This proposal is subject to change as the project progresses.
TITLE: FROM HOSPITAL TO HOME VIA INTERMEDIATE CARE – HOW DOES IT FEEL FOR YOU?
Background/Rationale
I am a social worker within a local authority social work team supporting older people and people with disabilities in the South area of Glasgow. I have worked within the hospital team for the past ten years, working with individuals, including older people, to facilitate a safe discharge from hospital.
This is a challenging time for effective provision of health and social care services in Scotland, (particularly with supporting individuals discharge from hospital). The Audit Commission highlights that over time, we are dealing with an increasingly ageing population. The percentage of the population who are over 65 years was 17% in 2010, and is forecast to rise to around 35% by 2035. It is also anticipated that as people live longer, they will present with increasingly complex health and care needs, all of which will result in an increased demand on services and costs incurred to support them. Compounding this, these changes are happening at a time when budgets are declining.
As a result, unless we change the way we deliver health and social care services to our older people, supporting them effectively will become unsustainable.
In recognition of this, the Scottish Government produced a report in 2010 ‘Reshaping Care for Older People: A Programme for Change 2011-2021, examining the feasibility of a sustainable future for effective delivery of health and social care services to support older people over the future decade. To support these more sustainable changes, a ‘Change Fund’ of ยฃ300 million was provided to fund the initial 4 years up until April 2015.
In addition to Reshaping Care for Older People (RCOP), a number of policies which will affect this older population were planned, relating to dementia, housing and transport.
Alongside this, are plans to integrate health and social care services across Scotland, which has resulted in the Public Bodies (Joint Working)(Scotland) Act 2014 coming into force in April 2015. This will require health boards and councils to produce an integrated plan for health and social care
Since 2004, it has been a policy objective of the Scottish Government to ‘shift the balance of care’ from hospitals and care homes, to people’s own homes and communities, and focussing more resources on preventing ill health. Progress on this has been limited due to the pressures of reducing finance and increasingly older population, however it remains an Important focus.
In July 2014, NHS (GGC) highlighted that around 10% of acute hospital beds are occupied by people who are clinically fit for discharge, but unable to move on for other reasons such as social care support or placement. These delays in discharge are detrimental to the health and wellbeing of the individual patient, and costly to the NHS.
In taking account of these issues, the change fund has supported a number of initiatives, which includes looking at alternatives to hospital placement, such as a virtual wards model, hospital at home model, and step up/step down models.
Within South Glasgow, assessment at home model was piloted in 2012, where patients age 65 or over who were fit for discharge, but unable to return home, were accommodated within a specifically commissioned unit within a care home. Here, their care needs, and any rehabilitation needs met by dedicated nursing, care staff, physiotherapy and occupational therapy services. This enabled time for a social care assessment, and any aids, equipment or adaptations be undertaken prior to returning home, or if this was untenable, to a care home placement. The following year, this was refined and superseded by a step down model. With the recent announcement that the target for ensuring patients are safely discharged from hospital changing from four weeks to 72 hours imminent, the step down model is now being expanded to facilitate a larger number of people over 65 who are clinically fit for discharge but unable to return home at that time, for other reasons.
From experience of working with service users both whilst they are in hospital, and then following them up after they have moved on, I have been struck by the sometimes substantial and at times unanticipated recovery, some people with good supports can make upon leaving the hospital setting.
In tandem with this, from observation of patients being cared for within an acute hospital ward setting, I can see many barriers to achieving the best outcomes and recovery for older people once they are clinically fit for discharge.
This question of environment, and the potential impact it may have upon an individual at such a vulnerable time in their life, has raised an interest I am keen to explore.
Using an intermediate care environment to facilitate hospital discharge is a relatively new practice, and is not a mainstream service at this time. Whilst there is much quantitative data being collected around this area, feeding to joint health and social care work streams, and to the integrated resource framework, there is no information on the views of service users or carers.
As a result, I am interested in exploring the service users experience of the intermediate care environment, and their views of this in comparison to that of the hospital ward.
Research Questions, Aims and Objectives
Aims
The aim of this research project is to explore, from the perspective of the service user and their carer, if the environment of an intermediate care unit within a care home, offers benefits to the experience of, and outcome for an older person, following acute care in a South Glasgow hospital, over the traditional environment of a hospital ward.
To explore what the service user and carer think might improve their experience, and to extrapolate findings from this research, which might inform future service providers to be more effective and service user led.
Objectives
โข To undertake a qualitative study of five older people who have been discharged from a South Glasgow hospital to an intermediate care unit for a period of assessment and rehabilitation prior to support their discharge back into the community.
โข Where carers are actively involved in supporting the older person, carers views will also be sought.
โข Use of semi-structured interviews, which will offer consistency in questioning, but also enable exploration of what the interviewee wishes to contribute.
โข Interviews will be recorded, and transcribed to ensure accuracy, and findings shared through a number of routes to enable the service users voice to be heard.
