Hospital to home

Introduction

Iriss's Innovation and Improvement team led a 30-month project from July 2013 until January 2016, to design a pathway to support the transition from hospital to home for older people. We worked with health and social care practitioners, older people, their families and informal carers to identify and improve care pathways from hospital to home and enable a more positive experience for all.

Currently, around 90,000 older people in Scotland are receiving some kind of care, either in their own home, a care home or through long-term hospital care. Furthermore, it is predicted that within the next three years this number will increase to 113,000 people who will be receiving ongoing care (Scottish government, 2013). However, current models of health and social care services are not fit to address this national challenge of an ever-increasing ageing population, whilst financial constraints only add to this demographic challenge.

In response to this demanding issue, the Scottish Government has developed key policies for "Reshaping Care for Older People", drawing attention to improved services for care of older people through a shift in focus towards anticipatory care and prevention. For this purpose, the Scottish Government has allocated an £300 Million Change Fund (2011-2015). In addition, the Scottish Parliament has recently introduced the Public Bodies (Joint Working) (Scotland) Act (2014) that aims to improve outcomes for older people through three key agendas:

1. Providing consistency in the quality of services they receive
2. Ensuring people are not unnecessarily delayed in hospital
3. Maintaining independence by creating services that allow people to stay safely at home for longer

In line with this agenda, the Cabinet Secretary for Health, Wellbeing and Cities Strategy recently released new governmental targets in October 2011 stating that by April 2015 no older person should be unnecessarily delayed in hospital for longer than two weeks. The current target period for delay is four weeks (April, 2013). Delayed discharges from hospital care to a person’s home, however, can occur for a variety of reasons including, but not limited to, a lack of services or care facilities available for older people once they leave the hospital, lack of communication between healthcare providers or lack of family support. These extended periods of time in hospital care can lead to a number of issues including, repeated illness, loss of independence and reduced mobility, despite which it is estimated that in 2012 alone over 200,000 bed days were taken up by delayed discharges from hospital (Delayed Discharge Expert Group, 2013).

This project was specifically concerned with the design of a new positive pathway to improve the transition of older people from hospital to home, a byproduct of which was helping to ensure that these individuals are not unnecessarily delayed within hospital care.