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Filling a care void: Countless lives saved by ending hospital discharge delays

4 May 2016

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 May 4, 2016
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Older people across the UK are dying in hospital because far from getting better, their health takes a nose dive the longer they are away from home.

Physiotherapist Andy Powell is cutting the rate of decline and death of people from 54 care homes, by offering care managers a ‘rapid response’ rehabilitation service to those discharged from hospital.

After identifying a gaping hole in care services for those needing a speedy referral for home therapy when they leave hospital, Mr Powell began treating people in care homes. Through his work, he has been responsible for a reduction in the length of stay in hospital for care home residents and a cut in the number needing to enter hospital in the first place.

His pilot project saw him receive 887 cases in his first year. One woman had left hospital but her care home manager phoned him to say she hadn’t got out of bed for three weeks.

A referral from a GP for a physiotherapist service could take four to six weeks. The care home is left to wait and this can often result in residents’ health declining to the extent that in some cases never walk again.

Andy Powell keeps his promise to contact a care home within 72 hours of someone being discharged from hospital and in urgent cases he’ll see them within 24 hours.

About 90 per cent of the people he sees were in hospital with fractures from falls and infections such as chest infections. Andy Powell’s advice to care home staff includes manual handling advice and how to prevent falls from happening.

“We found there was a delay in people being discharged from Royal Stoke [hospital] and me receiving the referrals.

“It was a new service and many people didn’t know I was there and the physiotherapy referrals via in some cases a GP, were taking anything from two to four to six weeks for me to get the referral.”

Andy Powell, secured funding from the North Staffordshire clinical commissioning group for his ‘direct referral’ pilot, and asked his commissioning manager Nicola Bucknell to approach Royal Stoke Hospital’s clinical lead for geriatric medicine Dr Aurora to see how patients could be discharged in good time from the geriatric unit to care homes.

Mr Powell then compiled an A-Z list of nursing and residential homes and private hospitals in the North Staffordshire area where he offers physiotherapy and gave the guide to the hospital’s physiotherapists so that they could discharge patients more quickly.

Now the hospital wards directly refer residents from North Staffordshire to Mr Powell, when they are about to be discharged to a care home.

Now the geriatric unit is not the only department that benefits from the pilot, with orthopaedic wards, A&E, and other departments using the scheme.

Those who enter a care home for a respite period as well as permanent residents benefit from the service. He doesn’t include those living at home unless they are having respite at a care home.

He is after all one man serving the North Staffordshire area and since starting the pilot has a technician Rob Pitcher (from June 2015) to help him with his workload at care homes. He recounts the story of a 99-year-old woman sent on respite to a care home after falling in her home and being discharged from hospital. She was discharged but was non-weight bearing.

“Over a period of three to four weeks we did intensive rehab with her, I got the staff involved. We managed to get her weight-bearing, mobile with a frame, roughly six weeks after her admittance, she actually returned home with a care package in place.”

He doesn’t know how long it would have taken to get someone to see the lady and believes by that stage she wouldn’t have been able to walk again.

“Hoisted for the rest of her life”

“The 99-year-old lady was discharged to the home as hoisted, if nobody had told that home any different, the home would continue to hoist that lady for the rest of her life”.

Stoke on Trent CCG is also looking to use the pilot in its area. ‘Hopefully’ he says South Staffordshire CCG will also use his service in the future so that care home residents across Staffordshire leaving Royal Stoke hospital can avoid a postcode lottery when it comes to benefiting from his direct referral scheme.

Four years after starting the pilot, Mr Powell has become the man care home managers go to as their trusted assessor of people leaving the hospital.

But it wasn’t always like that. “My role was initially met with resistance from some of the care home staff because they are private businesses at the end of the day. We are the NHS going into a private business. We can only give so much help and advice. They still have their own manual handling policies, lifting policies etc.

“We will leave exercise plans and different kind of therapy ideas with the staff which they can incorporate with their everyday activities with residents. He shows staff how little things can be build into the daily routine of washing, dressing etc, such as making residents walk a little more from a wheelchair to a dining room chair.

One care home manager called him on a Monday about a lady discharged with a fractured arm. He was told “Really struggling with her. She’s screaming in pain.”

He visited the next day. And the next. “We devised a new manual handling manoeuvring practice for this lady to protect the arm. I got her a new resting sling because the one she got was quite dirty and was getting worn and needed replacing.” She received the sling within 48 hours of referral.

“The staff didn’t have the knowledge to deal with someone with a painful humerus fracture. That’s not their fault. If you haven’t dealt with one before you don’t know. ”

Worn out slings, mis-shapen sticks, short frames

Worn out slings are not the only problem seen. Residents may arrive at care homes with a stick or a frame and may have had it for seven years but often nobody comes into homes to check mobility equipment. Worn sticks, dodgy frames, frames with legs too short for residents, can all contribute to falls in a care home.

With 20 years’ experience with people with dementia and mental health issues, Mr Powell says “There are some residents where we have to put our hands up and say we cannot stop them falling; that’s usually down to cognition and dementia.”

Mr Powell lost his mum to vascular dementia last year when she was in a care home after she had a fall and went into hospital.

He says “If there’s no physical or pharmaceutical reason we can’t stop them falling, I will do an environmental assessment. Rearranging rooms, looking at what part of the home the falls occur.”

Andy Powell targeted three homes in his area (large, medium and small) and found falls at two of the homes were reduced by over 50 per cent, three months after he’d visited and assessed the homes.

Care home manager Jayne Taylor at Hempstall Hall care home in Newcastle-Under-Lyme is one of many homes praising the service.

She said “The service is absolutely invaluable. It means you’re not struggling waiting for a physiotherapist for weeks and weeks. He has a lovely manner and the residents really like him.”

When asked what the best part of his job is, Andy Powell replies “You get a smile. The little lady today just turned round to me and said ‘That’s so much better’ and started crying.”

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