Pathways and Processes
Discharge, terminating professional contacts
how professional and or informal follow up is properly communicated, available and well prepared
COUNTRY / LOCATION: Switzerland
Keywords: discharge, interorganisational teamwork
Keywords: discharge, interorganisational teamwork
Improvement of discharge planning through formal collaboration between hospital and home care organisation: Express Service
Summary
The Express service from the home care organisation of the City of Bern is intended for elderly people who require home care after a hospital stay. The target population is 80 years old on average. About 20% of the (regular) hospital discharges are unplanned.
The hospital, GP, informal carers or the patient him/herself may announce the impending discharge to the home care organisation, by mail or by phone, through a single entry point. The request for care is forwarded to the home care centre of the district in which they patient is a resident.
The home care professional, who is usually the person who will take care of the patient at home, makes the initial assessment while the patient is still in the hospital. The hospital doctor gives the information on the spot, in presence of the patient.
This organisational setting enables a more direct and efficient communication between the parties involved during a hospital discharge as gaps and ambiguities are immediately clarified and needed home care services adequately planned. Thus, the Information flow between both institutions is guaranteed and the customer is informed by a single home care nurse.
The needs assessment in complex care situations can take place within 2 to 4 hours after notification from the hospital, even on weekends.
The reorganisation of the Express service achieved in 2010 caused a reduction in the hourly cost of care by 40%.
What is the main benefit for people in need of care and/or carers?
The Express service ensures an integrated follow-up in the hospital-home transition phase. It enables the patient to return home in adequate conditions and without undue worries.
What is the main message for practice and/or policy in relation to this sub-theme?
The facility shows that a “brokering service” working across organisations can improve the quality of hospital discharge and contribute to reducing the average length of stay in hospital.
Why was this example implemented?
The Express service aims to improve the quality and efficiency of the hospital discharge process by better integration of the follow-up process.
It promotes the involvement of the patient and his/her social network in the care process by considering them as full stakeholders.
The aim of this organisational arrangement is also to secure an efficient interface between hospital and home care in order to prepare the hospital to the implementation of the Diagnosis Related Groups (DRG’s), which will increase pressure on length of stay in the hospital.
Description
The Express service from the Home care organisation of the City of Bern is intended for inpatients who need support once they return home. The hospital, the GP, informal carers or the patient him/herself may announce the impending discharge to the home care organisation by mail or by phone, through a single entry point. The request for care is forwarded to the home care centre of the district in which the patient is a resident. The needs assessment is conducted in the hospital by a home care nurse. Wherever possible the same nurse will be in charge of the follow-up at home. In some cases, another team member will provide the care.
Older people are advised and informed in advance (verbally and in writing) before they agree to the intervention of the Home care organisation of Bern. A contract will be formalised through a signed service agreement. If the client has a guardian, he/she must also give his or her consent.
All complaints are recorded in written form and evaluated centrally within the framework of the QMS (Quality Management System).
Professionals’ rights are guaranteed by labour legislation in terms of daily work hours, etc.
The care plan is prepared with the client and kept by him/her at home. There is only one original copy. The client has permanent access to everything that is written about him/her by home care professionals.
Clients are fully informed about which care activities will be carried out. His/her social network is taken into account in the care plan, which also specifies who is responsible for what. A consulting service and a hotline (run by the Swiss Red Cross) is available for family caregivers.
The Express service is funded by health insurance according to standard hourly rates, by a contribution of the referring partner hospitals and by the patients themselves for services not covered by health insurance.
If the health insurance company refuses to reimburse mandatory services given by the home care organisation and prescribed by a medical practioner, legal representation paid by a special clients’ fund will be provided free of charge by the homecare organisation.
What are/were the effects?
The organisation allows for better integration of the follow-up between the hospital and the home care organisation and for faster discharge.
The discharge process is more flexible and even last minute discharge decisions can be implemented quickly and efficiently.
The service enables the patient to meet his/her future home care nurse while still in the hospital. It ensures an accurate application of the hospital prescriptions. All professionals involved in the follow-up know each other, which facilitates the transfer of information, especially through direct questions from the home care nurse to the physician in charge.
Lower costs result from timely discharge. Moreover, the number of readmissions caused by a poorly planned discharge return can be reduced (avoidable re-hospitalisations).
The reorganisation of the service in 2010 resulted in a 40% reduction of the hourly cost of the Express service compared to the organisational form the service had initially. This gain in efficiency was made possible through the suppression of the specific nursing team, initially dedicated exclusively to the Express service. Today, every nurse works in the regular home care team. Appropriately qualified nurses may be called upon at any point to respond to a request addressed to the Express service.
Evaluation and review of the Express service is conducted jointly by both hospital and home care organisation on the basis of patients’ feedback.
The home care organisation of the City of Bern currently negotiates with three private hospitals that are also interested in improving the interface between hospital and home care.
The home care organisations of Zürich and Zug are planning to develop similar projects.
What are the strengths and limitations?
Strengths
The strength of the Express service is its very high flexibility in terms of deployment. This makes for simplification and security of the care pathways as well as rapid intervention in case of unplanned or emergency discharge. Through the reorganisation of the service, costs have been reduced, so it can now be provided to a broader group of patients. The integrated character of the model enables the stakeholders to be heard and their concerns are taken into account.
The chances are good that many organisations will adopt this relatively simple organisational setting in the future.
Weaknesses
The weakness is that even if the goal of the Express service is undisputed, it is not popular among the home care staff, because it requires a high degree of flexibility from employees.
There is also a risk that, if the service’s commitments cannot be kept, hospitals may revert to previous discharge arrangements patterns even if though they may be less satisfactory for the older person.
Credits
Author: Pierre GobetReviewer 1: Roelf van der Veen
Reviewer 2: Michel Naiditch
Verified by: Marius Muff, Spitex Bern
Links to other INTERLINKS practice examples
- Coordinating Care for Older People (COPA): Team work integrating health and social care professionals in community care
- Integrated home care and discharge practice for home care clients (PALKOmodel)
