Hello, my name is Lynne FLYNN, and I am the Delayed Transfer of Care Nurse. The delayed transfer of care project is a 12-month project fully funded by SPCL. The aims of the project are to reduce the risk of hospital admissions for care home residents and to facilitate timely discharge for those residents who do find themselves in hospital. The project started in November 2021.
Hospital admissions for care home residents can lead to distress, immobility, and poorer health outcomes, even after a short stay.
Studies have shown that care home residents have a 40-50% increase in emergency admissions compared to the general population of a similar age.
(The Nuffield Trust 2015)
The project has predominantly focused on a good quality preventative care approach to try to prevent hospital admissions.
This has been achieved by improving the use of early identification risk tools during the yearly anticipatory care home reviews, implementing initial assessments on all care home residents to identify those at risk of admission and putting in strategies to prevent this and case holding residents on a ‘virtual ward list’ during periods of acute ill health.
These are questionnaires that are filled in by a health professional when they meet with the care home resident. Using information from the G.P records such as past medical history, medication use and up to date clinical examination to include blood pressure and pulse and examination of the heart, abdomen and lungs early signs of illness and risk can be identified. Once this has been completed, care plans can be put in place along with preventative measures to keep your relative safe.
When a care home resident becomes unwell the care staff from the residential or nursing home can call SPCL for health advice and treatment. The call will be taken by a clinician familiar with the residents. If treatment is required, the resident will be kept on a list ‘virtual ward’ until they become well again. Once on the list the care will be discussed daily with the elderly health care at home team, occasionally input will be sought from the community consultant and G.P. A treatment escalation plan will be put in place so that the resident, care home, G.P and clinical team will all know how best to care for your relative during their illness.
Sometimes hospital is the best place to cater for the health care needs of the resident. This can happen for example with a fractured bone, stroke, or the need for intravenous antibiotics.
Once admitted to the hospital the resident’s journey will be followed up by the delayed transfer of care nurse. The delayed transfer of care nurse will visit your relative on the ward and participate in the ward rounds with the consultants, acting as an advocate for the resident and liaising with the care home and next of kin regarding care planning for discharge.
Once discharged back to the care home a visit will take place to identify any additional health needs and these will be addressed and supported where able.
The project has been running for 6 months now and in this time, admissions to hospital have reduced by 50% with residents at risk being identified earlier and additional care and support being implemented in the care home sooner.