Innovative nurse-led Kent company Hilton Nursing Partners has developed and launched a service aimed at reducing residential care admissions for patient’s in an acute hospital assessed for requiring residential care.
Already successfully piloted with Kent County Council social services and now being rolled out nationally the service called Home to Decide is a nurse led intensive programme of holistic support and assessment delivered in a patients own home. The level of support is continuously reviewed, starting at 24 hours per day, but reducing as the patient shows confidence and ability to function independently.
The pilot covered five patients, four of whom had been assessed as requiring residential care, and one of whom who had been assessed for a step down bed. Based on hospital discharge experience, it was anticipated that a third of patients could remain independent at the end of the service. In fact, all five were able to remain at home, and all five continue to live independently.
Maintaining patients at home and connecting them into community support networks can be expected to deliver better patient health and wellbeing outcomes. The commissioner’s benefits from the service are significant. The average hospital stay for the five pilot patients was 44.2 days, which implies that the service can reduce delayed discharge days. Most significantly the average cost saving for the five patients is approximately £23,000 increasing by £228 per day. On an annualised basis, this would represent a saving of £86,000. Not to mention the £562 per week average cost of residential care.”
Ann Taylor, CEO of Hilton Nursing Partners says: “Home to Decide was developed as a result of recognition that acute hospital assessment underestimate the patient’s capabilities. The pressure on residential places for discharged patients can mean patients remain in hospital as DTOC’s (Delayed Transfer of Care) resulting in muscle wastage, loss of confidence and potentially creating a greater level of dependency.
“The moment one patient said to me ‘I never thought I’d come home’ was joyful but heart breaking at the same time. No one should ever feel like they aren’t in control of their own destiny no matter how old they are.”
Hilton Nursing Partners were called to aid husband and wife team both admitted to a local hospital. At 88 the wife suffered a stroke but her husband of 97 and suffering from dementia found himself injured after falling whilst rushing to her aid.
Ann continues: “Once a neighbour had raised the alarm the focus was to treat the wife whilst placing the husband in a community bed. This was an incredibly stressful prospect for both. The husband became difficult to manage as his anxiousness grew and his wife was growing more eager to care for her husband. The only solution was to transfer him to the same hospital allowing them to be together. Principally a great solution but practically not beneficial for the hospital with a bed now unavailable for the duration of his wife’s admission of seven weeks.”
Husband and wife, Connie and Fred*, were keen to go home and with Fred lacking capacity to be home alone, both were assessed in hospital as requiring residential care. This is where Hilton Nursing Partners intervened with their Home to Decide model of assessment and support.
Rather than forcing a decision, or forcing people into a corner, the principle is that people return to their own home and are supported to recover whilst deciding rationally what might be best for their future.
Ann continues: “In this instance Connie wanted to care for her husband and they both wanted to go home. Our responsibility was to aid that process and ensure they both settled back into their routine without difficulty. The best bit for us is the patient is empowered to aid his or her own recovery. From three days of day and night support they only required twice daily visits and after two weeks no assistance was required. We continue to monitor with a monthly visit or phonecall and now the rapport is so good it’s like a good catch-up with an old friend.”
Working with the NHS and Social Care Commissioners Hilton Nursing Partners successfully deliver safe, timely and supportive hospital discharges, patient assessments and patient recovery programmes via nurses, therapists and nurse led personal nursing assistants with a proven track record in freeing hospital beds, as well as reducing re-admissions and on-going social services support.
*names have been changed