Relieving the ever increasing pressure placed on the NHS and social care services nurse led Hilton Nursing Partners have developed and launched a service called Home to Decide aimed at reducing residential care admissions for patients assessed for requiring residential care in an acute hospital setting.
Underestimating the patient’s physical and mental capabilities to return home patients remain in hospital waiting to be transferred into available residential care beds. The difficulty with the transfer model is it requires patients to remain in a state of limbo in a hospital bed as a DTOC’s (Delayed Transfer of Care) until space becomes available.
The negative effects can be far more concerning. Any lengthy stay in a bed is proven to result in muscle wastage, but the psychological effects of not being in your own environment can result in loss of confidence and potentially create a greater level of dependency.
Keen to offer an alternative solution the Hilton Nursing Partners Home to Decide philosophy of thinking was designed with a number of guiding principles:
a) Patients who prefer to live independently at home after an acute hospital stay, and who believe they are capable of doing so, should be supported to achieve this.
b) Patients need integrated health and social care that takes into account the patient’s physical, emotional and social wellbeing.
c) Patients are better served by support and encouragement that fosters independence, rather than acute hospital care or social care which tend to create dependency.
d) Patient assessments undertaken in the service must be of the highest quality in order to provide realistic expectations of outcomes.
e) The service recognises that leaving one’s own home to move into residential care is a major life decision for the patient and for their family and that practical support and emotional space to come to terms with these next steps are paramount at this time.
f) Family members, neighbours and community organisations can all have a key role to play in maintaining a patient’s wellbeing and independence.
The Hilton Nursing model integrates health and social care, and draws upon Nurses, Occupational Therapists and Personal Nursing Assistants (PNAs highly trained healthcare assistants) to deliver an intensive programme of holistic support and assessment delivered in a patients’ own home. The level of support is continuously reviewed, starting at 24 hours per day, but reducing as the patient shows confidence and ability to function independently.
Having successfully piloted and tested the Home to Decide model of care with NHS Trusts and Councils across the South East the results have been self-evident. The vast majority of patients were able to remain at home and continue to live independently.
The far-reaching benefits of this care model have been clear to see:
- Reduction in acute hospital DTOC days
- Provides patient choice and control regarding next steps
- Reduction in residential care placements commissioned
- Better health outcomes as a result of patients living independently
- Reduction in annual social care costs of up to £20,000 per patient a year.
Ann Taylor, CEO of Hilton Nursing Partners says: “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 on-going situation and will often have no opportunity to return home to make arrangements prior to the move into residential care. Our service avoids a potentially stressful and distressing situation by providing patients with the ability to rehabilitate at home, and time to come to terms emotionally with their long-term needs.”
Rated “Outstanding” by the Care Quality Commission (CQC) Hilton Nursing Partners works with the NHS and Social Care Commissioners to successfully deliver safe, timely and supportive hospital discharges, patient assessments and patient recovery programmes via nurses, therapists and nurse led personal nursing assistants with a proven track record in freeing hospital beds, as well as reducing re-admissions and on-going social services support.
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