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Think home first

THE CASE FOR CHANGE

Consider the following statements:

• Imagine leaving your home and never returning to it again

• Imagine someone tells you that you are moving house tomorrow and you have no control over where you are moving to and how much it will cost.

This is what we do to thousands of older people every year. Many older people are admitted to hospital with a mild to moderate illness on top of any pre-existing conditions. We make judgements about how the person will manage when they return home based on perceptions about the person after the effects of a stay in hospital, often prolonged. We assess them in an environment that is alien and confusing.

Some Facts:

Simple Rules - R-G & SAFER vfab stuff2

We need to ensure that people are in hospital for the shortest possible time ensuring that medical and nursing needs that can only be delivered in an acute hospital setting happen there. All lower level care, recovery, rehabilitation and re-ablement should wherever possible happen in the persons’ usual place of residence.

We currently undertake assessments of a person’s ability to live their life once they no longer require acute medical or nursing care in the acute hospital setting. This is a time consuming process, comprising a number of assessments and information gathering (described by some as interrogation) that people report feels as if they are taking an exam. It adds to the amount of time people spend in hospital physically deconditioning and is a significant percentage of the days they have left in life.

We ask people to make cups of tea in hospital Occupational Therapy kitchens, walk upstairs even when they live in a bungalow or on one level in their house. We ask them intimate questions about how they manage their personal care and then decide whether they have passed or failed these tests. For people with dementia this is even more challenging, we decide based on their behaviour in hospital that they are not safe to be at home because they are wandering, or have challenging behaviour. They may just be trying to find home as they have forgotten they are in hospital. A person may appear incontinent overnight in hospital because they cannot get to the toilet unaided and assistance can often take a while to arrive. They may have had a catheter inserted on admission despite having no significant continence problems prior to admission. The issue of going to the toilet at night is often one of the deciding factors in the perceived need for 24 hour care.

We decide whether people have ‘rehabilitation potential’, take away the word rehabilitation and we are suggesting that as an individual they have no potential. I find it interesting that we do not as therapists consider a person with quadriplegia to have no ‘rehabilitation potential’ yet decide this to be the case for many older people who are no longer as mobile as they were. We decide they cannot possibly live the way they chose to live before admission because they have not reached their ‘baseline’ level of function. I don’t know about you but I struggle to make a cup of tea as efficiently in someone else’s kitchen so might appear less capable than I believe I am in my own environment. I am also not aware that we expect younger people to be at their baseline in order to be discharged from hospital.

In trying to do what we believe to be the best to keep people safe we have become risk averse on their behalf and paternalistic in a way that would not be acceptable if we were talking about a child. The legislation that covers children requires us to involve children in the decisions being made about them. We all live differently, we are individuals and we have a responsibility to allow people to live their lives as they want to

How often do we sit in multi-disciplinary team (MDT) meetings and make decisions as a team without the person in the room, making judgements about how people live. We may then have a family meeting and, in effect inform them of our decision, appearing to consult. I have often sat in these meetings imagining they were talking about me, I find myself thinking that I would not want them to talk about me in this way without me there to express my point of view and let them know what matters most to me.

What really matters to older people are the following to their standards not ours:

  • Having choice and control over their lives
  • Occupation and activity, having a purpose
  • Personal care and appearance
  • Food and Drink
  • Accommodation (cleanliness and comfort)
  • Personal safety
  • Social participation/inclusion
  • Dignity (in care) once you are acutely ill or dependent on care

These are all part of the wider determinants of health and well being and consider the role of broader local government, benefits, housing and the social capital in communities including the voluntary sector when considering how to deliver a model that allows assessment of older people in their usual environment during and at the end of a period of recovery.

We need to work on the principle that we should support people to return home to recover from their admission to hospital and cease to make decisions about long term care in a hospital setting.

I saw the man in the picture below earlier this week on the BBC news, he’s 94 and lives on his  boat in the Solent and he still regularly sails out of Portsmouth harbour, what would we say if he came into hospital after a fall or with an infection? Think home first.

Man living on a boat

Liz Sargeant – Integration Health & Social Care Lead (NHS Emergency Care Improvement Programme), OBE, MSCP @lizsargeant

Liz will be writing more articles for the ECIST Network on Fabstuff including:

  • What we need to change
  • How we need to change who does what and what we do

 

 

 

 

 

2017-07-09T14:07:36+00:00 17 February 2016Categories: Awards2016, ECIST Network, The 4 Candles Award1 Comment

About the Author:

Pete Gordon
Nurse by background and pragmatic improver. Member of the NHS Emergency Care Intensive Support Team (ECIST). Passionate about doing the right things to improve patient care. @PeteGordon68

One Comment

  1. fleggc 13 February 2017 at 6:38 pm

    Developing a Home First Mindset – Liz Sargeant

    THE CASE FOR CHANGE
    Consider the following statements:
    • Imagine leaving your home and never returning to it again

    This would generally only be the outcome after all other options that are available to support some one in their own home have been exhausted.

    • Imagine someone tells you that you are moving house tomorrow and you have no control over where you are moving to and how much it will cost.
    This is what we do to thousands of older people every year. Many older people are admitted to hospital with a mild to moderate illness on top of any pre-existing conditions. We make judgements about how the person will manage when they return home based on perceptions about the person after the effects of a stay in hospital, often prolonged. We assess them in an environment that is alien and confusing.

    The use of a reductive argument in illustrating what are generally complex circumstances bears little scrutiny. It depicts older people as assuming a passive role in the process. Assessments are used to inform decisions about older peoples’ needs. This information contributes to the dialogue of the decision making process in which the older person, their family, carer and professionals from both health and social care are all involved in.

