 to 4.1 million in 2030.. • 700,000 people with dementia • 33% of older people have at least one long-term condition, with numbers of people with three or more conditions likely to double by 2018. • 78% (of all ages) carers have significant depression or anxiety levels and feel their own health is affected by caring.

4. A changing NHS - Messages from the Five Year Forward View – and NHSE Carers Commissioning Support Principles • Even people with long term conditions who tend to be heavy users of the health service are less likely to spend less than 1% of their time in contact with health professionals. The rest of the time they, their carers and families manage on their own….we need to recognise that patients, their families and carers are ‘experts by experience. …………….the NHS will increasingly need to dissolve traditional boundaries and increasingly we need to manage systems, networks of care, not just organisations.’

5. A policy shift from hospital to community and home - A reminder about the anxiety of carers taking on complex care packages at home - Barbara Pointon’s ‘network of care’ for her husband Malcolm

6. Making discharge work – no unexpected readmissions if carers are fully involved and supported! • Evidence from range of studies that supporting carers permits early transfer from hospital and reduces risk of readmission. Carers Trust and others found that key factors in carer breakdowns and readmissions are: • Relationships, ‘not feeling being part of the team, valued and supported’’’ • Poor health, tiredness and interrupted sleep • High levels of intimate personal care • Frustration and lack of understanding of treatment or support. Availability of ‘navigator’ or care coordinator highly valued. • Creating the ‘expert carer’: An Australian random controlled trial found that 3-5 sessions of personal care training to carers prior to discharge (each lasting 30-45 minutes) resulted in a higher proportion of stroke patients achieving independence at an earlier stage and reduced the need for physio and occupational therapy and hospital readmissions. Carers also reported improved quality of life because they felt ‘confident and valued and understood the short, medium and long-term outcomes for the reablement programme.’ [Droes, R et al (2012)

7. Opportunities and challenges in discharge planning • Cooperation and integration – Care Act 2014, NHSE Five Year Plan, Better Care Fund and Commissioning for Carers Principles offer new opportunity to acknowledge interdependence of health and social care. • Acknowledging ‘parity of esteem’ between carers and patients [recognising that whilst carers are ‘experts by experience’, they need information, practical and sometimes emotional support in maximising the transition home]. • Understanding families’ concerns about discharge [Carers’ own health may be poor, they may be exhausted or they may already be caring for another family member]

8. Challenges in hospital discharge from the carer’s perspective! • Understanding the patient’s condition and the likely prognosis • [ ‘My husband went into a hospital after a stroke and he came out a different person. I didn’t know him, I was too traumatised to properly understand what had happened. Nobody had time to talk to me about the his – and the family’s - future.] • Insufficient time to plan the return home [She came home unexpectedly at 5.00pm on a Friday. Even the GP had gone home. I didn’t have all her tablets, I didn’t have a discharge plan and I didn’t know what to do. I couldn’t get her upstairs to the toilet on my own and she had a fall. The paramedics took her back to hospital five hours after she was discharged.]

9. Hospital discharge – it doesn’t have to go wrong! • ‘The hospital was marvellous after ‘Sue’s’ last admission. I felt in despair, I wondered how we would manage. I was offered a carer’s assessment and at first I said no, I’m not a carer! I am Sue’s husband thank you!’ • [ But then I was introduced to a volunteer on the ward (from the local carers’ centre) who sat down and talked through a lot of things with me. She told me about the Carer’s Passport. I realised that I WAS a carer! She helped me think about coping when I went home. I didn’t understand ‘reablement’ and all that but Maggie put me straight. She came to see us a couple of times after we came home, just to have a chat. I said to my friend, it’s like having an interpreter, I do feel as if I am on a foreign journey as a carer but at least I know now what our destination is – and I have my passport to remind me!’]

10. Hospital discharge: managing carers’ fears about leaving a ‘safe place’. • Care Act gives local authorities and the NHS new duties and powers with which to manage delayed discharges. • Section 58 of the Care Act statutory guidance states that patients and ‘if appropriate’ the carer should be involved in decisions about current and ongoing care and support needs. • Issuing of Notices around discharge(and aftercare, if any) can terrify carers. Important that Care Act guidance (Annex G) recommendation around local protocols and assessment notices is followed through – carer reluctance to agree to discharge from NHS accommodation often linked to anxiety and lack of information about real alternatives.

11. And an opportunity – using the Better Care Fund to improve carer support around discharge • Health and Well-Being Boards required to describe local agreed plans to support patients being discharged and to prevent unnecessary admissions at weekends. • Carers Trust survey [June 2015] found that only 9 out of 45 Health and Well-Being Boards surveyed specifically referred to carers in this section of their plans. • But some positive practice, including identifying new carers on admission; Carers Passport; Carer Emergency Card schemes; practical help in home for carers and a ‘Back Me Up’ contingency planning service to provide out of hours support if needed.

12. Hospital discharge and carers - Some blue sky thinking! • The Care Act 2014 [and NHSE Five Year Forward View] – unique opportunity to integrate health and social care and improve patient/carer experience. • Partnership with the third sector to improve the experience of care – in hospital and in the community.. • NHSE Commitment to Carers and ‘Experts by experience’ – ensure that carers are involved in discharge planning from the moment of admission!