Delayed transfers of care
Introduction
A delayed transfer of care occurs when a patient who is ready for transfer from a hospital bed to a community setting remains in hospital due to non-clinical reasons.
People who cannot leave their hospital bed and who do not need treatment:
- reduces the number of hospital beds available to other patients, reducing access to care and increasing waiting times
- puts patients at increased risk of an acquired hospital infection
- causes unnecessarily long stays in hospital for patients
- encourages low mood and reduced motivation, which can affect a patient’s health after they’ve been discharged and increases their odds of re-admission
Minimising delayed transfers of care and enabling people to live independently at home is therefore one of the key outcomes of social care.
Measuring delays in transfers of care helps understand how hospital services (acute, mental health and non-acute) and community-based care are working together and is an indicator of the effectiveness of the interface within the NHS, and between health and social care services.
Costs
The House of Commons Briefing Paper (7415, December 2015) states that delayed transfers of care are costly for hospital trusts because they: have to pay to provide places for patients who are ready to leave, have insufficient beds to carry out scheduled, elective procedures and lose income when elective procedures need to be cancelled. Monitor and the Trust Development Authority (TDA) estimated that in the year to 30 September 2015, delayed transfers of care cost hospital trusts £270m across the UK.
A report published by the National Audit Office (NAO) (May, 2016) estimates that 2.7 million bed days are lost due to the delayed transfer of older patients no longer needing hospital care. The NAO estimates that increasing social care services for older patients after hospital discharge could cost around £180 million a year but would increase the potential savings of £820 million that would arise from discharging patients earlier.
Key inequalities and risk factors
The Kings Fund gives several reasons for delayed transfers:
- patients can often be delayed waiting for onwards health care, for example at a community NHS facility such as a community hospital
- they can also be delayed by waiting for social care to be arranged at a residential or nursing home or for a care package at home to be developed
- patient assessments are not completed before they recover due to the complexity of agreement from a multidisciplinary group of acute clinicians, social workers and other care workers
- agreeing that a patient is fit for discharge, as well as acquiring a care package and getting paperwork completed on time, can be a difficult process
Effects on mobility can be particularly keenly felt by older patients. A wait of more than 2 days negates the additional benefit of intermediate care, and 7 days is associated with a 10% decline in muscle strength for people with frailty for whom muscle weakness is a defining characteristic.
Nationally, between 1987 and 2015, the average daily number of available hospital beds reduced by 54% to 136,000. Delayed transfers of care reduce the availability of specialist beds for people with learning disabilities, mental illness and for longer-term geriatric care (House of Commons Briefing Paper, 7415, December 2015).
Delayed transfers of care delay appointments for patients for planned, elective procedures prolonging care and support which would otherwise be avoidable.
Facts, figures and trends
Key to the issue of delayed transfers of care is the growth in the local population, and in particular, among older age groups. Am in depth analysis and projection of this growth can be found here.
National figures on delayed transfers are collated in NHS England Annual Statistics Reports. Recent data for Bracknell Forest shows that the average rate of delayed transfers of care is comparable to the England Average and lower than the South East Region. Delays have increased since the previous year, although the rate of increase in Bracknell Forest is slower (rate increase of 2.6 compared to 3 nationally). This data suggest that while delayed transfers of care are a national issue, they are a key priority for action in Bracknell Forest.
Average daily rate of Delayed Transfers per 100k population
So far in 2017 we are seeing a fairly steady number of delayed transfers of care. We did experience a temporarily rise in delayed days caused by social care factors in March due the unavilability of certain services during a procurement exercise. While the trend has stabilised again, this ‘blip’ does show how quickly delays can rise if there is even the briefest change in supprt availability.
Delayed Transfers of Care (Days) by Month in 2017
Prevention and management
There are a range of services within Bracknell Forest that can deliver or support intermediate care functions.
Key to reducing delayed transfers of care is the Community Response and Reablement Team, which delivers intermediate care in people’s homes and own communities as well as in the local bed based service in the Bridgewell Centre. Services such as community hospitals, Rapid Access Community Services, Community Health Clinics, specialist nurses, GP services, district nursing, physiotherapists and social care teams also have a role in intermediate care.
