We want to improve the flow of patients through acute beds’



Who’s in the Beds: Surveying and the Aftermath

Paul Forte

The Balance of Care Group

Occasional Paper: 2-05

This paper was first presented at the 30th meeting of the European Working Group on Operational Research Applied to Health Services, Stockholm, Sweden, June 2004

Introduction

In aiming for the ‘best use’ of hospital beds there are many drivers, but better efficiency in the use of resources, and the provision of effective, high quality - and appropriate - care for patients are typically top agenda items. Of course, in practice, these ideal goals are often distorted by various incentives and disincentives which abound in any given health system. Some of these will be clearly identifiable and deliberately engineered, but others may not be so obvious or planned and give rise to unexpected consequences which may even end up being in direct conflict with desired objectives.

The management and provision of services for older people is central to the efficient use of hospital beds in any health care system as, typically, over half of the patients occupying an acute hospital bed will be aged 65 or older. As a group these patients have the longest lengths of stay and the most complex needs – not just for health care but for social support as well. Meeting their needs appropriately requires a ‘whole systems’ perspective which embraces all local health and social care organisations. Ensuring that these organisations and personnel are all properly involved is a very complex process, made more so by the fact that the environment is usually poorly provided with routine management information.

As a result, most projects to address whole systems planning issues which the author and colleagues of the Balance of Care Group, have undertaken begin with broadly expressed requirements which are fundamentally similar in every location:

• ‘We want to improve the flow of patients through our acute beds (or, if organisations are genuinely talking to each other, ‘our local health economy’)’

• ‘What alternative care processes might we adopt, and for which patients?’

• ‘What will this mean for the types of resources required, and which local organisations will have to provide them?

The modelling work involved inevitably requires special data collection as routine information systems usually cannot link a patient’s care status and care requirements with their pathway through - and interactions with – all components of the health and social care system. For example:

• referral routes into the hospital and health/ social care system

• reasons for admission; diagnoses,

• social factors which may potentially affect admission into hospital or discharge from it

• the potential range of alternatives to acute admission - and to continued presence in acute beds

• discharge planning processes and factors which may be delaying these

It is only by obtaining these data that we can begin to model the capacity implications of improving the flow of patients in the system and making their care experience one which is more appropriate to their requirements and, ultimately, choices concerning the location of their care.

Our experience in several recent projects in acquiring these data and undertaking modelling has followed similar stages:

Pre-survey

This is a critical stage of the project as it is the time when it becomes clear just how well local organisations are actually working together or have shared objectives and understanding of the issues (as opposed to their claims that they are working together). While overall aims may be broadly congruent, the devil is often in the detail of how to go about reconciling long and short term operational objectives and their relative priorities across different agencies. An important aspect of the survey is to understand these tensions and, where possible, explain how they can be recognised, handled and, hopefully, resolved or lessened as a result of the project

The project methodology and the survey protocol need full explanation at this point and their application discussed with clinicians to gain their acceptance and to take on ownership of the survey results and subsequent actions.

Apart from helping to develop a shared perspective of the issues a parallel issue to address is the set up of the survey which will collect the required data. This an essential task requiring negotiation of access to patient records across several organisations. This can itself be time-consuming and fraught by diverse local interpretations of what is rather loose national guidance on patient confidentiality issues. Added to this are various questions raised concerning research governance, data security, and patient confidentiality issues. All of these are, of course, are very important and must be satisfied but, inevitably with several organisations involved, the bureaucracy takes time to satisfy which is one reason for usually having a lead time of at least two months between project initiation and data collection for a large-scale project.

Discussions on the scope of the project as a whole also determine the final version of the survey form itself (what data items to collect) and its coverage (how many patients to survey and where). Once decided the number of surveyors required can be estimated and arrangements for their training made. Surveyors are recruited among local care professionals from participating organisations. The majority of them are nursing and therapy staff; all have clinical backgrounds or, if not, are paired with surveyors who are as the survey requires an understanding of medical notes and a professional judgement as to potential alternative forms of care.

Data collection and the Appropriateness Evaluation Protocol (AEP)

For each patient included in the survey, survey data items are taken from their medical, nursing and therapy notes (the patient is not interviewed directly). These include data noted above and, where the patient is in an acute hospital setting, a comparison of their condition firstly on admission and secondly on the day of the survey itself against the Appropriateness Evaluation Protocol. This is a validated instrument [1] which is, essentially, a list of (clinically conservative) criteria covering the severity of the patient’s illness and their nursing/ medical care needs. Meeting any one of these criteria is an indication of ‘acute care need’; those outside the criteria may require care, but not necessarily in an acute setting and it is here that the surveyors can suggest what this might potentially be.

