Abstract
Background:
In response to the COVID pandemic when new robust discharge criteria were introduced to facilitate early discharge to optimise hospital capacity, Post Discharge Frailty Support (PDFS) was established. PDFS provides nurse-led telephone follow-up for patients discharged primarily from the Emergency Department (ED) and the Acute Frailty Assessment Unit (AFAU).
Objectives:
We aim to provide continuity of care by following up frail elderly patients at home, reviewing their medical, functional and social progress post discharge and ensuring they received adequate support to avoid hospital re-admission. Methods: The service is overseen by the Lead Frailty Practitioner, supported by Consultant Geriatricians. Calls are made Monday to Friday by a team of Advanced Specialist Nurses. The case load is split up into 3 categories with different levels of priorities – 1: at least weekly calls; 2: Fortnightly calls; 3: Monthly calls. This service engages closely with community partners such as community frailty service, social care, district nurses and general practitioners.
Results:
In year 1 (1/4/2020-31/3/2021), we had 598 patients on this PDFS. 93 patients were referred to therapy team for urgent equipment to maintain safety, 73 patients were referred to community frailty and 112 patients had urgent discussions with GP to avoid hospital admissions. The 30 days readmissions rate was 14%. 547 patients were discharged. In year 2 (1/4/2021 – 31/3/2022), we had 297 patients. 49 patients were referred to therapy team, 32 patients were referred to community frailty team, and 41 patients required input from GP. The 30-day readmission rate was 11%. 224 patients were discharged.
Conclusion:
PDFS is an effective service that has helped to reduce length of stay of frail elderly patients in an acute hospital setting, maintaining patient safety and prevent hospital re-admission, co-ordinated with community services. Our service has been highlighted in the recent GIRFT report on improving clinical practice.
Comments
Hi, that's a really interesting poster.
May I ask:
1) Have you looked retrospectively at a cohort of frail patients discharged prior to implementation of this program to look at their readmission rates?
2) How did you negotiate the sharing of clinical responsibility for the patients post discharge? Were they under the remit of your team for follow up appointments if they had a problem post-discharge, were they signposted to their GP, did your team liaise directly with the GPs to agree a shared plan?
3) Where did the funding stream come from, what was the costing of the project and is the team continuing to operate?
Thank you! Apologies if some of the answers to these questions are in your presentation - I am unable to open it currently.
Hello
Hi Kathryn, thanks for your questions.
I will try my best to answer them.
Answer: We did not retrospectively look at this cohort of patients’ readmission rate prior to implementing the service as it was set up rather quickly and we did not have time to get any baseline data. The 2 frailty nurses who were classified as 'high risks for complications from COVID' had to isolate from clinical work and thus this service was introduced and became part of their day job during COVID outbreak. It was started on the basis of supporting elderly patients – to facilitate early discharge to create bedspace for COVID positive patients at the initial stage of this service. However, we then retrospectively reviewed the patients who have been added onto the caseloads and review their readmission rates.
Answer: Once the patients have been discharged from the frailty unit, the sole clinical responsibility lies within the GPs. However, if there is some ongoing issue( i.e medical problems/ social needs/ therapist needs) that patients raised during the telephone follow up calls, the nurse practitioner will liaise with consultant geriatricians for advice – the options are
i) Can GP sort this issue? normally if this is a new concern raised by the patients, then the team will ring GP to highlight the concerns.
ii) If it is an ongoing issue -following discharge from the frailty unit/ ED – the case can be discussed with the consultant geriatricians – either arrange for HOT clinic review / telephone phone consultations by the consultants.
iii) The team will liaise with GP for a shared plan occasionally
iv) At times, we refer to the community frailty nurses to review patients at home / refer on to social care services to increase POC etc.
There is no extra funding for this service as when it was started, the 2 frailty practitioners (who needed to isolate) took on the project and yes, it is still running within existing resources, but the caseloads are smaller - probably around 140+ patients.