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Collaborative care

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VOL: 97, ISSUE: 46, PAGE NO: 38

John Mills, RGN, is operations manager, Collaborative Care Services, Essex Rivers and Tendring Primary Care Trust

In 1998 the waiting list for community care funding meant that elderly and vulnerable people in north Essex were waiting on average seven months for care packages to be provided before discharge could be arranged. The effects on patients of these prolonged and unnecessary hospital stays were:

In 1998 the waiting list for community care funding meant that elderly and vulnerable people in north Essex were waiting on average seven months for care packages to be provided before discharge could be arranged. The effects on patients of these prolonged and unnecessary hospital stays were:

- Increased dependency;

- Loss of confidence;

- Depression;

- Loss of choice and control.

The effect on the NHS was that the national policy agenda to reduce waiting lists, respond to emergency admissions, and manage care within a financial framework were seriously compromised. The patients' deterioration and their increased levels of dependency on discharge were also resulting in more expensive long-term care.

In February 1998, health and social services in north Essex jointly decided to commission a pilot project which would result in patients being discharged from hospital as soon as they were medically fit. The project was designed for Essex Rivers Healthcare NHS Trust and north-east Essex social services, as the trust has the advantage of being an acute and community trust and the social services department has a particularly high demand for services at home for older people in the 75-84 age range. On July 1, 1998, Collaborative Care was launched at Colchester General Hospital.

The pilot works on the basis that:

- Prolonged hospital stays result in the loss of confidence and self-esteem;

- Elderly and vulnerable people are prone to hospital-acquired infections;

- Assessment of long-term care needs should be carried out when the patient has had the opportunity to reach their maximum rehabilitation and recovery potential;

- Home care at the early stages of recovery can promote dependence unless a rehabilitative approach is taken, where the patient is encouraged and enabled to regain independence;

- Acute services are specialised and are most appropriate for patients who require the supervision of a specialist consultant and/or the provision of highly technical care.

Patients' inclusion in the project follows agreed criteria, but with recognition of the need for flexibility. Identifying patients suitable for the scheme within 48 hours of their admission to hospital is essential. The consultant notifies staff of the expected date of discharge and planning then begins.

The Collaborative Care multidisciplinary team meets to discuss all referrals. A key worker, with the therapeutic skills necessary to meet the specific needs of that patient, is agreed at this point.

The patient is given an information leaflet about the scheme. The Collaborative Care administrator is notified by the key worker of their expected date of discharge and the likely support which will be required and reassessment dates are confirmed.

The administrator rosters the support worker to ensure provision of the care package. Transport arrangements are then made for the expected date of discharge, and if the patient is medically fit on that date they go home without delay.

The following areas have been monitored to establish the impact of the project on the trust and social services department:

- Budgets;

- Bed occupancy levels;

- Elective surgery targets;

- Number of clients supported;

- Number of clients requiring ongoing care;

- Number of patients discharged from the service;

- Levels of independence achieved as a result of the service (random Barthel scoring at week 12);

- Review of readmissions for same condition;

- Review of readmissions for different conditions.

On the strength of ongoing audit, the pilot became a funded service in May 2000. The Collaborative Care service is accessible from any ward in the trust: patients must have the potential for rehabilitation. There is also a home support service accessed through A&E, district nurses or GPs; this runs as a 10-day support system to avoid hospital admission.

Community social care is accessed via a social worker, after a needs assessment. While social services are seeking a provider for social care, the trust provides patients at home with the relevant support.

We also provide a home trial service, where patients have the opportunity to return to their own homes for between 24 and 72 hours with planned support, to review the viability and safety of them returning home permanently.

Older people have made it very clear what they want from health care providers. It includes a seamless service with all agencies and professionals working together. They want better support on discharge from hospital and they see institutional care as a last resort. The Collaborative Care service is helping to meet these needs.

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