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Home goal: the award-winning physio team at Bradford Royal Infirmary

Kicking off the CSP’s Physiotherapy works programme, Robert Millett profiles the team that won in the ‘redesign of patient pathway’ category at last year’s CSP Awards

Home goal: The award-winning physio team at Bradford Royal Infirmary

Leaving hospital after an illness or injury can be a daunting prospect, especially for older people who live alone or lack support at home.

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Many need intermediate care and remain in hospital for rehabilitation, but now a service in West Yorkshire is proving the clinical and financial benefits of preparing patients for early discharge and providing them with home-based rehab instead.

The therapy-led Early Supported Discharge (ESD) service is based at Bradford Royal Infirmary and St Luke’s Hospital, both part of Bradford Teaching Hospitals NHS Foundation Trust.

The radical approach consists of three ESD schemes that have been applied to the care of older people and in orthopaedic settings since January 2011, and on medical wards since January 2013. Each means patients receive intensive, post-discharge rehab immediately they return home.

Each strand of the service is run by a multidisciplinary team that includes physiotherapists, occupational therapists (OTs) and therapy assistants. It began after Jill Gregson, head of therapy at the trust’s physiotherapy department, applied for funding to develop the service in December 2010.

Her application, to the then primary care trust, was successful and the service started just one month later, in January 2011.

Physiotherapist Phil Wright, ESD therapy coordinator for older people and community services, says staff acted swiftly to implement the redesigned pathway. ‘We only had a week’s notice to set up the service,’ says Mr Wright. ‘But thankfully we’d already been doing some recruitment, so we had a group of people we could call on.’

The aim of the redesign was to provide a pathway that would enable patients to regain their independence, increase their mobility, improve their ability to participate in functional activities and reduce the need for continuing care.

By forming a direct link between acute care and community services it was thought the ESD service would fulfil this ambition, by providing a home-based alternative to intermediate care.

Mrs Gregson says it was a novel idea, because most ESD schemes in the UK apply only to stroke care. ‘Our teams showed true innovation by extending the concept to all patients in an acute care setting,’ she says.

Lucy Kirke, a rotational band 6 physiotherapist, was instrumental in setting up the service and says it was difficult at first. ‘It helped that everyone on the team was flexible and supportive, and understood that the service was evolving, which made it easier for us to try out new ideas.’

Mrs Kirke was mainly involved in supervising staff and divided her time between shifts on the ward and community visits. She also had to participate in discharge planning, attend A&E and help to identify patients who were suitable for ESD or other onward rehabilitation.

Having previously worked in services for older people, Mrs Kirke says the new pathway was a radical departure from the trust’s earlier care plan. ‘Before the introduction of the service patients were usually admitted to another inpatient rehab facility, or put on the waiting list for community therapy – which could take up to four weeks,’ she says.  ‘But now they are followed up straight from the ward or A&E.’

Setting up and maintaining the service has presented the team with a series of challenges, including budget-related staffing issues.

‘The funding was initially only for three months and that was then extended and has been ongoing, but never permanently guaranteed,’ Mr Wright explains.

As a result most of the therapy assistants have been employed on temporary contracts and there has been a high turnover of staff. But despite its rapid launch, and a financially uncertain future, the service has continually shown its worth and now, three years later, its success is garnering widespread attention.

In 2012 the service was shortlisted for a Patient Experience Network National Award in the ‘continuity of care’ category, and the team triumphed at the CSP Awards 2013, winning in the ‘redesign of patient pathways’ category.

Intensive rehabilitation

Bradford has a population of 300,000 people and the ESD team visits people within a six-mile radius of the city.  The ESD team for older people works closely with the therapy team which provides care on the acute wards at Bradford Royal Infirmary and St Luke’s Hospital.

The ward team consist of three physiotherapists, two OTs and a therapy assistant. While the ESD team includes one band 5 physio, one OT and two therapy assistants. The orthopaedic service meanwhile has funding for 11 therapy assistants and they and the OT staff are split between ESD, A&E and the wards.

‘The majority of the patients are frail older people who are admitted to hospital with falls, or conditions like chest infections or urinary tract infections,’ says Mrs Kirke.

Patients are assessed in hospital prior to being discharged, to ensure their needs can be safely met and all the home-based rehab is supervised and supported by daily visits from the team.

‘We usually visit first day post-discharge then daily for up to six weeks, though most patients are discharged before then,’ says Mr Wright.

‘It’s about bridging that gap between hospital and home and getting patients back on their feet.’

