NHS Newcastle Gateshead CCG: Bringing care homes from the periphery in to the system

NHS Newcastle Gateshead clinical commissioning group (CCG) was selected to be part of NHS England New Care Models Care Home Vanguard Programme. One of the initiatives to be introduced was the ‘transfer of care bag’, which sought to improve communication between hospital and care home teams when residents moved between both settings. This example of a local initiative forms part of our managing transfers of care resource.


NHS Newcastle Gateshead CCG, was selected to be part of NHS England New Care Models Care Home Vanguard Programme, which supported them to build meaningful relationships with their care home staff. 

Now one year post Vanguard, it can be seen that many of the changes made as a result of these closer relationships has had a sustained impact, and in addition further evaluation of some of the initiatives has been undertaken helping to promote the continuous improvement ethos established at the time.

The plan

During the Vanguard Programme, one of the initiatives to be introduced was the ‘transfer of care bag’, which sought to improve communication between hospital and care home teams when residents moved between both settings. At the outset, stakeholders agreed that the ‘transfer of care’ approach taken was not about the introduction of a bag but was about raising the profile of older people living with frailty and very complex needs in care homes.

Implementation

Through the establishment of a robust clinical engagement forum, time was taken to ensure that all involved developed a common understanding and vision given that it was understood this would be a key contributor in terms of implementing the change successfully.

Importantly, the local system considered the needs of care home residents and confirmed that on average they lived in care homes for two years and that their needs were very complex. Documentation was subsequently developed and tested before a final version was agreed and it was anticipated that improving communication could result in earlier discharge planning and improved patient flow. It was planned therefore to evaluate the introduction of the bags in two ways, one considering length of stay and the other to consider staff experiences and perceptions of using the bag and its documentation.

Outcomes

After the bags had been in use for six months it was noted that emergency bed days had reduced by 10% since the Vanguard base year of 2015 compared to a growth of 3 per cent for the non-Vanguard sites. In terms of staff experience of using the bag, both care home and hospital staff are very positive about its introduction and conclude that it has been a great way to raise the profile of care home residents in hospital. It is thought that this is what has led to the reduction in the length of hospital stay as communication has occurred earlier and the documentation has shared what the residents usual state is meaning goal setting has potentially been more realistic. There has only been one reported occasion when the bag wasn’t returned to the care home with the resident and another when the bag returned without the resident as family members were requested by the hospital staff to return it to the home. Despite a robust communication plan that included ambulance staff, care home staff reported that some of them didn’t know about it.

Next steps

There is a plan to refresh the communication plan and share it with all involved staff to keep the momentum of the bag use going and also to share some of the findings above.

Find out more about the "transfer of care bag" scheme