Alyss Nowell, Occupational Therapist for the Hip Fracture Early Supported Discharge Team at the Royal Berkshire hospital

Shirley Cramer CBE, Chief Executive of RSPH, introduces our guest blog by Alyss Nowell, Occupational Therapist for the Hip Fracture Early Supported Discharge (HFESD) Team at the Royal Berkshire hospital, after experiencing the service.

A personal experience of secondary prevention  

"In January this year, I had reason to be grateful for the professionalism and caring of the brilliant staff at the Royal Berkshire Hospital. My husband was on his customary Sunday morning early bike ride with a friend when he had a bad fall and broke his femur.

After 30 years of cycling and many competitions, this was his first serious injury and his first time in hospital. I am delighted to say that seven months later he has just got back on his bike for a few gentle rides and will be firmly back in the saddle by the end of August.

His treatment at the Royal Berkshire was excellent but we were particularly grateful to the Hip Fracture Early Support Discharge (HFESD) team who could give a masterclass in secondary prevention. By providing an occupational therapist and physiotherapist to accompany my husband home, they were able to adapt the house and watch him try stairs, make a cup of tea, get up from the chair and all the other daily activities that are so important in building confidence in routines that are otherwise daunting.

This is a pilot programme, but the fact that no one on the programme has been re-admitted to hospital speaks volumes for its effectiveness and I hope that this becomes part of their mainstream services very soon. Here Alyss Nowell describes the programme."

The role of the HFESD Team

The HFESD team was formed as a result of a successful bid to the CEO transformation funds at the Royal Berkshire Hospital. The investment funded the employment of two experienced Occupational Therapists and three Therapy Technicians for a 12 month pilot. 

The aim of the HFESD is to improve patient’s functional outcome and service experience; as well promoting patient flow through the hospital. The service that HFESD provides is driven by the ‘Home First’ approach to a patient’s care and rehabilitation. This is done through providing a comprehensive, personalised assessment of the patient in their home environment and ‘bridging the gap’ for the community rehabilitation teams until they can start. 

It is estimated that older patients in hospital beds who are no longer benefitting from acute services cost the NHS £820 million. These patients are at increased risk of hospital acquired infections, delirium, deconditioning and institutionalisation. For these reasons, it is imperative that medically fit patients leave the acute hospital as soon as possible. 

Patients meeting the below criteria (as per NICE guidance) are eligible to receive HFESD: 

  • Medically stable
  • Have the mental ability to participate in continued rehabilitation
  • Are able to transfer and mobilise short distances
  • Have not yet achieved full rehab potential, as discussed with patient and family
  • Live locally to the hospital 
Additional rehabilitation and assessment

Patients receive additional rehabilitation and assessment on the ward to facilitate a timely discharge. An experienced occupational therapist will also assess patients in their home environment; this enables a much more accurate and personalised assessment than in the hospital environment. 

As part of the home assessment and functional rehabilitation in their own home, patients will be provided with appropriate equipment and advice to maximise their independence at home. The team work closely with the patient and their relatives to ensure areas of concern are addressed.

The home visit may include altering the environment, practising coping strategies, as well as setting up pendant alarms. If a patient is considered to be safe at home, they will be left at home with medications and discharge letter.

"Their knowledge and patience gave me confidence."

Following this assessment, the HFESD team can provide follow up care for around 3 days until community rehabilitation teams can start, so as to ‘bridge the gap’. Patients may be supported for slightly longer periods if there is capacity to do so. This ensures a supported and seamless discharge from the acute hospital to the community. 

Through a comprehensive assessment at home, patients are able to leave hospital earlier with appropriate community services. This enables community care to ‘free up’ capacity for other patients, and, in turn creates bed capacity and promotes flow in the acute hospital. 

"I was scared to go home, but now I feel confident"

Patients who have sustained a hip fracture often feel vulnerable and anxious to return home. The HFESD team provide, what one patient referred to as ‘a safety blanket’. The service aims to prevent further falls and admissions through careful assessment and therapeutic input. 

Efficacy of HFESD

To our knowledge, since commencing the project in September 2017 to May 2018, there has been no patients from the Hip Fracture Unit readmitted with ‘not coping’ or falls at home (who received HFESD). We believe the therapy assessment and advice provided at home plays a key role in preventing readmission and maximising an individual’s ability to complete Activities of Daily Living (ADLs) safely and independently. 

The project aims to listen to the patient’s concerns and choices to provide a personalised approach to discharge. This involves addressing issues ‘there and then’ where possible. In turn, this ensures ‘right intervention, at the right time, in the right place’.

"Like a safety blanket"

Since September, the project has developed to include patients not based on the Hip Fracture Unit in order to roll out the benefits of this project to as many patients as possible. The HFESD team is able to support patients in the transition from acute hospital to home, particularly for those who are anxious, at risk of falls or require set up in their home to maximize independence. 

"Practicing on my own stairs has been invaluable"

The project has enabled individual patients to be able to go home between 1 – 30 days earlier. In turn, according to the National Hip Fracture Database, the overall length of stay for patients with hip fracture has reduced as has the length of stay for the Hip Fracture Unit (when comparing the same period on the previous year). 

This shows an encouraging trend for patient flow. Better flow also increases the likeliness of patients being initially allocated to the most appropriate ward for their needs, ensuring patients receive the most appropriate specialist medical input.

Ultimately, the service aims to provide a person-centered service leading to better outcomes for patients, the acute trust and community services. 

Case Study 

Below shows a case study of a typical patient who would have waited 14 days for her care to start. With a home assessment, it was clear she would manage most of her ADLs, with minimal support required for washing and dressing.

Her anxieties regarding the stairs and cooking for her husband were put at ease with the support of the HFESD team. It was of great significance to her to be able to return to the role of making meals for her husband, an assessment at home enabled her to feel confident doing this. 

On follow up visits, the patient was able to manage her washing and dressing through developing strategies in her own bathroom, as well as recovering well from her hip surgery. 

The care of a typical patient
diagram to show case study of typical patient

Since starting on 4 September 2017, the project has arguably improved patient experience, used community resources efficiently and promoted patient flow. We hope to continue to develop this project and are putting a business case together to secure funding for the longer term.