Home to Decide Services from Hilton

Many elderly frail people are admitted to an acute hospital due to an unexpected crisis, a fall or an episode of illness. A lengthy stay in hospital tends to result in further deterioration in patients’ health and fitness, a loss of confidence and a decline in emotional wellbeing. They may then present as unable to return to independent living and be assessed as requiring residential care or a community bed for a period of rehabilitation.

In these circumstances, patients will have little or no opportunity to consider their ongoing situation and will often have no opportunity to return home to make arrangements prior to the move into residential care. These patients would benefit from an early discharge from hospital with the ability not only to rehabilitate at home but to come to terms emotionally with their long-term needs.

Hilton currently estimate a saving of approximately £400 per week, which would equate to £20,800 per annum.

The Process

The aim of the Home to Decide service is to provide intensive, short term, person centred support for up to 14 days to establish whether they could in fact continue to live independently and, where residential care is required, to support the decision-making process, provide emotional support and assist in practical matters.

Our service supports the NHS when a patient is assessed as requiring a short-term bed prior to moving into residential care. Hilton provide the opportunity for the patient to return home instead. After assessment, the Hilton team, social services and the NHS work together to ensure the patient feels safe to return home and that their living environment is adapted to meet their requirements. Once home Hilton linked the GP and community health team into the partnership.

We work with the patient to understand the patient background, current situation and potential outcomes for the future.

For up to 14 days, the patient will receive the Home to Decide support package which includes a comprehensive suite of assessments, confidence building and daily living needs. We organise a further period of rehabilitation with the Social Services enablement team when the patient no longer requires our support.

Case Study – Brenda

Brenda, 82 years of age, was referred to Hilton by the KCC Adult Social Service team from MTW acute hospital. Brenda had been in hospital for a total of seven weeks, having been admitted with a urinary tract infection, and a history of falls. Brenda had full mental capacity and the desire to return home but, due to her anxiety and lack of confidence in mobilising, she was assessed as requiring a short-term bed prior to moving into residential care.

Brenda had been assessed by the hospital OT as requiring two people to mobilise due to her high level of anxiety. Brenda walked with a wheeled walking frame before she was admitted. Brenda had a very supportive family who were eager that she should have the chance to return home where she would be best placed to make decisions about her future.

The Team

A dedicated project team led by a Registered General Nurse was put in place to develop the Home to Decide pilot. The team included experienced Personal Nursing Assistants (PNAs) and a Hilton OT all working solely on this pilot. This team approach provided continuity of staffing in delivering person focused care and support at a critical decision point for the patient. The team recognised the need to provide support as it was needed, but to give the patient the confidence and the space to take on more day to day activities.

The Partnership Approach

The Hilton team, Kent Social Services and the Acute Trust OTs worked together to ensure that Brenda felt safe to return home and that her living environment was adapted to meet her requirements. Brenda and her family were central to the planning throughout the discharge process. Their wishes and thoughts were communicated with all parties daily and drove the programme success. Once home Hilton linked the GP and community health team into the partnership. The team also ensured that Brenda was once again connected to her social and community networks with friends and neighbours by informing them of Brenda’s return home.

Pre Planning the Discharge for Brenda to go ‘Home to Decide’

The Hilton Project Lead met with Brenda in hospital on 4th September 2017, and spent time with both Brenda and her family understanding Brenda’s background, current situation and wishes for the future. The pilot aims, the Hilton approach, and potential outcomes were explained, and emotional concerns for both Brenda and her family were discussed. A home visit was undertaken with Brenda’s family to ensure all equipment and Brenda’s micro living space were organised to enable a smooth discharge from hospital and return home to be achieved.

Discharge Day – 8th September 2017

A further home visit with Brenda’s family took place on the morning of 8th September and at 14:30 Brenda arrived home by hospital patient transport. Even with detailed planning, Brenda’s medication had not been available from the hospital pharmacy on her discharge but was couriered to her home at 6pm.

Brenda was initially very anxious to be returning home after her long period in hospital. This was contributed to by her room arranged differently and her chair raised to support her mobility, but she was very happy to be home. The Hilton RGN completed the required environmental, medication, nutrition, Braden and moving and handling assessments with Brenda once she was settled and comfortable to do so.

After a small meal, a rest and time with her family Brenda was ready to mobilise out of her chair. She did this well with only the aid of one team member. During the evening Brenda felt more confident to stand from her chair with the aid of her walking frame, but was aided to the toilet and assisted to bed.

As Brenda was micro living in one room, she had a restless first night home. The transition from the hospital environment together with the presence of the PNA sitting with her in the room meant that Brenda found it difficult to sleep that night.

The First 72 Hours

For the first 48 hours the Hilton team stayed with Brenda and supported her with confidence building, nutrition and hydration, personal hygiene and daily living needs. It was obvious that Brenda could mobilise well once her confidence was restored, and the team understood that if Hilton remained a constant, Brenda would then become reliant on them.

On day three the team began withdrawing for short periods during the day to give Brenda space and time alone. They also arranged the reinstatement of her telecare assistive technology (lifeline), organised a keysafe to be installed via the care navigator service and worked with the community therapy teams to help Brenda’s movement and balance.

On the third night home, Brenda felt safe on her own without the Hilton team overnight, but with the ability to call them back if required. An on-call phone was put by her bed with the number programmed so that Brenda could access assistance immediately if she needed it. The team stayed until late into the evening and returned very early morning to reduce any anxiety Brenda may have felt at this time.

The Project Lead identified three areas of concern that the Hilton team needed to focus on:

• Confidence Building – Brenda was still anxious that she may fall again
• Strength Building – the community therapy team produced a tailored exercise plan for the PNA’s to work on daily with Brenda as she was still struggling to get out of bed
• Nutrition and Hydration – Fluid intake needed to be encouraged and monitored to ensure Brenda remained free of urinary infections.

Brenda’s Success

With ongoing support and encouragement to undertake daily living tasks independently, by the end of day 10, the Hilton team were only required for two visits per day.
Brenda was managing her own medication, preparing meals and using the toilet rather than a commode. The Project Lead remained in constant communication with Brenda’s family to give support and encouragement and organised for the Social Services enablement team to take over on 19th September for a further period of rehabilitation.

Conclusion

The outcome for the first patient on this pilot service has been a complete success. The patient is living independently, rather than in residential care, and the Hilton model of focusing care at the times where it is required has proven successful in achieving a rapid increase in patient confidence.

A further four patients will complete the Hilton pilot of Home to Decide, the second of whom is already at home. This patient has a significantly different personal profile. She has a diagnosis of dementia but has already re-adjusted to returning and living at home with a reducing Hilton support programme.

Hilton have asked KCC commissioners to provide data on savings arising from the pilot in order to confirm the value of the programme.