Managing Transitions between Care Home and Hospital

Managing Transitions - Projects

Sharing information to support better transitions for older people between care settings.

Tayside Y1/Y2 Project

STAGE ONE - Year 1

This project brings together 12 staff from the community (including care homes), Medicine of the Elderly and acute settings in Tayside. Our objective is to share experience and expertise across sectors to better support the health and well-being of older people during transitions between care settings.

The overarching question is this:

“How can information about an individual be carried between care settings to help staff to understand what that person needs (by way of contact) to feel safe while receiving care?”

At the first meeting the group shared experiences of transitions and the following common themes emerged:

  • The process and habit of labelling people appears in all care settings and, where it takes place, there are consequences for the care that is received. An example is of an elderly man who was labelled as ‘faecally incontinent’ when the reality was he didn’t have his glasses on and so couldn’t see the toilet.
  • Education is needed to enable staff to understand the meaning behind behaviours rather than applying their own prejudices or jumping to conclusions. One example given was of an older female patient who swore a lot while on the ward. Because she ‘looked respectable’ it was assumed that this behaviour was a symptom of (mental) illness when in fact she’d sworn all her life!
  • Staff may have insufficient knowledge of what is available locally (in terms of what other care settings may provide or not provide) to make the best discharge decisions. The picture of health and social care is so complex and the terminology so various that it is a challenge for even the hardened professional to navigate their way through.
  • Staff may also have insufficient knowledge of the needs and experience of colleagues in other care settings. Nurses working in care homes will have experienced the NHS but this doesn’t necessarily apply the other way round. Misconceptions can create barriers to effective communication.
  • Staff from different care settings need to develop more trusting relationships so that information can be more effectively shared.

So what do we learn from all this?
  • Across all care setting the issues/challenges are the same.
  • The group has a common set of values and beliefs (around person-centred care).
  • The group has a common goal (to make it better for patients).

In relation to the communication of information around transitions, we discussed transfer letters.

Jean, one of the care home managers, carried out an audit of transfer letters sent to hospitals by Tayside care homes. During the discussion of this work with staff from the acute setting she said “I thought I knew exactly what information you needed and I’ve been filling out this form for years. Now I realise that it isn’t what you need at all!” Through discussion we identified that the critical transaction around the transition of a resident/patient involved not giving information but rather asking staff in the receiving care setting what information they need. The group has identified a way forward which is now being piloted.

 

STAGE TWO - Year 2

Background

The aim of the Managing Transitions project was to share experience and expertise to support older people during transfer across care settings. The project brought together staff from Dundee CHP, Secondary Care Settings and Care Homes (n=12). The group met monthly between April-October 2008.

It was recognized by the group that staff ignorance about the experience of colleagues in other care settings (both inside and outside the NHS) contributes to miscommunication and that this situation needs to be addressed. It was also recognized that there is no “one size fits all” solution to improve the experience of transitions for older people because each care settings operates slightly different systems.

The following plan is suggested for Stage 2 of this work:

Stage 2

  1. Challenging myths: build up and share “Where I Work” summaries from staff from across care settings to facilitate understanding and start to build connections.
  2. Focus attention not on trying out the protocol in different care settings (drafted in Stage 1) but in creating a ‘passport’ which might accompany the older person through their care journey. This development would build on work already carried out in Tayside to improve care for people with learning disabilities. The group involved in Stage 1 would be invited to take this work forward.
    • Need to consider where to start (e.g. with those with long term conditions?)
    • Need to gather intelligence from similar work carried out elsewhere.
  3. The Senior Charge Nurse group (that works in learning communities of 12) may use the “Who Cares?” DVD resource to support work by care teams in developing standards of care relating to dignity.

In these ways, Connect in Care may support NHS Tayside to draw together local initiatives operating successfully (Releasing Time to Care, Transforming Care at the Bedside) as well as national strategic priorities (Better Together, Leading Better Care).

This may also enable the care home sector involved to consider how national strategic NHS led initiatives may be relevant to them (e.g. Leading Better Care).

Next Steps

  1. This proposal will be presented to the Senior Nurse Leader Group at NHS Tayside in March.
  2. Invite group involved in Stage 1 to a meeting in April at which Stage 2 will be planned.

 

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