Research Questions
This research explores the experience of a number of older people who’s discharge from hospital is facilitated by a period of assessment and rehabilitation within an intermediate care unit. It seeks any evidence that might identify factors which could drive successful transition from hospital for older people.
โข What are the feelings, perspectives, expectations and aspirations of the service user having moved from hospital to intermediate care?
โข What are their views following transition from this intermediate care environment?
Methods
This will be a small scale qualitative study using semi-structured interviews of five service users, and their carers.
Social work team leaders responsible for hospital casework will identify service users over 65 years who retain mental capacity, and have been discharged from hospital to an intermediate care setting before moving on to their home or another community setting.
Letters will be sent to both service users and carers explaining the purpose of the research what would be expected of participants, and inviting them to take part in an interview in their home (if they prefer), at a date of their choice.
Letters will be followed up by a telephone call to prospective participants to ascertain if they are prepared to participate, and if so, a suitable appointment will be scheduled. If responses are negative, then this process will be repeated.
Semi- structured interviews will take place in the participants home. If the participant does not wish to use their own home, I am happy to consider other options, so long as safety and privacy are afforded. I will be able to offer use of the social work office if this is preferable.
These interviews will be recorded, and will then be transcribed as soon as possible after the interview. They will be scheduled for an hour, however, will be cut shorter if the service user is in any way unable to comfortably sustain this for any reason.
Once transcribed, the data will be analysed, enabling the final report with findings to be completed.
I have chosen semi-structured interviews, as I think this lends itself well to a biographical approach, which would give the participant the best opportunity, whilst sitting in the comfort of their own environment, to explore their views and experience of the hospital, and intermediate care environments, yielding much richer, more valuable results. The experiences and attitudes which are being explored, are likely to have been traumatic to some degree, and so a one to one interview, in the privacy of the participants home, where the tone can be modified to suit the individual would be more appropriate. The open ended nature of the questions in the semi structured interview enable depth in exploration of the views and feelings being sought. It enables you to ‘probe beyond the answers’ and thus ‘enter into a dialogue with the interviewee’ (May, p134)
Before the interview begins, I will provide the participant with a consent form, explain this to them and ask they sign if they are happy to proceed. I will explain what is expected of them, and reassure they can stop the interview at any time.
In preparation, I have researched successful semi structured interviewing techniques, and hope to practice these prior to starting the interviews for this research.
Ethical Considerations
In order to ensure participants do not feel uncomfortable or coerced, participants will be selected by social work team leaders, and not necessarily known to me. They will be known to retain mental capacity. Prior to directly approaching potential participants, they would receive an easy read letter briefly explaining the purpose of the project, what they would be asked to do, and the potential benefits their participation could have. It will invite them to participate in an interview within their home, explain the time this would take, and emphasise that all information gathered would be anonymised.
Participants agreeing to this, will be invited to agree an appointment at their convenience.
All participants will have already been screened as retaining mental capacity prior to being allocated,and hence will be fit to consent to their participation in the project. Prior to any interview proceeding, I will provide an information and consent form. I will give the participant a copy and read it to them as appropriate. I will ask them if they still wish to continue with the interview, and if so, invite them to sign the form. In doing this, I will be clear with them, that they do not need to continue, and if they do consent, they can change their minds at any time through the process.
I will advise the participant about the recording equipment, and perhaps invite them to suggest a good place to site this. The participant will be informed about what will happen with the data, that the recording will be kept in a locked cabinet at all times, apart from when I will transcribe the interview, and that it will be destroyed afterwards to ensure confidentiality. I will assure the participant that the transcription will be completely anonymised, and that anything such as copies of letter will be kept in a locked cabinet, and then shredded.
In explaining the participants anonymity, I will stress to them that any views they express or information that they provide, either positive or negative, being anonymous, will not affect any service they receive, emphasising the purpose of the project.
I will note that the only time I might need to share any information they provide would be if it related to a criminal activity, or highlighted an individual at risk of harm, which would require to be acted upon.
To assist the participant to feel at ease, I will use appropriate language, tone and body language. I will encourage the participant to make choices, use appropriate listening skills, and take time to engage, build trust and empathy. I will build rapport with the participant, and reassure them that their participation is very much appreciated, and valued. If the person appears uncomfortable with any particular question, I will reassure them and divert to a neutral topic as appropriate.
In keeping with data protection legislation, all data will be kept in a locked cabinet, and only accessed by myself or my supervisor. The participant data will be confidential, with participants names coded using a reference number. A key to the cod reference number will be held in a separate document,a nd stored securely.
Knowledge Exchange
It is planned that the experience and outcomes from this research will be shared in a number of ways.
โข IRISS Knowledge Exchange event in July 2015
โข At an organisational level, through GGCNHS and SocialWork Services Performance and Integration work streams; relevant commissioning services, and South SWS team Development forums.
โข The participants will be offered information on the findings, including CD recording of their interview if they wish and the postcard or final reports.
โข Through information postcards for dissemination from information points in various community locations including libraries, local GP surgeries, local community centre, carers services, and social work services offices.