Hospital Discharge Service ‘Bridging the Gap Scheme’, Age Concern Swansea

Background

This project provides access to a team with complementary skills to address health related quality of life for older patients who have been discharged from hospital. For example, access to advice and information for patients and their carers, and improve communication between patients, carers and staff. The project also ensures that the essentials of good health are met with input from nurse professionals, in addition to social work input for patients with more complex needs.

This project draws on the support of other projects within Age Concern Swansea to provide continuity of care with a preventative ethos and sustainability post-discharge: Supporting People Project (a long term help and friendship face to face or by telephone); and Home Maintenance Scheme (a service for those struggling to find assistance with small but vital tasks). We also offer advice on welfare benefits and form filling, housing information, and luncheon clubs to help reduce isolation and provide nutritious meals.

What is the problem you are trying to solve?

Facilitate safe and sustainable discharge of older people from hospital and to prevent readmission.

What local organisations are involved?

The project operationally links to partnership agencies throughout Swansea including: Care and Repair; Chronic Illness Management Team; Intermediate Care Teams; and Fire Service. In addition, there are strategic service-planning links with Social Services, the Local Health Board (roughly equivalent to Primary Care Trusts in England) and the Swansea NHS Trust (secondary and community care).

How many people are running this project and who are they?

There are 12 staff involved: one manager, two assistant managers, two district nurses, one social worker, one benefits officer, five visiting assistants and 17 volunteers who provided 210 hours during 2005-6.

What local population are you targeting?

Older people aged 55 years and over living within the City and County of Swansea who have recently been discharged from hospital or the Accident and Emergency unit. The project accepts open referrals and there are no other eligibility criteria.

How many people are you targeting?

The project targeted over 700 patients during 2005-6. The target for 2006-7 will remain the same because of funding and staff capacity.

Interventions

What interventions are you using to address the problem?

Older people being discharged who have been assessed as having ‘low level needs’ are visited and we put in place whatever services are required to stabilise and prevent readmission. We complement any other services which may already be in place, for example some patients may already have a district nurse or social worker. Our multidisciplinary team can provide nursing, social work support, benefits advice, emotional and practical support with daily living tasks, action regarding Protection of Vulnerable Adults, and liaison with other Age Concern services like home maintenance and befriending services.

Is the project design based on evidence? If so, please state reference.

Age Concern services are based on their Services Information Framework Resource Packs, in this case, number 18: Hospital Aftercare Schemes, March 2000. The project is also based on recommendations for intermediate care services resulting from the Townsend report on the NHS in Wales ¹ .

Outcome

What outcomes or planned outcomes are you measuring?

We are measuring: patients’ emotional wellbeing (life satisfaction and self esteem); patients’ psychological wellbeing (anxiety and depression indicators); physical wellbeing (health status and physical functioning); and social wellbeing (indicators of social network structure and support, community integration and functioning in social roles).

Do you have any outcomes or results yet? If so, what are they?

We compile evidence from: corporate compliments and complaints procedures; case histories; satisfaction questionnaires; reports; statistical information; external evaluation by University of Wales Swansea on the role of volunteers in health ² ; and internal evaluation based on A&E services ³ . There will be an external evaluation in 2007.

The outcomes are positive for most patients: significant improvements in all four types of wellbeing, an increase in benefits for many who previously had ineffective contact with statutory services, and a high level of referral to other continuing services.

Is your project relevant to a government target or guideline?

• Targeted programme to address health inequalities identified by Targeting poor health ¹ .
• The NHS in Wales through Service and Financial Frameworks (SaFF) is trying to reduce the number of delayed transfers of care. This project works with others involved with management of discharge toward achieving this ⁴ . A unified discharge planning policy is to be completed and issued in 2007 by Swansea NHS Trust.
• The NHS is also trying to reduce the number of older people returning frequently to hospital as a result of insufficient care and support at home. This project works to put in place sufficient, long term and broad-based help after discharge so as to reduce readmissions ⁴ .
• Two of the key objectives of the Strategy for Older People in Wales are to promote the health and well-being of older people, and to promote services which enable older people to live as independently as possible ⁵ .

Feedback

What obstacles did you have to overcome to set up this project?

There was insufficient time to establish good working systems and relationships when shifting from an all-volunteer service to a funded project based on service level agreements. The mix of professional staff among volunteers was also difficult at times.

What have you learned about the project so far?

The project was built on an already successful hospital discharge service. The change from all-volunteers to a mixture of paid and professional staff was done quickly, and the changes in roles and ethos caused some conflict. A lot of hard work was put in to develop a cohesive team with the same goals.

What would you do differently?

A more-timely changeover might have saved conflict, but this was made harder by the fact that the scheme was already live. The scheme has filled gaps in service and proved that integrated care and collaborative working gives speedier and better outcomes for patients.

References:

1. National Assembly of Wales: National Steering Group on the Allocation of NHS Resources. Targeting poor health. 2001. http://www.wales.gov.uk/organipo/index.htm (accessed April 12 2007).
2. Swansea University: School of Health Science. An evaluation of the volunteers’ role in the ‘Bridging the Gap’ Project: executive summary. 2005.
3. Age Concern West Glamorgan. Home alone: a study of people aged 60+ leaving Accident and Emergency, Morriston Hospital, Morriston, Swansea. Age Concern West Glamorgan. 2001.
4. Swansea Local Health Board. Service and Financial Framework (SaFF) 2004-5. http://www.wales.nhs.uk/sites3/docmetadata.cfm?orgid=267&id=33125 (accessed 12 April 2007).
5. Welsh Assembly Government. The Strategy for Older People in Wales. 2003. http://new.wales.gov.uk/about/strategy/strategypublications/strategy_olderpeople/?lang=en (accessed 12 April 2007).