Abstract
Aim
To determine the efficacy of selection of patients for NHS (Scotland) continuing care using revised guidance eligibility criteria, CEL (2008).
Methods
On September 2009, a census was conducted of 632 patients, distributed over 10 hospital sites in NHS Lanarkshire Older People's Directorate, to identify those patients who had future care needs assessed using revised NHSS CEL (2008) eligibility criteria during the previous 3 months. These patients were then assigned to one of four categories: (1) eligible for NHS continuing care; (2) likely destination care home; (3) likely discharge home with complex care package; and (4) outcome uncertain. ‘Frailty’ was recorded in a sub-group of patients using Rockwood’s frailty index. The index records frailty on a scale 0–1, a higher score indicating greater frailty. Outcomes were recorded at 2-monthly intervals for 1 year. Patients undergoing acute assessment and/or specialist rehabilitation, those admitted before 1 April 2009 and already accepted for NHS continuing care and those with a planned discharge date were excluded.
Results
Two hundred and eleven patients were identified as meeting the criteria for allocation to one of the four categories. Mortality at 1 year was as follows: NHS continuing care 40/45 (89%), likely Care Home destination 39/81 (48%), likely home discharge 22/61 (35%), outcome uncertain 13/24 (54%). Mean frailty scores were: NHS continuing care 0.4, likely care home 0.34, likely discharge home 0.29; p=0.0002 (ANOVA). Re-admission rates were high, 60% once and 40% twice or more, in patients discharged from hospital.
Conclusion
The revised guidance on Eligibility for NHS Continuing Care in Scotland, CEL (2008), is useful in identifying the frailest patients with complex needs and limited survival. However, hospital re-admission rates and mortality are high in all patients considered for eligibility to NHS continuing care in whom the guidance is applied.
Keywords
Background
NHS Scotland has long recognised the need to plan strategically for the healthcare needs of older people, including meeting the challenges of changing demography. ‘Shifting the Balance of Care’ of older people from hospital to community has become a priority for the devolved Scottish Government1–3 and, in this context, in July 2007, the Cabinet Secretary for Health and Wellbeing requested a review of the then current guidance on NHS continuing health care contained in MEL (1996) 22. 4 New guidance was issued in February 2008 regarding the responsibilities of the NHS in Scotland for providing continuing health care services (CEL 2008). 5
The revised guidance affirmed that the decision on eligibility should be based on the clinical needs of an individual as assessed by a multi-disciplinary team. Continuing inpatient care should be provided where there is a need for ongoing and regular specialist clinical supervision of the patient as a result of:
the complexity, nature or intensity of the patient’s health needs, being the patient’s medical, nursing and other clinical needs overall; the need for frequent, not easily predictable, clinical interventions; the need for routine use of specialist health care equipment or treatments which require the supervision of specialist NHS staff; or a rapidly degenerating or unstable condition requiring specialist medical or nursing supervision.
Aim
To determine the efficacy of selection of patients for NHS (Scotland) continuing care using revised guidance eligibility criteria, CEL (2008).
Methods
During mid September 2009, a census was carried out on all in-patients managed by NHS Lanarkshire Older People's Directorate to identify those patients who had their future care needs assessed in the context of the revised NHSS CEL (2008) eligibility criteria during the previous 3 months. Typically, such patients had the following characteristics:
‘frailty’ multiple co-morbidities functional impairment physical dependency cognitive impairment multiple previous admissions
Patients who had been accepted for NHS continuing care before 1 June 2009, those undergoing acute assessment and/or specialist rehabilitation, and those with a planned discharge date were excluded.
Patients who had been assessed using revised NHSS CEL (2008) eligibility criteria during the previous 3 months were assigned to one of four categories: (1) currently eligible for NHS continuing care, (2) not currently eligible for NHS continuing care and likely to be discharged to a care home environment, (3) not currently eligible for NHS continuing care and likely to be discharged home with a complex care package, and (4) not currently eligible for NHS continuing care but outcome uncertain. At the time of the census, cognitive status was assessed on all patients using the Mini Mental Status Examination (MMSE) 6 and performance in basic activities of daily living was assessed using the 20-point Barthel Index. 7 In addition, ‘frailty’ was recorded in a sub group of patients (all patients in the first three categories in three hospital locations) by independent analysis of patients’ case notes using Rockwood’s frailty assessment methodology 8 in which 39 recorded deficits are used to generate a single numerical value, the frailty index. The index records frailty on a scale 0–1, a higher score indicating greater frailty. We have previously used this method of assessing ‘frailty’ to select patients at high risk for adverse health outcomes. 9 Patients were then followed up for 1 year using NHS Lanarkshire Patient Management System and, when necessary, telephone confirmation with GP surgeries and Care Homes. Patient outcomes were recorded at 2-monthly intervals in terms of place of care, re-admissions to hospital and mortality.
