Frank’s journey: How a new guideline can help staff improve experience of transfer of care from home to hospital to home

Featured article - 09 December 2015
Dr Olivier Gaillemin, Consultant Physician in Acute Medicine, Salford Royal NHS Foundation Trust

Head-shot of the author

We have all met "Frank". Frank has had a torrid time of it lately. He was well enough to have an elective operation but on return home was struggling and losing confidence as a result. His niece was also concerned, unsure as to whether he was deteriorating or on the mend. Changes to medication on discharge had not been clearly explained to Frank or his formal carers and subsequently Frank was readmitted to hospital under the care of a different team. In A&E, Frank was very anxious and muddled which was distressing to him and to his niece.

People like Frank with both complex health and social care needs, often alongside impaired memory, are core users of hospitals. They are a vulnerable group. This is true particularly at times of transition from home to hospital and back. The destabilising move itself is easily exacerbated by the potential for miscommunication as multiple teams become involved in care across multiple clinical "boundaries".

I was proud to sit on the guideline committee that helped draft the NICE guideline on transferring from home to hospital and back, published last week. The guideline, developed by the NICE Collaborating Centre for Social Care - a partnership led by SCIE, looks to ensure that people with social care needs receive the support they need when admitted to and returning from hospital.

People’s experience of these transitions is a key indicator on how well integration is working. Along with ensuring systems are in place for the multi-disciplinary group to better communicate together, good communication with Frank, his carers and his family is also crucial. Frank will at times require hospital assessment and care but unnecessary prolonged stays can too easily have adverse consequences as can a precipitated, poorly planned discharge.

The focus on our Frailty Unit has moved from ensuring rapid multi-disciplinary assessment and treatment to initiating discharge planning from the outset. Clear communication is at the centre of planning. This includes an enhanced discharge summary and liaising verbally with community teams and family in anticipation of discharge. Evaluations of this approach have proved positive both with regards to GP and patient satisfaction as well as reducing unnecessary readmissions.

I really believe in what the guideline committee has done. This is a common sense guideline: do the simple things well and keep people like Frank involved in the process.

The result? Frank’s anxiety reduces and his niece is reassured and knows whom to turn to if she has questions. Let’s make sure that we use these guidelines. They’re for all those in the caring professions, not just those working in health.

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