Two important points to emphasise here are that the survey is not employed as a clinical audit to review ‘unnecessary admissions’ or ‘delayed discharges’. All clinical decisions are assumed to have been correctly made at the time; all the survey is doing is attempting to identify the potential for alternatives in an ‘ideal world’. This is the second important point; where patients fall outside AEP criteria surveyors are asked to specify what potential care alternatives might be appropriate, irrespective of whether they currently exist locally or not. The aim of the survey is to identify the potential demand for alternative services and not to be restricted in any way by the current pattern of provision.

As well as surveying acute hospital patients, we also survey those in community hospital settings. Here the AEP cannot be used as it is not relevant - the hospitals are primarily for rehabilitation purposes - but we still obtain similar patient data and surveyors record their judgement as to potential alternative locations.

Paper records from the survey are entered into a database (and anonymised prior to analysis). Initial analyses are undertaken and fed back first of all to surveyors to cross-check with them on their experience of data collection on the day. Following the survey day, we obtain data from the routine information systems about four weeks later to find out whether patients surveyed have been subsequently discharged

and if so, when and to which location. This information gives us a longitudinal perspective on the survey population including length of stay and discharge destinations. This enables us to distinguish patients for whom an alternative care setting might have been identified in the survey, but in the event would not have been appropriate for them to go to because they were subsequently discharged within a short time of the survey day. It is at this stage that we can start to undertake capacity analyses and postulate potential changes - and consequent resource implications - to local health and social care capacity through local workshops and presentations.

Post survey results

We have undertaken several surveys in UK settings and have obtained similar patterns of results despite differences in the circumstances and scope of the individual studies [2]. The data illustrated below show results from several recent studies.

A common feature of the surveys are the age ranges of the patients; typically over half will be 75 years and older in an acute hospital setting; a figure rising to 80% or more in community hospitals. Of course, it should be borne in mind that we are usually selective in the specialties surveyed in acute settings. Medical and orthopaedic specialties are always included; paediatrics, obstetrics, psychiatry are always excluded. Inclusion of other, mainly surgical specialties, varies depending on the required scope of the local project. Typically, therefore, patients surveyed are frail, elderly people with uncertain diagnoses and with social as well as medical factors, playing an important role in their admission to hospital.

Figure 1 shows an analysis of acute and community hospital reasons for admission which highlights this; a variety of clinical diagnoses may be responsible for any single admission reason.

Figure 1: Typical recorded hospital admission reasons for patients

It is, of course, in this stage of a project that the implications of the survey findings really begin to be understood by the participating organisations (although it is also true that this local engagement is often only just getting into its stride when resources for the project itself are at an end!). Part of this, we believe is the difficulty people have in fully appreciating the potential of the survey data in the immediate aftermath of the exercise to inform and support exploration of a wide range of different scenarios.

Figure 2: Potential alternative locations for patients outside AEP admission criteria

Figure 2 illustrates the typical range of alternatives to acute hospital admission that we find in the surveys with many identified as being capable of care provision in home-based or non-acute bed environments, and often with therapy support as a component.

A similar picture emerges for alternatives to remaining in an acute hospital with an even larger number of – particularly medical and orthopaedic patients - identified as capable of receiving care in alternative settings (figure 3).

Figure 3: Alternative care settings to remaining in acute or community hospitals

Note, too, that there are also alternatives for existing community hospital patients many of whom are receiving post-acute rehabilitation at levels which could, in turn, be carried out in home-based or care home based settings if the services existed. The alternatives identified by the surveyors can then be transformed into diagrams such as figure 4. These we use to illustrate potential shifts in care settings in workshops with senior managers. The scenario takes into account the fact that not everyone identified as a suitable for an alternative on the day of the survey will actually be so if, in fact, we see from our post-survey data check that they went home or to a care home within a few days of having been surveyed anyway. If these patients were not accounted for then we would be over-estimating the number for whom alternative care settings would be appropriate.

Much of this potential demand is a manifestation of the fact that many patients in an acute hospital at any one time are actually in a ‘post-acute’ phase of care and usually receiving some form of rehabilitation (and virtually all patients in community hospitals fall into this category). Having identified that such a demand for rehabilitation exists, the question then becomes one of in what location might it best be provided. Modern care practices tend to seek more ‘active rehabilitation’ models in community hospital, care homes and the patient’s own home settings and there is increasingly a blurring of the boundary between health and social care environments (home-based health care and rehabilitation services can rarely take place without adequate social care support as well). This also ties in with other, related trends in health care such as patient choice (with most patients preferring to remain in their own home environment as long as possible). However, currently, this area of care provision in any locality is typically fragmented and has grown in an ad hoc manner, partly in response to central initiatives and pilot projects but also in response to the local legacy of service development and the leadership of individuals. ‘Intermediate care’ – as an example of a national policy driver – has been good at focusing attention on providing services for patients who are capable of being rehabilitated quickly, but this has overshadowed the development of other community-based services for ‘slow-stream’ rehabilitation of six weeks or more (and there are no clinical reasons preventing this).

