This article explores how involving older patients in their care by closing care gaps identified by the national Adult Inpatient Surveys can make the transition home safer. This is a Journal Club article and comes with a handout that you can download and distribute for a journal club discussion.
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The Covid-19 pandemic has forced change by minimising hospital stays, which has made the transition from hospital to home more difficult for older people. Post-discharge adverse events in older patients can be reduced if those individuals are better prepared for the hospital-to-home transition. This article discusses identified gaps in care during this transition and considers the importance of patient involvement. Good communication and facilitating patient engagement can help to reduce the effects of these care gaps for patients and their relatives or carers, as well as staff.
Citation: Moore S, Schofield J (2022) Transitions of care: helping older people to return home from hospital. Nursing Times [online]; 118; 10.
Authors: Sally Moore is patient safety research nurse; Jane Schofield is patient safety research allied health professional; both at Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research.
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Access to healthcare has been particularly difficult during the Covid-19 pandemic. This has increased the need for us to ensure that our older patients are medically fit for discharge and prepared to support themselves safely when they are discharged home.
The transition period from hospital to home has always been problematic, as the goals of the hospital staff can sometimes differ from the needs of the patient once at home (O’Hara et al, 2021). Problematic areas include:
- Staff encouraging patients to get up and move, versus the risks of a fall and harm;
- Staff managing medicines for patients in hospital, with patients then needing to self-manage them at home.
In the past 10 years, inpatient numbers have increased by 21% (Care Quality Commission (CQC), 2021), causing pressure on the NHS bed base and leading to shorter hospital stays for older patients. This, combined with fewer staff, a reduction in beds and a move to care in the community (Friebel et al, 2019), means that the ward clinical teams must focus on getting patients medically fit and discharged as quickly as possible. We might think that patients, once discharged, are received into primary care (Baxter et al, 2020), but this transition does not always happen as anticipated, and can become the cause of a gap in care through which patients can fall.
Before the Covid-19 pandemic, emergency readmissions to hospital for older patients were increasing year on year (National Audit Office, 2018), and around 30% of all readmissions for this age group had been estimated to be avoidable (Auerbach et al, 2016). For older patients especially, the move from hospital back to their own home can be difficult. As many as one in five patients have experienced an adverse event within three weeks of discharge, 77% of which caused harm (Williams et al, 2015); some of these will lead to readmissions (Friebel et al, 2019). Nurses on older people’s wards are familiar with seeing a decline in the health of patients who become ‘ward regulars’ (British Red Cross, 2018).
What are the care gaps?
Some of us will already be aware of the care gaps some of our patients fall through and will feel that everything has been done to close them. Some of us will have developed workarounds – for example, adjusting patient expectations or making direct contact with known members of community teams (Baxter et al, 2020). Some of us might not even realise the gaps are there and assume we have handed over our patient safely to primary or community care.
Evidence that gaps exist can be seen in the results of the Adult Inpatient Surveys for 2019 (CQC, 2020) and 2020 (CQC 2021), which identify patient discharge from hospital and integrated care as an area requiring improvement. This article focuses on the 2019 results, as those from 2020 reflect experiences during the Covid-19 pandemic rather than usual practice. We were past the peak of disruption in care when it was conducted in November 2020, but people were still not vaccinated and bed occupancy with patients who had Covid-19 was high enough for the CQC to compare results between patients who had Covid-19 and those who did not. As a result of the unusual circumstances, the CQC changed the questionnaire for the 2020 survey, so the results are no longer directly comparable with previous surveys; they do, however, indicate that the care gaps described in 2019 still exist (CQC, 2021).
The 2019 survey results showed that:
- 40% of respondents felt they were not given any written or printed information about what they should, or should not, do after leaving hospital;
- 38% of respondents felt they had not been told by a member of staff about any danger signals they should look out for after they went home;
- 35% of respondents did not always understand what their take-home medications were for;
- 44% of respondents did not know the side-effects they should look out for;
- 35% of respondents were not always given printed information about their take-home medications (CQC, 2020).
The 2019 survey also identified frailty using questions designed to reach different sections of the community. Responses showed that:
- 39% of respondents with frailty had not been told who to contact if they were worried about their condition or treatment after leaving hospital (15% more than respondents without frailty);
- 30% of respondents with frailty replied ‘no’ when asked if staff had discussed with them their needs for further health or social care support after leaving hospital – this compared with 19% of respondents without frailty;
- 70% of respondents with frailty discussed with staff the need for additional equipment or adaptations needed to their home to help them recover after leaving hospital (this figure was 81% for respondents without frailty);
- 79% of respondents with frailty reported that the care and support they expected after discharge was made available when they needed it (13% more than the figure for respondents without frailty) (CQC, 2020).
