Enhancing care transfers from hospital to home for older people with complex needs

Introduction Care transfers for older people with complex needs should be person-centred with effective multi -disciplinary teamwork (MDT) across hospital and community settings (Bolsch et al. 2005). This paper presents a project to enhance care transfers within Southwark and Lambeth Integrated Care (SLIC), which is a federation that promotes integrated care in south London, through bringing together general practices, acute hospitals, mental health care, social care providers and commissioning groups. This project comprised: Phase 1: Literature review of best practice in care transfers of older people; Phase 2: Scoping staff educational needs through: meetings with key individuals and teams, observation of MDT meetings; analysis of a local patient discharge survey; Phase 3: Development, delivery and evaluation of a one day interprofessional simulation course (‘Good to go: enhancing care transfers for older people’) for health and social care professionals. Phases 1 and 2 findings indicated the need for understanding integrated care and service provision in the community; mutual trust, honesty and respect; communicating about patients across settings; and understanding local services and referral processes. There was strong support for simulation using complex patient scenarios, delivered interprofessionally, which can improve understanding of each profession’s role (Tofil et al. 2014). This paper will focus on the Phase 3 courses, their delivery and evaluation. Short description of practice change implemented The course aims were to: Draw upon shared experience and knowledge to promote best practice for the safe transfer of care across a range of settings. To enhance discharge planning skills including more effective communication, assessment and evaluation of needs, and multi-agency, inter-professional working. The course design reflected a patient’s journey from hospital to discharge and community care, based on real life local scenarios delivered with actors. The course’s target population was health and social care professionals across SLIC and whose roles included the care transfers of older people with complex needs. The six pilot courses (June-September 2015) were funded by a local education board. There was no backfill for course participants so engagement with key stakeholders (senior health and social care service managers) was essential for enabling attendance. Key findings A total of 49 staff attended and each cohort included varied professions across hospital and community settings, enabling them to learn together, build professional relationships and improve understanding of each other’s roles and services. Course evaluation was based on Kirkpatrick’s (1994) model: initial reaction to training; participants’ learning; application of learning from the training; and achievement of targeted results and outcomes. Participants completed questionnaires pre-course (n=44) and post-course (n=47) on the day, thus exploring the first two levels of Kirkpatrick’s model. Pre-course, 30 (68%) participants reported having experienced difficulty in transferring or receiving the care of a patient with complex needs. Post–course, 44 (91%) intended to make changes to their clinical practice and all believed these would enhance their MDT working. All agreed they understood the importance of effective communication and early communication. The open text comments included many about increased understanding of roles and communicating effectively across settings. Further evaluation is currently in progress using semi-structured interviews with a purposive sample of 12-15 course participants, exploring application of their learning from the course in practice and perceived outcomes (Kirkpatrick’s model, levels 3 and 4). These results will also be presented. Highlights The course aims were achieved, with a positive evaluation and the value of interprofessional attendance from community and hospital settings was evident, supporting recommendations for staff to have opportunities to gain better understanding of each other’s roles and build relationships (Baillie et al. 2014). One course was poorly attended due to late dropouts and the original project timeline was extended to enable sufficient time for rostering staff attendance. It was originally hoped to co-deliver the course with an older person with complex needs or carer but this population was difficult to recruit from due to ongoing health issues. This remains an aspiration for future courses. The follow-up interviews are enabling exploration of perceived application and impact on practice from participants’ perspectives. Conclusion The interprofessional simulation course was developed from best practice review and local scoping and staff perspectives. The course could be transferred to other settings and has been shared through simulation networks. A challenge is that staff turnover across London is high but staff would be able to transfer learning to new organisations. Evaluation is essential as simulation course delivery is labour-intensive and has to be justifiable in economically constrained times