Results
Functional and cognitive profiles.
p < 0.002, **p < 0.0001 (ANOVA).
Frailty profiles (Rockwood methodology 8 ).
p = 0.0002 (ANOVA).
Outcomes
1. Met revised eligibility criteria for NHS continuing care
The 45 patients who met the revised eligibility criteria at the census point comprised the frailest group as evidenced by measures of cognition, physical dependency and frailty per se. None of these patients was subsequently discharged from hospital and mortality during 1-year follow up was high at 40/45 (89%).
2. Likely to be discharged to a care home
Eighty-one patients were in this category at the census point and 52 were discharged to a care home destination during subsequent weeks. Three were subsequently accepted for NHS continuing care during the index admission because of a change in status, and a further 6 were accepted for NHS continuing care following one or more re-admissions to hospital. During the follow-up period 25 of the 52 patients discharged to a care home were re-admitted to hospital once, 11 were re-admitted on two occasions and 6 on three subsequent occasions. In total, 39 of the 81 patients (48%) allocated to this category at the census point had died at 1 year.
3. Likely to be discharged home
Sixty-one patients were thought likely to be discharged home with a complex care package and 47 were discharged home as predicted. Of these 47 patients, 18 were re-admitted to hospital at least once, 10 twice and 4 patients were re-admitted from home on 3 or more occasions during the follow-up period. At 1 year, 35 were still at home. Twenty-two patients (35%) allocated to this category at the census point had died at 1 year.
4. Outcome uncertain
There were 24 patients who had been assessed using revised NHSS CEL (2008) eligibility criteria in whom the outcome was undecided at the census point. Five were subsequently accepted for NHS continuing care during the index admission, 6 were discharged home and 6 were discharged to a care home. Remaining patients died in hospital during the index admission. Of the 12 patients who left hospital, 4 were re-admitted to hospital once; 2 were re-admitted on two occasions and a further 2 on three occasions during the follow-up period. At 1 year, 4 patients were at home, 6 were in a care home, 1 was in NHS continuing care and 13 (54%) had died.
Discussion
In this study of 211 hospitalised frail elderly patients considered under the new eligibility criteria for NHS continuing care (CEL 6, 2008), 45 (21%) met the criteria. The ‘eligible’ patients were the frailest as evidenced by measures of cognition, physical dependency and frailty per se and mortality in this group during 1 year follow up was high at 40/45 (89%). Of the 166 patients not considered eligible for NHS continuing care at the census point, 74 (45%) had died at 1 year. Re-admissions were common among those not considered eligible for NHS continuing care and subsequently discharged from hospital; 29/54 (54%) of patients discharged to Care Homes and 31/56 (56%) discharged home were re-admitted at least once during the follow-up period; 13/54 (24%) discharged to Care Homes and 19/56 (34%) discharged home were re-admitted twice or more.
This process of consideration for NHS continuing care selects those patients who are eligible under the revised guidance and also helps to identify a larger group of patients who, whilst they might not meet the criteria, are nevertheless in a phase of significant physical and cognitive decline and whose care needs are likely to increase. It highlights the need for continuing development of robust community services and wider, more effective use of Anticipatory Care 10 pathways in care homes and in the community.
Conclusion
The revised guidance on Eligibility for NHS Continuing Care in Scotland, CEL (2008), is useful in identifying those older patients with the most complex needs and limited survival. However, this study illustrates more generally the extent to which frailty and limited life expectancy are common features among older patients selected for specialist Geriatric Medicine care on admission to hospital. Although the majority of patients considered for NHS continuing care might not be eligible initially under the revised guidance, hospital re-admission rates and mortality at 1 year are high even if such patients do not meet the revised criteria for NHS continuing care.
Footnotes
Acknowledgements
We wish to thank the medical, nursing and AHP staff of NHSL Older People's Directorate for their support in conducting this study.
Declaration of conflicting interests
None declared.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.