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Joint action plan helps 'delayed' patients to leave hospital sooner


Oxfordshire health and social care providers are developing a joint plan to enable patients to leave hospital sooner to be cared for in the best place for them. This may mean being transferred to their own home with a care support package or to intermediate care in a nursing home. These are patients who do not require any further hospital based medical treatment and who would benefit from being in a more appropriate environment.


Up to 150 patients currently delayed in Oxfordshire's hospitals will be transferred to a number of the county's nursing homes for intermediate care. Patients will remain in the nursing homes for a period of up to eight weeks, where they will receive multidisciplinary clinical and social work rehabilitation support to enable them to return home at the earliest possible opportunity. Where it is more appropriate, other patients will be transferred from hospital to home with an appropriate package of care to support them remaining there.   The transfers out of hospital are expected to take place in early December 2015.


The Oxfordshire health and social care system has long-standing problems in being able to transfer patients to the next stage of their care from Oxford University Hospitals - whether home with domiciliary support, or to a residential or nursing home setting.  Likewise, Oxford Health NHS Foundation Trust experiences delays in being able to transfer patients from community hospitals.


Currently there are 120 patients in Oxford's John Radcliffe Hospital, the Nuffield Orthopaedic Centre, and in the Horton General Hospital in Banbury and a further 30 patients across Oxfordshire's community hospitals who are waiting to move on to the next stage of their care. 


Intermediate care in a nursing home environment offers the most appropriate care for such patients whilst rehabilitation continues and arrangements for their return to home or longer term placement are made.


Delays in transferring patients can have a considerable impact on hospital services, as the inability to discharge patients in a timely manner makes it more difficult to admit patients who need to be in hospital for both emergency and planned treatment.  The transfer plan will relieve pressure on the county's emergency departments at the John Radcliffe Hospital and the Horton General Hospital by releasing capacity and allowing extra beds to be opened in the Emergency Assessment Units.  This will facilitate the flow of people through the Emergency Departments.


In the video below, health system leaders explain about a joint plan to enable patients waiting for intermediate care to leave hospital sooner and be cared for in the best place for them.

Oxford University Hospitals Chief Executive Dr Bruno Holthof said: "It is really important that our patients are able to leave hospital as soon as they are clinically fit to do so and no longer need acute care.  The longer patients are delayed, the greater the risk from hospital infections and loss of independence and mobility for more vulnerable older patients. 


"Patients who are ready to leave hospital but who are delayed in doing so can, over a sustained period of time, become dependent on inpatient care, with the loss of skills for independent living leading to a requirement for a higher level of ongoing care at home or in a residential nursing home.


"This plan supports our joint aims that patients, who are medically fit, are transferred to a more appropriate environment for their care needs, while helping to increase our bed availability for our acutely ill patients."


Oxfordshire Clinical Commissioning Group Chief Executive David Smith said: "There is a need to take radical action prior to winter to improve the flow of patients in and out of our hospitals in order to manage the expected increase in hospital admissions due to winter illness affecting the elderly and those with chronic conditions.


"Delays in discharge can create capacity problems within our hospitals with patient flow slowed across the entire patient pathway, adversely impacting on the quality of treatment and care through longer waiting times and access to beds for patients who need to be admitted for both emergency and planned treatment.

"It is important that we work together as a system to make sure patients leave both community and acute hospitals as soon as they are clinically fit to do so - and with the right support to enable them to do this."

Oxford Health Chief Executive Stuart Bell said:  "This is a really good example of the Oxfordshire Health and Social Care system pulling together to make the very best use of all the people we have, to prepare for the coming winter and to make sure that we care for patients in the very best environment to support their recovery and rehabilitation.

"We know that the clinical evidence is that for most of us, once your immediate medical needs are addressed and with appropriate ongoing health and social care support, the best bed is your own bed at home."