These results reveal that there are significant care gaps through which patients can fall, particularly around transitions from hospital to home. Box 1 gives an overview of care gaps that can lead to a readmission or safety incidents after discharge.
Box 1. Care gaps that can lead to patient readmission or safety incidents after discharge
- Understanding what to do/not do once home
- Knowing and recognising when things are not right
- Knowing and recognising when and where to ask for help
- Having realistic expectations of the help and/or equipment available once at home and making sure these are met
- Understanding any changes in medication, the reasons for medication and any possible side-effects
Source: Interpreted from Care Quality Commission (2020)
Another perspective on the issue
Back in 2012, Compassion in Practice, co-written by the then chief nursing officer for England, Jane Cummings, and Viv Bennett, then director of nursing at Public Health England, stated that “all the people in our care need to have a voice, choice and control” about what happens to them (Cummings and Bennett, 2012). This was set out as one of the fundamentals of care delivery for all staff, not just nurses. These values are reflected in the section of the Nursing and Midwifery Council’s (2018) Code, entitled ‘Prioritise People’, which emphasises the need to treat patients as individuals, to listen to them and respond to their concerns, as well as assessing and responding to physical, social and psychological needs.
The NHS Long Term Plan suggests we need a more fundamental shift in how we work alongside patients and individuals to deliver more person-centred care, recognising that the importance of “what matters to someone” is not just “what’s the matter with someone” (NHS, 2019). Since individual preferences differ, ensuring choice and sharing control can meaningfully improve care outcomes. Many trusts’ visions and values support The NHS Long Term Plan to make care more patient centred, but how can it happen in practice and how can it be managed at ward level?
Giving control back to patients
It is important to understand how involvement in care works for patients, and what both staff and patients must do for this to happen. Murray et al (2019) developed a ‘state-change’ model of involvement, following a systematic review of patient experience literature and work with a patient and public involvement panel. It explores patients’ differing needs for involvement and information, which can help us understand how to fill some of the care gaps. The model identified four types of patient involvement (including carer involvement):
- Desired non-involvement;
- Information acting (passive and active);
- Challenging and chasing;
- Autonomous acting.
This may or may not be because of deliberate choice or action on the patients’ part, and it is important that nurses are aware of this.
Desired non-involvement is when the patient chooses to hand over all responsibility to care staff or carers. Some patients are happy to let decisions be taken in their best interests; some will even continue on a care plan without questioning it, despite having doubts about it being right for them.
For older people with complex health problems, it can be difficult to question health professionals. They generally have a lot of implicit trust and respect for all professionals (Meyer et al, 2012) and, sometimes, may feel it is not right to question professional authority. On a busy, short-staffed ward, it is easy for staff to see these patients as ‘no trouble’ and to accept this handover of responsibility.
Where desired non-involvement can be identified, the whole team should encourage the patient to:
- Become involved;
- Understand what they need to do to support a safe discharge home.
Information acting – passive
Passive information acting is when patients are willing, and actually want, both to give and receive information, but they tend to wait for the ‘right time’ (Murray et al, 2019). They do not want to disturb or distract staff, but they want to ‘tell’ and ‘know’ things about themselves and their care. These patients might also be seen as ‘no trouble’, but they are often worried about being a nuisance, as they can see that staff are busy (Nyborg et al, 2016). We need to be aware of how we are perceived by patients and make opportunities available for them to both give and receive information.
When a patient desires non-involvement or is a passive information seeker, care needs might be missed. These unmet care needs can lead to readmission (Murray et al, 2019).
Information acting – active
Active information acting is a two-way information exchange between staff and a patient/relative/carer, when the latter will engineer times to talk to staff. This can vary from asking questions during ward rounds, asking to talk to a member of the nursing team or attending their own multidisciplinary team meeting. Being active in seeking information can be quite hard for patients to do, especially with the professional barriers we often have to erect to get work done – for example, when a ward is very busy or short staffed, patients may notice and not like to cause more work.
Ball et al (2014) showed that the things most often left undone by nurses at the end of a shift were “comfort/talk” with patients (66%) and “educating patients and family” (52%) so, despite actively seeking it, patients might still struggle to get the information they need. With long-term staffing problems now exacerbated by the Covid-19 pandemic (The King’s Fund, 2021), staff do not always have time to deliver anything but the most essential care.
