Since 1992, a Day Rehabilitation Unit (DRU) has been operating within Whiteabbey Hospital. It was based on the traditional Day Hospital model providing consultant-led multidisciplinary specialist assessment and rehabilitation to enable older people to continue to live at home and prevent hospital (re)admission. Referrals generally took a minimum of five days to be processed. According to Black (2005) the majority of day hospitals within the UK still consider rehabilitation as a major role and it seems an effective service for elderly people who need rehabilitation, but he argues that it had no clear advantages over other forms of care. Khan (2009) argues that, in order to survive, the day hospital needed to evolve in line with the needs of the service.

One role for Day Hospital is in crisis intervention. The British Geriatric Society (BGS) calls for Accident and Emergency (A&E) departments to carry out routine screening processes for frail older people presenting for treatment, althought they highlight that this may be unrealistic proposal (British Geriatrics Society, 2008). Black (2005) acknowledges that assessment of the frail elderly person in the A&E Department is difficult particularly within the context of Government Priorities for Action targets (‘four-hour’ A&E operational standards) and proposes emergency Day Hospital assessment as an alternative and one which is preferred by the patient and the general practitioner. In the Geriatric Day Hospitals for Older People Best Practice Guide (2006), it is recommended that the Day Hospital should provide comprehensive assessment of frail older people as well as rapid access admission avoidance clinics. The DRU at Whiteabbey is ideally suited to fulfil this role in terms of physical proximity to the A&E department and staff expertise.

As part of the modernisation reforms (DoH, 2002), a review of day hospital provision within the newly established Northern Health and Social Care Trust was undertaken. This recognised that there is a continued need for the services that the DRU provides and identified the potential for new service development such as a rapid access multi-disciplinary service for the “frail elderly”: those older persons with multiple, acute or chronic health problems which are compounded with functional and/or cognitive impairments. The aim of the rapid access unit would be to achieve optimal health outcomes, improve quality of life and to minimize inappropriate use of resources. Following the review, senior management recommended the setting up of a Rapid Access Department for Assessment and Rehabilitation of Older People (RADAR OP).

It was important to audit the Trust’s environmental influences with the purpose of using this information to guide strategic decision-making prior to launching the RADAR OP. A ’PEST’ analysis, a strategic planning tool, was used to gather information about the Trust and its environment to evaluate the potential impact political, economic, social, and technological factors might have on the RADAR OP project.

Political factors

The Department of Health’s PfA ( Priorities for Action) targets affecting Day Hospital include:

• From March 2008, older people with continuing care needs should wait no longer than eight weeks for assessment to be completed. Any further care needs must be met within a further 12 weeks.
• From March 2008, 95% of patients attending A&E should be either treated and discharged home or admitted within 4 hours of their arrival in the department.

Professional and Policy guidelines:

• National Service Framework for Older People
• National Institute of Clinical Excellence (NICE) guidelines on the Assessment and Prevention of Falls in Older People
• Strategy for Older People Northern Board (2002)

These call for health and social care providers to work together to redesign services and systems around the needs of older people. In order to improve lives and deliver greater value for money these providers must implement early interventions for older people at risk and streaming to specialist care.

Economic factors

The Trust must reduce budget by £44 million over three years ( Northern Health and Social Care Trust, 2009) this implies:

• No additional funding for extra staff, equipment etc
• Need to reduce costly hospital admissions/facilitate timely discharges
• Stopping untimely and costly institutionalisation

Social factors

• Consumer attitudes and opinions: Improved quality of care for patients is necessary and expected
• Lifestyle changes, improved living standards and superior health has led to population shifts, there is an increasing ageing population
• Education – health promotion role for Trusts to promote healthy ageing

Technological/Research factors

Research has demonstrated that early involvement of old age specialist teams has been shown to improve outcome, reduce length of stay and reduce inappropriate admission, in addition to being preferred by patients (British Geriatrics Society, 2008). Older people have complex needs and multiple pathologies; as such it is imperative for early identification of older people at risk who need specialist involvement. Specialist involvement and a comprehensive geriatric assessment are known to improve health outcomes and identify those who would benefit from intermediate care rather than hospital admission (Caplan et al., 2004; Ellis and Langhorne, 2005).

