Anticipatory care is needed in care homes to reduce unplanned hospital admissions. This initiative won the award for Care of Older People at the 2016 Nursing Times Awards
Citation: Rushton J, Roberts L (2017) Reducing unplanned admissions to hospital from care homes. Nursing Times [online]; 113: 9, 42.
Author: James Rushton is clinical nurse associate based at North Staffordshire and Stoke-on-Trent Clinical Commissioning Group; Leslie Roberts is integrated service manager for end-of-life services, intermediate care and specialist services at Staffordshire and Stoke-on-Trent Partnership Trust.
- This article has been double-blind peer reviewed
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In 2015, North Staffordshire and Stoke-on-Trent Clinical Commissioning Group (CCG) identified a problem with unplanned hospital admissions from care homes. Care home staff suggested that delays in obtaining an early clinical review followed by rapid provision of wider interdisciplinary support were a key factor leading to avoidable unplanned hospital admissions. They also reported feeling disconnected from the wider health economy and being left to ‘just get on with it’, leading to frustration and reduced job satisfaction.
Staffordshire and Stoke-on-Trent Partnership Trust had an established intermediate care team (ICT) led by nurses and physiotherapists, who perform advanced roles such as health assessment and independent prescribing.
ICT practitioners reported that they played a reactive role in care homes, as only GPs could refer to the team and referrals often arrived too late for interventions, leading to potentially avoidable hospital admissions. They suggested that lack of confidence in managing deteriorating residents among care home staff, exacerbated by a lack of support from core NHS services, contributed to the number of hospital admissions.
We identified the 18 care homes with the highest number of non-elective hospital admissions by volume and proportional to the number of beds. Clinical audit of admissions confirmed that up to half of admissions from care homes into the local acute trust had the potential to be avoided with early ICT intervention.
In response, North Staffordshire and Stoke-on-Trent CCG created a rapid access service for 18 care homes (nursing and residential care) using the trust’s ICT. The purpose was to reduce unplanned admissions from care homes with high admission rates and improve the quality and experience of care for residents. The scheme was piloted for six months from March 2015.
Pilot care home staff from the 18 homes received an educational package targeting key clinical issues, including signs of deterioration and end-of-life care. The education was delivered by the ICT team to promote proactive clinical management and to engage care home staff with the harm-free care and hospital admission prevention agenda.
After completing the education package, care home staff could directly request an ICT review for residents with the expectation that this would occur within two hours between 9am and 10pm, seven days a week.
Weekly automated updates of admissions from care homes were sent to the ICT team so that they could challenge homes where hospital admissions had occurred without an ICT referral. The team also made a daily call to each of the 18 homes to check whether staff had any concerns about residents and to facilitate early
identification of individuals who may require a clinical review – including wider interdisciplinary team support in the community. Monthly audits of patients admitted to hospital from targeted care homes were used to develop the pathway by identifying gaps in care leading to admission, as part of a ‘Plan Do Study Act’ improvement cycle.
During the pilot, there was an 11% reduction in non-elective admissions and by November 2015, the scheme had been extended to a further 17 homes. Between April 2015 and November 2016, there was a 26% (n=350) reduction in admissions. The average cost of each admission from local care homes is £2,265 so the approximate cost saving was £792,750. The mean length of stay for each admission from a care home is 6.7 days, so 2,345 bed days were saved over eight months.
In addition to its effect on healthcare costs and capacity, admission of care home residents to hospital is associated with a reduction in quality of life, functional deconditioning and increased mortality. This key message was relayed to care home staff to help them engage with the project and give them the necessary motivation to take all reasonable steps to prevent hospital admission.
Implications for practice
- The care home population is becoming increasingly complex and NHS services need to ensure care homes are appropriately supported
- Care home residents have a higher risk of admission to hospital compared with the general population
- Community services need to provide responsive, proactive anticipatory care with an emphasis on community based interventions
- NHS services need to identify homes with higher than expected numbers of unplanned hospital admissions