From hospital to care home, and back again

Bose smiling with care home resident
By Bose Adegbola, Older Person's Specialist Nurse, Guy's and St Thomas' NHS Foundation Trust

Increased life-expectancy combined with population growth has naturally led to a rise in the number of elderly people with complex needs. This has come as a challenge to health services the world over; Southwark and Lambeth are no exception.

Nowhere is this more important than during the transfer of care process between hospitals and care homes.

In my experience, as a member of the Care Home Support Team and an older people’s specialist nurse, and through the available evidence, we know that a poor transfer of care for our frail older people has the potential to create life-changing experiences. From readmissions and unexpected long-lasting physical effects to emotional and psychological impacts – that’s exactly why I believe our Acute-Care Home Interface Project was so important and why I wanted to be involved in getting transfer of care right.

I was the Interface Practitioner on this project which meant acting as a bridge between the hospitals and care homes to improve patient experience for frail older people who have either been transferred to or from Lambeth or Southwark care homes. The project focused on building relationships and improving communication between the care settings, to improve transfers of care and how these care setting jointly work through any problems.

From my perspective, this was a challenge in almost every way as these two care settings are very different, in terms of their structures, governance and cultures – to name just a few.

To achieve our goal we worked extensively with consultant geriatricians, care home managers, ward managers and matrons, hospital and care home nurses, and discharge co-ordinators to develop the Transfer of Care Bundle and Checklist. This bundle sets out a gold standard for how a transfer of care should take place, which has already improved patient experience during testing.

This engagement was extremely valuable because it demonstrated that staff had bought into the process and believed, like I did, that it would improve transfers. It was fantastic to see how many of my colleagues were keen to make a real difference.

For me a key aspect of the bundle is a new discharge checklist, which we hope will prompt professionals to share all of the required information with each other when the patient is being discharged to a care home.

We also decided to include a prompt about the PEACE (Proactive Elderly Advance Care) document within the bundle to encourage professionals to have difficult, but important, conversations with their patients, their families and carers. This helps identify advance care planning needs and avoid preventable hospital admissions.

PEACE is important to older people as it empowers them to tell family, carers and medical staff what their wishes are towards the end of life. In my various roles I have seen the benefits of completing a PEACE document and believe that this is a crucial element of the bundle.

So far we’ve received a lot of positive feedback from care home and hospital staff, as they become better acquainted with the bundle and the new documents within it.

As you would expect, this will take time to become fully embedded across all care settings. We recognise that it’s always difficult to transform existing processes, but there is no doubt that I believe it will be worthwhile.

Despite the promise of early testing, there remain challenges to fully embedding this new transfer of care process into both environments. For this to happen it requires the support of care homes and hospitals, so that in the future every transfer of care follows this new way of working.