In addition, DRU staff have access to specialist equipment not readily available to community services e.g. X-ray, laboratory testing, rehabilitation equipment; computer terminals for access to electronic records. There are also facilities to allow provision of all assessment and rehabilitation interventions for older people that can not be provided at home.

Following the PEST analysis of the drivers for the change of existing services, a SWOT assessment was conducted, in order to identify any potential threats and to exploit the particular strengths of the DRU. This enabled strategic planning for RADAR OP. See Table 1.

Table 1: Follow up on PEST analysis.

The RADAR OP Process (see Fig 1)  

Referrals are generally sent by General Practitioners to DRU for specialist assessment and rehabilitation. Those marked as urgent/high priority can be offered a RADAR OP assessment. Once the screening assessments are completed by the multi-disciplinary team, those patients identified as frail or at high risk can be fast-tracked for a more comprehensive assessment and intervention programme at the DRU or, if more suitable, referred to a more appropriate service. Additionally, during RADAR OP assessment if any interim measures to maximise patient safety are identified, these are addressed by the multi-disciplinary team at that time. The General Practitioner is informed of the outcome of the assessment.

Another source of referral to RADAR OP is from attendance at A&E following a fall or rapid deterioration in health/functional status. A copy of the A&E documentation of intervention is forwarded to the RADAR OP department which the multi-disciplinary team can use these to identify those frailer older people who may require comprehensive geriatric assessment/intervention. A screening assessment is carried out by telephone, and patients requiring rapid access will be offered an appointment within 72 hours.

This way RADAR OP staff offer appointments to patients within 72 hours of receipt of referral and can identify the most suitable service for their needs. Patients can then receive the correct care at the right time in a safe environment.  

RADAR OP Process diagram

Implications of the change

The most appropriate service needed by each patient is identified and unnecessary referrals or expensive duplication of services is prevented. High risk patients can be prioritised and the GP is made aware in good time. There will be considerable financial savings for the Trust made if costly hospitalisation can be prevented. For the patients the personal cost of loss of functional independence can be reduced or indeed prevented by getting quicker access to appropriate services. The patient is happy they can receive the service that is most appropriate and acceptable to them in a timely fashion.

In addition DRU operations will hopefully be minimally affected. For staff, there will be more job satisfaction of getting the right type of help for their patients in a more timely and effective manner.

There will be a comprehensive programme of quality improvement activities to ensure that all patients receive the most effective, up to date and appropriate treatments, delivered by clinicians with the right skills and experience. In order to achieve this clinicians involved will continue to use evidence-based practice, risk management, continual professional development, and follow clinical guidelines. Quality of the service provided will be monitored and continuously improved upon through systematic review of care against explicit criteria and implementing any changes required. Clinical audit and outcomes measurements help to close the gap between what is known to be the best care and the care that patients are receiving. Other tools to use will be patient feedback where patients attending the unit will be invited to comment on the quality of the service they receive.Ultimately the goal is to ensure the best quality of service to older people at risk of deterioration in health who live in the Whiteabbey/Newtownabbey area.

References

Black D (2005). The geriatric day hospital. Age and Ageing, 34, 427-429.

British Geriatric Society (2006) Geriatric (Medical) Day Hospitals for Older People Best Practice Guide 4.4, [online]. Accessed: http://www.bgs.org.uk/Publications/Publication%20Downloads/Compen_4-4%20Day%20Hospitals.doc (12/5/2009).

British Geriatric Society (2008) The older person in the accident and emergency department best practice guide, [online]. Accessed: http://www.bgs.org.uk/Publications/Compendium/compend_3-2.htm (12/5/2009).  

Caplan G, Williams A, Daly B and Abraham K (2004). A randomized controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department – the DEED II study. Journal of the American Geriatric Society, 52(9), 1417-1423.

Department of Health (2002) Developing better services, [online]. Accessed: http://www.dhsspsni.gov.uk/index/hss/developing_better_services.htm (09/4/2009).

Ellis G and Langhorne P (2005). Comprehensive geriatric assessment for older hospital patients. British Medical Bulletin, 71, 45-59.

Khan SA (2009). The geriatric day hospital: past, present and future. Age and Ageing, 38, 3, 354-355.

Northern Health and Social Care Trust (2009) Trust Delivery Plan, [online]. Accessed: http://www.northerntrust.hscni.net/ (10/4/2009)