    Some Facts:

    We need to ensure that people are in hospital for the shortest possible time ensuring that medical and nursing needs that can only be delivered in an acute hospital setting happen there. All lower level care, recovery, rehabilitation and re-ablement should wherever possible happen in the persons’ usual place of residence.
    We need to ensure that where ever practicable, the needs of the individual are at the centre of all decisions. Decisions regarding discharge from hospital need to take these needs into account; an early discharge to a home where the needs are not met will increase the likelihood of rapid readmission.
    We currently undertake assessments of a person’s ability to live their life once they no longer require acute medical or nursing care in the acute hospital setting. This is a time consuming process, comprising a number of assessments and information gathering (described by some as interrogation) that people report feels as if they are taking an exam. It adds to the amount of time people spend in hospital physically deconditioning and is a significant percentage of the days they have left in life.

    The assessment process provides objective information that informs the decision process for everyone involved. This process of assessment inevitably involves the active participation of the older person and in itself will not contribute to physical deconditioning. If one the main thrusts of argument is that hospital admissions lead to deconditioning it appears cavalier to suggest that the impact of this on an individual’s function should not be assessed. Citing emotive language used by “some” is not helpful generating constructive debate. The use of vague terms, “some”, “people” and “significant” in supporting statements often reflects poor or a paucity of evidence.

    We ask people to make cups of tea in hospital Occupational Therapy kitchens, walk upstairs even when they live in a bungalow or on one level in their house. We ask them intimate questions about how they manage their personal care and then decide whether they have passed or failed these tests. For people with dementia this is even more challenging, we decide based on their behaviour in hospital that they are not safe to be at home because they are wandering, or have challenging behaviour. They may just be trying to find home as they have forgotten they are in hospital. A person may appear incontinent overnight in hospital because they cannot get to the toilet unaided and assistance can often take a while to arrive. They may have had a catheter inserted on admission despite having no significant continence problems prior to admission. The issue of going to the toilet at night is often one of the deciding factors in the perceived need for 24 hour care.

    Assessments in hospital are not ideal. Having a room that looks like a kitchen is a step in the right direction. Generally what is assessed is what is pertinent to the individual; it is not a test. Do older people regard how they manage personal care intimate? The physiological process of senescence results in changes in bladder function. It is normal for older people to experience nocturia. Yes it can be one factor in deciding what level of care is required; one of many.

    We decide whether people have ‘rehabilitation potential’, take away the word rehabilitation and we are suggesting that as an individual they have no potential. I find it interesting that we do not as therapists consider a person with quadriplegia to have no ‘rehabilitation potential’ yet decide this to be the case for many older people who are no longer as mobile as they were. We decide they cannot possibly live the way they chose to live before admission because they have not reached their ‘baseline’ level of function. I don’t know about you but I struggle to make a cup of tea as efficiently in someone else’s kitchen so might appear less capable than I believe I am in my own environment. I am also not aware that we expect younger people to be at their baseline in order to be discharged from hospital.

    Using reductive statements detracts from establishing a constructive dialogue. When any person has a baseline level of function which is “low”, a further “drop” in function is likely to have consequences that impact on their life and prevent them living as they had before the drop. This would be as “true” for a person with quadriplegia as it is for an older person.

    In trying to do what we believe to be the best to keep people safe we have become risk averse on their behalf and paternalistic in a way that would not be acceptable if we were talking about a child. The legislation that covers children requires us to involve children in the decisions being made about them. We all live differently, we are individuals and we have a responsibility to allow people to live their lives as they want to
    How often do we sit in multi-disciplinary team (MDT) meetings and make decisions as a team without the person in the room, making judgements about how people live. We may then have a family meeting and, in effect inform them of our decision, appearing to consult. I have often sat in these meetings imagining they were talking about me, I find myself thinking that I would not want them to talk about me in this way without me there to express my point of view and let them know what matters most to me.

    This is a matter of personal responsibility. I hope you were able to express how you felt and help make changes to address this issue?

    What really matters to older people are the following to their standards not ours:
    • Having choice and control over their lives
    • Occupation and activity, having a purpose
    • Personal care and appearance
    • Food and Drink
    • Accommodation (cleanliness and comfort)
    • Personal safety
    • Social participation/inclusion
    • Dignity (in care) once you are acutely ill or dependent on care
    Using a list appears contrary to all the previous content. Promoting the individual as an individual negates the credibility of lists.

    These are all part of the wider determinants of health and well being and consider the role of broader local government, benefits, housing and the social capital in communities including the voluntary sector when considering how to deliver a model that allows assessment of older people in their usual environment during and at the end of a period of recovery.
    We need to work on the principle that we should support people to return home to recover from their admission to hospital and cease to make decisions about long term care in a hospital setting.

    Again the writer appears to have missed the mark. We would benefit from clear “guiding principles”. We should not “work on the principle”. I choke on using the word “should” and do so only to reflect the use of the word by the author. We need to work on good information, the fullest available information, include the relevant people in decision making with the “patient” at the centre the process, be open, honest and transparent in our communication.

    I saw the man in the picture below earlier this week on the BBC news, he’s 94 and lives on his boat in the Solent and he still regularly sails out of Portsmouth harbour, what would we say if he came into hospital after a fall or with an infection? Think home first.

    The language and emotive terms used by the author in this narrative are perhaps one of the greatest barriers to establishing an “adult” dialogue within health care to improve health care.
    Though a cliché in itself I’ll end on a quote:
    The great enemy of truth is very often not the lie–deliberate, contrived and dishonest–but the myth–persistent, persuasive and unrealistic. Too often we hold fast to the cliches of our forebears. We subject all facts to a prefabricated set of interpretations. We enjoy the comfort of opinion without the discomfort of thought.

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