Still no way out for discharged delayed

RIGHT NOW, there are about 700 patients lying in beds in acute hospitals nationwide who don’t need to be there. Though fit to move on, they’re not going anywhere – that’s because there is nowhere for them to go.

Walk through the Republic’s hospital emergency departments, meanwhile, to see a different picture. Sick and injured people who, due to a shortage of beds, just can’t get in.

Our hospitals mirror an airport in disarray, with delays and confusion on clearing recovered patients for takeoff. Meanwhile, a constant queue sits in a holding pattern, their fuel running ever lower, as they await permission to land.

Established last June, the Department of Health’s Special Delivery Unit was set up to monitor hospital traffic, to “unblock access to acute services by improving the flow of patients through the system”. That the monitoring is happening no one can deny. Monthly scorecards now measure all our hospitals’ ability to get patients in and out on time. But while there are now enough performance metrics to make even the steeliest statistician swoon, many would say the answers to blockages were already staring us in the face.

“I couldn’t impress on you more that the absolute problem with our health service is almost nothing to do with the front door – it’s to do with exits from our hospitals,” says Dr Michael O’Connor, a consultant geriatrician at St Finbarr’s Hospital and Cork University Hospital.

While many families can share emergency department stories of interminable waiting times and stays on trollied corridors, the real log-jam is amongst those ready to leave – long labelled “the bed-blockers”, as though the situation is their fault.

“It’s a terrible word,” says Dr O’Connor, who is also secretary of the Irish Society of Physicians in Geriatric Medicine. “These are people who are now occupying an acute medical bed but who don’t have the requirement for an acute medical bed. That is probably the best way to phrase it.”

Predominantly older people, with pre-existing conditions such as stroke disease or dementia, they come into hospital with a new issue, perhaps a chest or urinary tract infection, explains Dr O’Connor. Once that infection is cleared, many go home, but a minority are not able to get better, or will no longer be able to manage at home. And so they wait in acute hospital beds for long-term care to be provided under the Department of Health’s Fair Deal Nursing Homes Support Scheme, for modifications to their home to be completed, or for a bed in a rehabilitation unit to be made available.

Because of this waiting, some 5,000 bed days are lost every week, according to Fianna Fáil health spokesperson Billy Kelleher. With this backlog in processing people on the way out of hospitals, it’s no surprise that targets on the admissions side are not being met. The Minister for Health James Reilly’s answer to the problem is to add a new kind of bed to the system, via the “Transitional Care Initiative”. It will cost €28 million, comprising €13m diverted from Fair Deal funding and €15 million from National Treatment Purchase funds. As part of the scheme, “Hospitals will develop a new capacity to provide treatment to frail older persons that will focus on enhanced independent health rather than directing people to long-term care,” says a statement from the Department of Health.

And supporting people to live at home independently is a good idea. Department statistics show that in the case of 80 per cent of persons currently in long-term care, it cannot be determined if they were ever offered a home care package or home help. In the case of 40 per cent of those in long-term care, it is known that they were not offered a home care or home help package. Dr Reilly hopes to reverse the trend of long-term care as the default option, and instead help empower people to stay at home.

Is a new kind of “transitional care” bed the answer? In hospitals, the new transitional care policy will mean special wards providing care to frail older persons. “The full ‘acute’ capacity of the hospital will not be required in that context,” according to the department. Transitional beds, it acknowledges, may also be in non-hospital settings.

But is this not just a re-packaging of the existing delays in the system? A more formalised holding pattern? Why not instead tackle the underlying delays to the processing of the Fair Deal scheme, the home help and home care packages and the provision of rehab beds? The department says there is a “significant push” to speed up these processes but acknowledges disparities in the length of time it takes different regions to process older people to the next level of care. Dr O’Connor says his experience in the Cork area is that things are moving slightly faster this year than last.

In a statement issued last week, the Department of Health said it is a feature of the HSE service plan not to reduce the number of home care packages, but the reality on the ground seems different.

“[Reduction] in the home care package is definitely something that bites,” says Dr O’Connor. “Where someone was dischargeable home, with a home carer calling maybe twice a day, now it’s unusual to be able to get that level for someone being discharged from an acute hospital.”

He queries whether money put into these new transitional beds is the right use of resources.

“We are creating a new category of beds for patients as a stop-gap, whereas if they need long-term care or rehab care, we should get them there as quickly as possible, rather than moving people between care environments or care levels that they don’t need. Moving elderly and frail patients is associated with excessive mortality. That would be my personal view on it.”