Improving care between hospitals and care homes in Plymouth

ContactKaren Grimshaw, Associate Director of Nursing/Nurse Consultant Older People, Plymouth Hospitals NHS Trust
AddressDerriford Rd, Crownhill, Plymouth, Devon, PL6 8DH

What is being done?

A review of urgent care admissions from care homes has enabled the Trust to identify the care homes which most often have patients admitted to the acute hospital, in particular those care homes for people living with dementia.

Working both with the local Care Home Network (Dignity In Care Homes Forum) and individually with the top ten admitting care homes, improved working relationships have been established between hospital and care homes. Of the ten top admitting care homes, six are registered for people with dementia.

Through individual visits to care homes, there is now an increased awareness and understanding of the issues care homes face, both when admitting patients to hospital and when patients are discharged from hospital. Improvements in communication between hospital and care homes have been gradual; dealing with individual issues of communications has enabled an ongoing dialogue with some care homes.

Managing communication on a personal basis has increased the confidence of some homes with the relationship they have with the hospital, allowing individual discussions to plan patient needs and to address issues of concern or even to undertake investigations.

An improved working relationship with care homes has enabled better patient care planning and has facilitated patients’ return to the community setting in a more timely and supportive manner.

What is new and different?

There is a history of lack of awareness and understanding between the acute hospital and care home sector in the local area. Communications from some care homes had in the past been limited to only formal, written communication; myths around poor discharges had created a mistrust in arrangements for patients from hospital.

What difference this seems to be making

Improved working relationships have resulted in  more personal communications between hospital and care homes. Regular attendance at the Care Home Network, has enabled questions or issues to be addressed openly and to a large group of care home managers.

The one-to-one approach to the top ten admitters means that there is a personal relationship and response to any questions or concerns regarding patients being transferred. The introduction of supportive interim discharge to care homes has resulted in reduced length of hospital stay, reduction in delays for discharge, and reduction in readmissions.

Plans for taking the project forward

The working relationships with care homes will continue, both through the Care Home Network and on an individual basis. A review of this year’s top ten admitting care homes will ensure that the face-to-face meetings will be focused on those care homes sending the most patients to hospital.  A review of the supportive interim discharges will identify those care homes receiving the most patients on this discharge scheme, and thus those who may need further support from the hospital teams.