Recent policy emphases in the UK have been towards the ‘active management’ of older people in the community, particularly those with long-term conditions (such as asthma, diabetes, etc.). The aim here is to monitor and maintain them in the community, avoiding as far as possible any unnecessary hospital admission. Such case management requires not only promoting and looking after their health care needs, but also close attention to their social circumstances and ability to manage activities of daily living in their home environment. Of course this entails much work in developing information systems which enable patient groups to be identified and targeted, and which support inter-organisational working including: single assessment (ie. all health and social care professionals working to common definitions of patient requirements), and ensuring accuracy and transferability in patient records.

This move towards increasing interdependence on health and social care in community-based settings has a significance which goes beyond the need for organisations to be working more closely together; it also has serious implications for the method with which that care is delivered by health and social care professionals. More flexibility in terms of how their skills are delivered through, for example, multi-skilling of individuals or greater devolution to assistants working to lead care professionals has significant implications for workforce recruitment and development. There are already major concerns about skills shortages and this needs to be addressed at an early stage in capacity planning in order for recruitment and training to be scoped and developed.

Figure 5 illustrates estimates of therapy, nursing and care assistant requirements stemming from identification of potential alternatives for patients currently in hospital settings. The top rows of the table indicate ideal inputs (hours per week) of these staff types related to three broad dependency levels of patients. The second block of rows shows the total hours required given the identified numbers of patients in each of those groups and, based on existing volumes of available staff time, the bottom rows estimate the likely additional WTE capacity required if these alternative care options were to be made available.

|  |  |Therapy |Nursing |Care Assistants |

|Weekly Input per Care Package |Dependency Level |Hrs per week |Visits per week |Hrs per week |

|  |High |7 |7 |21 |

|  |Medium |3 |3 |10.5 |

|  |Low |1 | |3 |

|Input required to meet demand previously |  |  |  |  |

|met in hospitals | | | | |

|19 |High |133 |133 |399 |

|12 |Medium |36 |36 |126 |

|10 |Low |10 |0 |30 |

|41 |Total per week |179 |169 |555 |

|Additional WTE to meet additional demand |Capacity/ WTE p.w. |25 |40 |30 |

|  |WTE |7.2 |4.2 |18.5 |

|  |  |  |  |  |

Figure 5: Implications for numbers of care professional staff required

The AEP-based surveys described here are about obtaining a ‘snap-shot’ understanding of a local health and social care economy for older people and indicating the potential for change in provision of services at a strategic decision making level. Figure 5 illustrates that, at a more detailed level for individual staff types, it is possible to be more explicit about the mix of different staff grades that are required as well as their potential working locations. So, once a strategic direction is adopted by all stakeholders, then detailed capacity planning and targeted operational work can begin guided by that direction. This brings the scope of the analysis closer to modelling work previously undertaken by the Balance of Care Group (outlined by Bowen in this publication [2], and described in more detail elsewhere [3]).

Finally, beyond the important aspects of quantification of capacity it is crucial to engage clinical and care professional staff in the implications of the actual change in the provision of services. This needs to be addressed from an early stage of any project as managing the change of investment in some areas – particularly if at the expense of others – requires clinical drive and engagement if it is to happen at all. Local ‘blame cultures’ and cynicism can be a serious drag on attempts to bring about change.

The value of taking a ‘whole systems’ approach to capacity planning is that these issues can be explicitly recognised as an important component of the process. We have found that involving care professionals closely in the survey process is a valuable way to start breaking down some of these - often entrenched – attitudes by offering them new insights into how the local system is currently working, and how it might do so in new ways in the future.

References

[1] Lang T, Liberati A, Tampieri A, Fellin G, Gosalves M, Lorenzo S, Pearson M, Beech R, Santos-Eggiman B, 1999, A European version of the Appropriateness Evaluation Protocol, Intl J Technology Assessment in Health care, 15 185-197.

[2] Bowen T, 2005 ‘Whole System’ models of care for older people. In: Proceedings of the 30th Meeting of the European Working Group on Operational Research Applied to Health Services, Stockholm, Sweden, June 2004.

[3] Forte P, Bowen T. Improving the balance of elderly care services. In: Cropper S and Forte P, (eds), Enhancing Health Services Management pp 71-85 (Milton Keynes, Open University Press), 1997.

© The Balance of Care Group, 2005

For more information contact Paul Forte:

Email: paul@paul40.demon.co.uk Tel: +44 (0)20-7359 6820

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