Improving Hospital at Home for frail older people: insights from a quality improvement project to achieve change across regional health and social care sectors.

BACKGROUND: Against a background of rising numbers of frail older people, there is a need to improve quality and safety of services whilst containing costs. Improving patient outcomes requires change across hospital and community systems. Our objective was to change practice in order to deliver a Hospital at Home programme (admission avoidance and early supported discharge) for frail older people across a regional commissioning area. The programme, undertaken within the Northern, Eastern & Western Devon Clinical Commissioning Group (CCG) sub-localities of Exeter (population 120,000) and Woodbury, Exmouth and Budleigh Salterton (towns with populations of around 10,000), involved reconfiguration of existing services rather than being a stand-alone intervention.

METHODS: Quality Improvement methodology, with hospital and community staff using Plan-Do-Study-Act (PDSA) cycles to implement and test service changes.

OUTCOME MEASURES: 1) Discharge destination; 2) Length of stay; 3) Acute Community Team referrals.

RESULTS: Against a backdrop of intense financial pressures, significant community bed closures, and difficult relations between hospital and community services, outcomes remained stable (discharge destination, length of hospital stay, and number of referrals to the community team).

CONCLUSION: PDSA cycles enabled stakeholders across acute and community services to be involved, promoted a process of collaborative inquiry and ownership of findings, and improved motivation to act on results and produce change. Practitioners and managers seeking to improve the delivery of complex, cross-cutting services in other areas can learn from the experience of applying Quality Improvement methods reported here.