In this blog Dr Inder Singh, consultant geriatrician and national clinical lead (Falls and Frailty), considers changing how we view hospital admissions, transfers of care, and professional challenge to drive a patient-centred and whole-person approach to care.
The case for change
Our population is ageing. We are seeing more older people with multiple co-morbidities being admitted to hospital. However, each admission to hospital could pose several risks. The impact of hospitalisation includes risks of hospital acquired infections or thrombosis, falls, delirium, dehydration, increasing physical dependence, and loss of sleep hygiene, dignity and privacy.
Are our patients, carers or even everyone in our multidisciplinary teams (MDT) aware of this? Do we explain the impact of hospitalisation with patients or explore at each MDT meeting, ward round or board round?
There is increasing self-reported burnt-out among healthcare staff. Junior doctors are juggling speciality training and multiple patient-related jobs, which is having a huge impact on wellbeing. If we focus on practising holistically and on generalist care, maybe our jobs will be more satisfying and less about ‘creating the next empty bed’.
Making a change
We need to truly understand our patients and not forget about the importance of a really good history, get to the bottom of their concerns, keep listening and ask three simple questions: ‘tell me more, tell me more, tell me more’.
‘Tell me more’ is about understanding the routine of our patients. Hospital admissions can disrupt a patients’ routine, affecting their independence and cognitive ability upon transfer, increasing the risk of delirium. It keeps patients at the centre of their care, recognising the impact of hospitalisation on loneliness, isolation and poor sleep hygiene creating unpleasant hospital experiences.
It prompts us to take a comprehensive assessment of ongoing medical conditions and consider ongoing care plans, underpinned by timely communication to support transfer of care to the community.
In doing this we can focus on the patient as a whole – factoring in the impact that hospital stays have on a patients’ wellbeing – and prevent the need to place patients on care pathways, prolonging their admission and the ‘taskification’ of their care.
We also need a relentless focus on education and partnership working among MDTs. Let’s start with language – using the term discharge can exclude the opportunities of MDT working outside hospital settings and fails to consider the potential long term care needs of the patient.
By changing the language we use from discharge, transfer of care and hospital ‘episodes’, and focusing on care planning, we can support wider integration and partnership with primary care and community teams.
Equally, viewing a patients’ episode in hospital as a ‘day away from home’ can help to capture the impact of a secondary care ‘episode’ on food choice, toilet facilities, freedom to roam and being themselves. It can help to bring a whole-person perspective and prompt us to explore the impact on an individuals’ dignity, privacy, sleep hygiene, and independence.
It can also help to shift cultures, promoting alternative models of care such as ‘No place like home’; avoiding the potential negative consequences of hospital admissions, particularly for our older patients.
Patient and carer education and awareness around the benefit and harms of being in hospital is vital, and focussing on optimal conditions for transfer of care remains the cornerstone of any medical treatment. This is where my 4Cs are crucial – compassionate, person-centred, comprehensive, care planning.
How do we realise this way of thinking?
In 2018, the Welsh government has proposed a long-term plan for the future of health and social care. It set out a focus on providing more joined-up services and care closer to home.
Admission to secondary care is often a sign of the trajectory of disease or condition and should trigger discussions about future care planning. As such, using language such as patient ‘days away from home’ in secondary care can help to capture the nature of likely need to consider long term care planning.
Robust professional challenge can help prompt us to think about likely future visits to secondary care and provision of care beyond the hospital (linking to other services, such as occupational therapy and even social prescribing), helping to prevent the need for future hospital admission wherever possible.
Let’s focus on the optimum conditions for transfer of care, keeping in mind the future care needs of our patients and not the quick route of ‘safe to discharge’.