When patients and/or relatives/carers are not able to communicate with us, or when we unintentionally professionally exclude them for any reason, they may start displaying different behaviours, such as autonomous acting and challenging and chasing. Patients can also start to do their own thing (Murray et al, 2019), which can cause problems with adherence to care plans and medication post discharge (Mulhelm et al, 2013); this, in turn, can lead to readmission (British Red Cross, 2018).
Challenging and chasing
Challenging and chasing is familiar to ward teams and is usually displayed by relatives or carers on behalf of a patient, especially when the patient is an older person. They will ask questions: they want to know what is happening or why things are not happening. With restrictions on visiting during the Covid-19 pandemic, it was not easy to act on behalf of a relative or friend, and there was a greater danger of large gaps in care occurring when a patient did not wish to be involved in decisions or was a passive information seeker.
Autonomous acting can occur when a patient is excluded from decisions and information about their care. When acting autonomously, patients will make their own decisions about their care after discharge without the information to support that decision. Examples include:
- A patient who does not understand the need to keep mobile may choose to stay seated or in bed, which can lead to deconditioning;
- A patient might follow an old medication list because they did not get, or did not understand, the information they needed to understand a new prescription (CQC, 2020; Murray et al, 2019);
- Relatives or carers might use equipment that has been prescribed for someone else or is not fit for purpose, or they might think a treatment is not necessary and stop it.
All these actions have the potential to lead to a safety incident in the home or a readmission.
Understanding the different types of patient/carer involvement and seeing how non-involvement can lead to behaviours that could be dangerous to a patient after discharge gives us an opportunity to:
- Change our approach and encourage patients to be involved in, and share, decisions about their care;
- Close some of the care gaps that can be the start of a cycle of readmission.
Studies by Hardicre et al (2021) and Murray et al (2019) have shown that patients do want to be involved in decisions about their care and will react positively when included. Unfortunately, with the Covid-19 pandemic, increased levels of sickness and up to one in 10 nursing jobs vacant (NHS Digital, 2022), it is difficult to find time to step back and reflect on the care we are delivering to patients on a daily basis.
Understanding that the lovely patient who is ‘no bother’ might desire non-involvement or be a passive information seeker can make a difference to our professional activity. We can make small changes in how we see and communicate with our patients to encourage empowerment.
Partners at Care Transitions research by Yorkshire Quality and Safety Research Group involves trialling interventions to support older patients transition between hospital and home. Results will be shared once the trial is complete. In the meantime, ward staff might consider making some of the small changes listed in Box 2.
Box 2. Tips for nurses to encourage patient empowerment
- Understand patients’ different communication needs and adapt your communication to help empower them and give them the confidence to question care
- Use the time when delivering routine care to encourage patients to think about any questions they might have for the team
- Let patients know when a ward round will happen so they can prepare questions
- Be available to advocate for patients during ward rounds where possible
- Support patients to write down questions they would like answered
- Allow patients to practise with new or changed medications before they are discharged
- Use a ‘teachback’ technique when discussing care with patients
- Make sure the patient and relatives/carers are involved in decisions about themselves, as part of the discharge process
- Encourage the whole ward team to get involved in the patient knowing and
- Encourage movement and a greater level of independence where feasible
Source: Yorkshire Quality and Safety Research Group (2022)
Health professionals have shown amazing resilience and an ability to problem solve during the Covid-19 pandemic. A blog published by The King’s Fund states that we have already “seen changes in the relationships between those receiving care and those delivering it. There have been more mutual, more respectful and more understanding relationships with patients based on shared decisions” (Bailey and West, 2020).
Has the absence of visitors and carers on our wards meant that patients have had to become more involved in their care? Have the changes forced on us by the pandemic closed some of the gaps in care identified in the 2019 Adult Inpatient Survey? The 2020 survey showed that we may have made some improvements despite – and possibly because of – the pressures Covid-19 has put in our way (CQC, 2021).
We know from national inpatient survey data that we are not always meeting patients’ needs around their transition from hospital to home, and that care gaps emerge as a result. All healthcare staff, especially nurses, showed an incredible ability to adapt and deliver safe care during the Covid-19 crisis. The changes forced on us by the pandemic are beginning, already, to close some of the gaps in care identified in the CQC’s 2019 inpatient survey.
The improvements we have seen may be temporary but empowering patients through greater involvement in care is a fundamental part of ensuring safety for patients.
- Many hospital readmissions are estimated to be avoidable
- The national Adult Inpatient Surveys highlight significant gaps in patient knowledge around the discharge process
- Empowering patients to know more about their care can improve patient safety and reduce readmissions
- Patients seek information about their care in different ways
- Staff need to be supported to understand what it means to fully involve patients in their care
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