Get Me Home, Keep Me Home

Speakers:

Naomi Phillips (Day 1) – Director of Policy, Research and Advocacy, British Red Cross

Norman McKinley (Day 2) – Executive Director for UK Operations, British Red Cross

Ashley Young – Independent Living Operations Manager, North Scotland, British Red Cross

Lynne Morman – Integrated Manager (Discharge Management), Dundee Health and Social Care Partnership

This session provides an overview of a British Red Cross and Dundee Health and Social Care Partnership pilot service on Assessment at Home and admission prevention. It will explain the model, outcomes, challenges and impact. 

The design of the pilot is aimed to:

  • Enable earlier decisions and discharge for patients whom there is uncertainty about whether they can go home. 
  • Prevent admission for patients with medical conditions that do not require hospital treatment but need extra care. 

As part of a multi-agency team, the British Red Cross provides home-based care, support and assessment for patients, through the model’s ‘Discharge to Assess’ process. It enables informed decisions regarding the ability of the patient to remain at home, levels of support needed or an informed decision if this is not possible. People remain hospital patients during the assessment at home with care as needed up to 24 hours in the initial stages.

The British Red Cross, as part of the multi-agency team support GP clusters to provide care to patients (not receiving care) with a medical condition which can be treated at home, but who would have been admitted to hospital because they required extra care during this time, for example with a UTI, through the ‘Admission Prevention’ process. 

The assessment outcomes for the model during the pilot (March 2017 – November 2018) were that, 127 patients received the Assessment at Home and 110 people received Admission Prevention. 

Using Assessment at Home, 61 patients (54 per cent) were able to stay at home with longer-term support. These are patients who would have likely been moved to a 24-hour care setting if the Assessment at Home service was not available. Out of the 110 people that received the admission prevention support, only 14 people had to be admitted to hospital.

Key elements of how this approach was developed included:

  • Hospital staff not discharging the patient during the assessment process, the partnership approach and building relationships across sector boundaries.  
  • Acute staff maintain oversight of patients, therefore they see themselves the benefits and value of assessing at home. 
  • Working closely and providing emotional support to the patient and family members to understand the service, the purpose, and the tapering off of support that they are comfortable with.
  • Understanding the impact of availability of long-term care at home options.