Admission Avoidance and Community Support

Introduction

Over a number of years at IPC we have undertaken (and continue to be engaged with) a range of research and development work relating to hospital discharge pathways, admission avoidance, and capacity and demand planning. As a result we have established an in-depth understanding of the key features of ‘what good looks like’ across policy and practice.

The challenges for health and care systems are well known and of long standing, although they were thrown into sharp relief during the additional pressures associated with the Covid pandemic. The following are of particular significance:

• Maintaining system flow is fundamental to the optimum efficiency of acute hospitals.
• Extended length of stay leads to rapid deconditioning – particularly for older and frail patients – and associated poorer outcomes.
• Ensuring timely discharge of patients who no longer need hospital care demands clarity over discharge pathways.
• Understanding capacity and demand across the entire health and care system is essential in supporting a Home First strategy, particularly in commissioning recovery and reablement support.
• Assessment of ongoing needs should only take place following a period of recovery and support.
• A ‘single version of the truth’ should be owned by partners with meaningful data and metrics that monitor outcomes beyond length of stay.

Admission avoidance

Continuing problems in managing discharge pathways are reflected in acute hospitals becoming gridlocked, with ambulances queueing to book patients into Accident and Emergency departments; insufficient capacity resulting in extended trolley waits with patients treated in corridors and other spaces poorly suited to quality care; and wards unable to accept admissions without first achieving discharges. People who experience extended stays are typically those awaiting Pathway 2 (P2) discharges (rehabilitation in a bedded setting), while facilitating discharges from those P2 beds can be similarly challenging without active recovery support enabling people to regain independence and return home. For too many people, a discharge on P2 becomes a default admission to permanent residential care.

It is not only the discharge side of the equation that is critical, admission-avoidance is also vital in ensuring that only people in need of acute hospital care are admitted, and that others are supported in the community. There is a need for capacity and demand planning to embrace commissioning of new models of integrated community-based support including:

• Urgent response multi-disciplinary teams.
• Single Point of Access services supporting self-referral.
• Community therapy and equipment services.
• Community nursing and therapist support.
• Community-based intermediate care services.

So far, so familiar, but what might these principles actually look like in practice? Consider the following case study.

The case study provides a vivid example of what can be done with all the right services in place; with a community-focused approach achieving a ‘left shift’ from centralised hospital-based response, and a shared understanding of the importance of supporting independence rather than defaulting to risk-averse practices that err on the safe side and admit to hospital ‘just in case.’ Not only was the support timely, high quality and efficient, but it delivered the outcomes that the patient and the family carers valued most highly – ensuring Cynthia’s safety but protecting her autonomy and ability to remain at home. All the people involved in the support expressed their astonishment that Cynthia was doing so well at 95 and highlighted their personal satisfaction in enabling her continued support at home.

This is more than just a happy ending, and a ‘feel good’ case study to illustrate the potential of thinking, commissioning and providing services differently, it is also a very personal matter. Cynthia is my Mother; this is the story of what happened to her this week, and of our great appreciation of the support from the paramedics (who are also studying at Oxford Brookes), and from Oxford Health NHS Foundation Trust, and the Community Therapy Team.