Working with the local Health Board to avoid hospital admissions

Project overview

Caring for a loved one at home can be challenging for families and providing the right level of care can take its toll on carers’ own wellbeing. If a patient’s condition deteriorates it can lead to a crisis, which can be very stressful and might lead to the patient having to be admitted into hospital against their will.

Hospice of the Valleys is working in partnership with Aneurin Bevan University Health Board to help prevent frail patients who may or may not have palliative care needs from having to go into hospital. A Health Care Assistant (HCA) from the Hospice @ Home service supports patients with treatment plans at home, which helps prevent a crisis and avoid a hospital admission.

Referrals to HAAP (Hospital Admission Avoidance Project) come from a variety of sources such as GPs, community resource teams and social services. The referrals are mainly for people who have become unwell at home, do not wish to go into hospital and whose condition can be managed safely in their home. HAAP will provide support in the day or night, and carers often ask for night support.

HAAP is intended to be a short-term measure and provides each patient with seven “sits”. This allows the referrer time to put long-term support plans in place if required.

Outcomes

A pilot project ran from early 2021 and supported 29 patients with 90 night shifts and nine day shifts. During the first half of 2022, the project supported 31 patients with 129 night shifts.

The majority of referrals have come from social care services, who are concerned about elderly patients who are unwell with an infection and do not wish to go into hospital. The hospice has been able to support patients at home, monitoring their condition and giving respite to families and carers. 

HAAP is providing patients and carers with the support they need and preventing patients from having to be admitted into hospital.  

 

Key facilitators

HAAP is run by Hospice of the Valleys’ Hospice @ Home team. This means a team of skilled healthcare support workers is able to provide specialist care for patients and families. At the end of the seven days of care provided by HAAP, the staff are able to give a comprehensive assessment of the needs of the patient and carer, which help health care professionals to plan care going forward.

The Hospice @ Home team have given presentations to a range of local groups to explain HAAP and the referral criteria.

Challenges

There can be a quick turnover of staff in the statutory sector, so it is important to maintain regular contact with referring organisations. The HAAP team regularly send information about the project to relevant allied healthcare professionals.

Sometimes HAAP receives unsuccessful referrals – for example if social services are unable to provide the necessary support and are looking to bridge a gap, or if patients have been discharged from hospital without a full package of care. HAAP is not able to provide this level of support.

Hospital admissions are at an all-time high and hospitals are having difficulties discharging patients due to lack of home care packages. More funding is needed to enable HAAP to meet this need.