The home-based rehab is administered at the same level of intensity as patients would have received in an inpatient setting. In addition, it is delivered by staff the patients have already met in hospital, which provides a comforting element of continuity. ‘The same therapist who assessed them in hospital goes to see them at home on their first day back, so they have the reassurance of a familiar face,’ says Mrs Kirke.

The service requires close communication between physiotherapy and OT staff and collaborative working, most often in the form of joint visits to patients’ homes.

Formal handover meetings are held twice a week, allowing staff to discuss their caseloads and ensure that patient goals are progressing.

Linda Wood is the ESD therapy coordinator for orthopaedics, A&E, vascular and wheelchair services.

She explains that the orthopaedics team visits patients twice a day, for an average duration of five days, matching the frequency and length of rehabilitation that ward based patients would normally receive.

‘A lot of our patients undergo hip replacements,’ says Mrs Wood. ‘But falls are by far the biggest reason and ankle fractures are also common.’

Mrs Wood believes the ESD service provides a seamless therapeutic pathway from admission to community, and the continuity of care helps to alleviate anxiety among recently discharged patients.

As therapy assistant Janine Emsley explains, a lot of people ‘feel too scared’ to leave the house once they get home from hospital.

‘It’s not that they are unable to do it,’ says Ms Emsley. ‘It’s just that they haven’t got the confidence – so we work with them until they are able to go out alone.’

The service focuses on setting individual, patient-specific goals and aims to promote independence and optimise functional recovery.

‘In hospital we get people fit to be discharged, but there’s a big difference between that and getting them fit to lead a normal lifestyle once they are home,’ says Mr Wright.

As a result the ESD teams focus on long-term goals that take account of people’s normal routines, which might include target destinations such as local shops or the pub.

Becky Leedale, a band 6 OT, says the team frequently liaises with other agencies, including pharmacy services, district nurses and various community services, in order to ensure that patients receive a holistic package of care.

‘We work alongside home care services, and if we think a patient isn’t going to be safe or their family can’t support them then they may need a different setting for rehab,’ says Ms Leedale.

In cases where patients do have ongoing, long-term needs the service refers them on to the standard community team.

The ESD service also treats a significant number of patients with dementia. ‘About 50 per cent of the patients we have on our older people care wards have some degree of cognitive impairment,’ says Mr Wright.

‘But they respond better in their own environment, so we often manage to make far more progress with them at home than was expected when they were in hospital.’

Service saves trust £600k

About 700 patients were seen by the ESD team for older people from January 2011 to September 2013, and the latest data has revealed that referrals to the service have increased by 60 per cent compared to the last quarter.

Yet, in spite of increasing referrals, the early supported discharge of patients has resulted in the service saving the trust an estimated 2315 bed days in the last year.

In addition, since 2011, the orthopaedic strand of the service has saved a total of 2,698 bed days, which has been estimated to equate to cost savings for the trust of more than £600,000.

The service uses standardised outcome measures, including the Barthel index and the Tinetti gait and balance scale, and these have shown clinical improvements among patients of between 25 and 50 per cent.

The measures have shown a reduction in the average falls risk for patients, with a decrease from ‘moderate’ to ‘low’, and an average increase in patient mobility. The service has also led to an average decrease of approximately five hours for ‘help needed’ by each patient per week.

Readmission rates for patients have fallen from a trust average of from 10 to 12 per cent to five to six per cent.

‘And as a result the trust has reduced its penalty costs for readmissions within 30 days,’ says Mrs Wood.

Mr Wright says the results prove that patients respond and recover much better in their own environment. ‘People are more active at home,’ says Mr Wright. ‘Hospital is such an alien environment and promotes a culture of staying in bed all day. It takes away people’s independence.

At home people follow their normal routines, diet and sleeping patterns.’

Increasing integration

The next formal deadline for funding is the end of the financial year, in March 2014, but the team is positive that the service will continue. It is currently seeking additional funding that would allow members to provide a therapy-led ESD service across all in-patient environments.

‘Our service is integrated between the therapists on the ward and those in the ESD, but there needs to be more integration – and that’s one of our future challenges,’ says Mr Wright.

Mrs Kirke agrees that  integration into a larger health and social care model would be the ideal way forward.  ‘Our staff are now used to dealing with fairly acute patients in the community and will be able to use that experience when the service becomes fully integrated.’ says Mrs Kirke. fl

Patients’ comments on the service

  • ‘I was more comfortable in my own home, and being at home increased my morale and in turn helped me have a speedy recovery.’
  • ‘Staff did very well, and the scheme is a good idea as I’m on my own.’
  • ‘Very satisfied, grateful to be getting out of the house and the team’s input.’

Physiotherapy Works: a new programme to demonstrate the value of physiotherapy

 

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