Managing Transfers of Care & Reducing Hospital Admissions

The UK’s ageing population have increasingly complex needs, many of which are not met by the care they receive.

Older people are the biggest consumers of care and have the highest hospital admissions out of any demographic.

This case study focuses on the efforts of the North East and North Cumbria Ageing Well Network to improve care and minimise hospital admissions.

Understanding the Needs of Frail People

The British Geriatrics Society define frailty as a distinctive state related to the ageing process, but not an inevitable consequence of ageing.[1]

Not all elderly people are frail, and not everybody living with frailty is old. Younger people with complex needs can be categorised as frail.

As multiple body systems, both physical and psychological, lose their built-in reserves, people begin to develop frailty.[2]

NHS England characterise frailty as a progressive, long-term condition and entails a loss of physical and/or cognitive resilience.

This makes them vulnerable to sudden changes in their health and social needs. These changes can be triggered by seemingly small events such as a change in medication or a breakdown in carer support.[3]

An example of a traditional frailty crisis will be a fall, confusion, or the inability to walk. People with frailty can deteriorate unexpectedly and the recovery is often fragmented.

A recurring problem is that people with frailty who have a multitude of complex needs are boxed into a single system disease process.

Staff require training to be informed and comfortable dealing with patients with multiple needs and frailty.

The NHS’ long-term plan is now based around three pillars;

A recurring theme in the Ageing Well bracket is to better connect and join up care to support older people living with frailty.[4]

Jackie’s Story

To exemplify the real-life challenges that occur when managing care, the North East and North Cumbria Ageing Well Network shared Jackie’s story.

The case study highlights the importance of understanding the social context of a patient, such as Jackie’s enthusiasm to keep working into their seventies.

It was fundamental that a holistic view of Jackie’s care and needs was taken, painting a complete picture of Jackie as an individual was central to developing a quality care plan.

Jackie had access to specialists in his area, who were able to provide a timely diagnosis, treatment, and discharge. This minimised his hospital visits and set up the course for a strong transfer of care.

In total, there were six occasions where hospital visits were safely avoided due to the urgent community responses being available, as well as the family carer support that was implemented.

The Model Behind Jackie’s Story

Pulling together a model that prevents admission, facilitates a successful discharge, and supports a transfer of care is no easy feat.

The four building blocks behind the North East and North Cumbria Ageing Well Network methodology are:

• Identify
• Assess
• Plan
• React & Reable[5]

Identifying different presentations of illness and being able to break them down is important in providing the right care.

1. Deconditioning

This occurs usually when a patient has an acute illness and is admitted to hospital for over a week.

Deconditioning is a complex process of physiological change induced by inactivity that can affect multiple body systems and may result in a decline in physical, psychological, and functional abilities.[6]

A patient who is laying flat in bed for days on end, particularly an elderly person, will experience more rapid muscle deterioration.

The psychological effects of being in a hospital environment, in a gown, with a reduced ability to carry out tasks as seemingly basic as using the bathroom can also be detrimental to someone’s overall welfare. 

2. Normal Ageing

When humans age, their overall muscle strength and exercise capacity declines. This leads to more falls and general immobility.

Ageing happens at a less intense rate than deconditioning, and can make other conditions, be they acute or chronic, harder to spot in older people.

3. Pre-existing frailty, disability, impairment

Patients with pre-existing conditions provide another unique challenge, which is spotting what is happening as a result of said condition and what is happening as a result of ageing.

These impairments are easier to spot in younger people, as the process would be as follows:

• Patient previously well
• Acute illness
• Single system pathology
• Can give history

For older people, the process is more complex and harder to spot:

• Multiple health problems as well as ageing
• Can be acute or chronic
• May have more than one new problem
• May not be able to give a history

Pulling it Together

Creating integrated care communities, to ensure a patient’s history is known and each part of the process operates efficiently is crucial to providing smooth transfers of care and also reducing transfers of care.

By following the model above and continually evaluating each part of the health and social care system, hospital admissions will become less commonplace for ailments that could and should be dealt with elsewhere.

The priority should be to provide as much care as possible whilst still empowering the patient to live as full a life as they can.

The best way to do this is to think of the home as the best place for people until it becomes absolutely apparent they cannot be cared for there any longer.

The social care ecosystem has to maintain a person-centred approach that treats all patients with dignity.

From shared care planning, to timely discharges in the case of hospital admissions, every part of the puzzle has to work in sync to allow Britain’s ageing population to age well.

[1] British Geriatrics Society. 2014. Fit for Frailty. Part 1. Consensus best practice guidance for the care of older people living in community and outpatient settings.

[2] frailtyicare.org.uk. 2021. What is frailty?

[3] NHS England. 2021. Older People Living with Frailty.

[4] Northcumbriahealthandcare.nhs.uk. 2019. Strategy Update Item 10. Part 4.

[5] Bainbridge, Lesley. 2021. Clinical Lead, North East and North Cumbria Ageing Well Network. Managing Transfers of Care & Reducing Hospital Admissions.

[6] British Geriatrics Society. 2021. Topics: Frailty.