I have been leading an admission avoidance and early supported discharge team for the last eighteen months in Mid Essex. The admission avoidance has been challenging but most member’s of the public and fellow clinicians understand admission avoidance. However, try to explain to other clinicians that you want to take the patient out of hospital earlier or tell the ward manager that the patient will be safe at home without their teams 24 hour care and devotion and that is a whole new challenge.
However three weeks ago an ECIP team (emergency care improvement programme) came to the hospital to facilitate MADE events (multi agency discharge event). They also suggested that we start to trial home to assess which I had been trying to set up for the previous four months and although it did take the first two weeks of the event to prove it, last week we saw a system change.
One example of this change was when I visited a ward that had an end of life patient who had been told he would not be receiving any more treatment as his disease had progressed. He was then told that he would need a continuing health care (CHC) assessment which could take up to three weeks in hospital. The young man lived at home with his parents who were not aware of the change in his condition. The sister of the ward asked me if I could get his CHC assessment completed sooner as he wanted to go home to tell his parent’s his prognosis. I went and spoke with him and he said that he had carer’s at home twice a day already and a profiling bed. He said that he was desperate to go home and on discussion with him, his preference was to go home without delay. I spoke to the carer’s who said they would increase the care package but would need notification from Social care that this was agreed. I spoke with social care who said he would only be allowed to go home with the twice a day care package but they would visit him at home to assess the increase.
So we put the wheels in motion, the sister on the ward organised for the anticipatory medication to be written up and booked the ambulance, so he was able to go home that day with the twice a day care package, the admission avoidance team greeted him at the door and filled in the care package gaps for the initial 24hrs until the care provider took over. The team completed a CHC fast track the next day and informed the local hospice team and district nurse team so that they could go in and offer continuing support over the weeks to come.
This was a really good example of joined up working but more importantly the patient was able to go home to tell his parents that he only had weeks to live in a place where he felt comfortable to do so.