A new operating model will work on the concepts of “meeting immediate needs then assess” for community referrals and a ‘discharge to assess’ concept for referrals received from the hospital. Thsi is because decisions about rehabilitation and long term needs are better made when the person is in a settled and or familiar environment. A multi-disciplinary triage service will receive referrals, with this team determining the onward care decision. The service will work with health partners in the acute setting to ensure incoming referrals concentrate on levels of function and medical interventions rather than a recommendation by the acute sector on what service needs to be delivered.
In addition, a new Domiciliary Care Model will commence in August 2017. Support at home and in the community will bedelivered with greater focus on an Individual’s outcomes, with a significant emphasis on regaining, preserving or achieving an optimal level of independence and promoting community access and integration with health services; thereby delaying increases in need, and reducing dependency on paid support.
A recent development is our British Red Cross “Home from Hospital” service – offering up to 6 weeks practical support for people leaving hospital. This is ommissioned through our Better Care Fund. The service takes a person centred approach with patients, working collaboratively with them to enable them to achieve their Top 3 Goals. The first home visit is completed by a member of staff who will discuss with the patient what they would like to achieve and how the service can enable them to do so. From this conversation the Top 3 Goals are set and a support plan is put in place so that both the patient and member of staff/volunteer know how best to work together.
A continuing challenge exists in being able to source Domiciliary Care workers in the rural areas of the Borough including Winkfield Row, Ascot, Warfield Park and Binfield; as well as male carers when the client expresses a preference on the gender of the carer. The re—generation of Bracknell Town Centre, while an significant positive boost for Bracknell Forest in general, is likely to result in a shortage in the domiciliary care workforce, as prospective employers in the new town centre seek to recruit up to 3,500 new jobs. Work to recruit more care workers int local agencies and organisations is a priority.
Want to know more?
A report of investigations into unsafe discharge from hospital (Parliamentary Health Service Ombudsman, 2016) – highlights 3 issues for particular attention for successful discharge, namely; checks of mental capacity and offer legal protections for those who lack capacity, increased involvement of carers and relatives in discharge planning, better co-ordination within and between services
As part of individual assessments, health and social care professionals also consider the use of assistive technology solutions to ensure that people have personalised support for independent living.
Discharging older patients from hospital (National Audit Office, 2016) – an exploration of the underlying issues affecting the timely discharge of patients deemed ‘medically fit for discharge’ but who remain in hospital, exploring issues in health and social care, capacity in the system, an argument of costs of impact and value of investment and a range of recommendations for system leaders and services commissioners.
Joint Commissioning Strategy for Intermediate Care 2012-2015 (Bracknell Forest Council and Bracknell and Ascot Clinical Commissioning Group, 2012) – sets out the model for intermediate care in Bracknell Forest which seeks to avoid unnecessary hospital admission, reduce unnecessarily long hospital stays, help patients to improve and maintain independence and reduce readmissions to hospital following discharge.
National framework for NHS continuing healthcare and NHS funded nursing care (Department o Health, 2012 updated 2016) – sets out the principles and processes of the National Framework for NHS continuing healthcare and NHS-funded nursing care (the National Framework) incorporating responsibilities for transfers of care.
Transition between inpatient hospital settings and community or care home settings for adults with social care needs (NICE, 2015) – guideline which includes recommendations on person-centred care and communication and information sharing, care planning, establishment of a hospital-based multi-disciplinary team, recording medicines and assessments and regularly reviewing and updating the person’s progress towards discharge, the role of the discharge coordinator and training and development for people involved in the hospital discharge process.
Preventing excess winter deaths and illness associated with cold homes (NICE, 2016) – sets out arrangements for people who are vulnerable to the health problems associated with a cold home who will be discharged to their own home from a care setting to have a discharge plan that includes actions to ensure their home is warm enough.
Transforming urgent and emergency care services in England (NHS England, 2015) – good practice for commissioners and providers of community health services to work together to convert urgent care into planned care by developing community nursing, rapid response and provisions for early supported discharge.