How Covid-19 has accelerated closer partnership working between health and social care for older people
Before we had even heard of Covid-19, the Trust’s frailty team was showing the importance of working with care homes, helping to spare older people unnecessary hospital admissions and reducing length of stay in hospital. But partnership working with our local authorities really came into its own as we joined forces in response to the pandemic, providing a blueprint for our future integrated model of working. In this joint blog, Kate Sendall, frailty clinical programme manager at the Trust (pictured left), and Dr Niki Lang, director of public health at Hammersmith and Fulham Council, explain just what was achieved by building on existing partnerships and what we have learnt to help us respond to future outbreaks.
Since April 2019, Imperial College Healthcare has been improving the way it works with local care homes. In Hammersmith and Fulham, we started by developing a good relationship with one home and then expanded the approach over a year to four of the biggest homes in the local area. When coronavirus hit it became more important than ever for us to work together and our teams made it their mission to quickly scale up in response to the unprecedented challenges. We had to learn rapidly and things changed almost constantly but, by the beginning of April, the Trust was working directly with 26 homes, including nursing, residential and extra care sheltered homes
Early on, we realised that supporting local care homes with testing capacity and processes was key in helping to reduce transmission of Covid-19. Though the surge in demand for testing came with some significant operational challenges, we kept it as our focus, alongside providing clinical advice, ensuring the provision of personal protective equipment (PPE) and enabling patients to be discharged from hospital and cared for safely.
It’s not been easy and we didn’t get everything right at the start. We did know from experience that acute hospitals, care homes and community health services working together would enable us all to do our best for our local communities. That meant ensuring open lines of communication and working to a shared goal, breaking down any institutional barriers. Between us, we managed to get ahead of the curve in terms of best practice for care homes during the pandemic and, most importantly, we have been able to care for residents in their own homes wherever possible. Not only is this generally where residents prefer to be, it also reduced the risk of exposure to Covid-19.
Testing of patients and staff quickly became a priority to allow care homes to cohort and care for patients with Covid-19 while keeping other residents safe and free of infection. This is especially important for frailer individuals who are at a higher risk of severe, life-threatening disease.
We had no knowledge of Covid-19 at the beginning of 2020 but we now understand that, early on, it was sadly spreading through communities much faster than we were able to scale up testing capacity. To protect our communities in the future, we need to make sure testing capacity can be ramped up immediately if faced with a similar situation and partnership here is key. Working closely with North West London Pathology – a joint Imperial College Healthcare, Chelsea and Westminster and Hillingdon Hospitals service - and Imperial College London, we were able to expand testing to residents of all care homes in Hammersmith and Fulham during April.
Once testing was in place, it provided a vital indication of levels of infection in care homes and also allowed us to understand more about how Covid-19 was affecting older people. We noticed that around 40 per cent of care home residents presented with different symptoms to those generally expected. For example, they were less likely to have fever and cough while there was a strong association with elderly Covid-19 positive patients not eating. This insight is invaluable for future spikes and preparation, as we can be ready to identify outbreaks early through an improved knowledge of the symptoms.
Testing also allowed us to provide support for the health and wellbeing of care home staff, with a sickness rate of up to 25 per cent in some areas before wider testing was put in place. By better managing and reducing transmission between both staff and patients, we can continue to improve outcomes for all those living and working in our care homes, to help prevent further spikes.
These were some of the first nursing homes in the country to swab residents for Covid-19 and so everything we did was uncharted territory - collaboration between staff at the Trust and our local GPs was vital for finding a way through. Testing materials were delivered by bike or on foot and all the care home staff were taught to swab residents (and eventually themselves), as well as being guided through the nuances of virological testing by experts from the Trust. The system worked because everyone was totally committed. Empowering staff in care homes to understand and conduct the collection of swab samples themselves has helped to bolster and broaden the testing process and increase capacity.
Education and training
Trust staff continue to visit and support local care homes. This includes ad hoc education and training in small groups on topics such as managing dehydration without admission to hospital. In response to coronavirus, the focus of these sessions shifted to training around the effective use of PPE and best practice in infection control. As well as PPE education, we helped address some key concerns, such as ensuring staff had enough supply and supporting homes to order more. It was important for care home staff to feel confident about using PPE and so the Trust team helped train PPE champions in the homes and they will play a key role in preparing for – and responding to – any future pandemics.
The care homes benefited hugely from access to the latest training from the most senior nurses. The frailty team visited each nursing home almost daily to provide support and share expertise with the care staff, such as how to safely ‘don and doff’ and use the PPE exactly as it was being used in hospital.
Supported hospital discharge
Supporting discharge from hospital to care homes was vital to help ensure everyone felt safe during the pandemic. This is something we were already experienced in through our existing work and meant we could scale up with ease during the pandemic response.
By ensuring good communication between the Trust and the home before the patient is discharged, and Trust staff visiting residents when they arrive home, we make sure everyone feels supported. It is important the homes and their residents have all the information they need about their care, so Trust staff talk through care plans and answer any questions.
Our priority is always to help patients get the care they need in the right place at the right time. It may mean discharging patients from hospital and arranging additional support for them in a care home. Recently, a care home resident was admitted to one of our hospitals because of a fall, and there was no involvement of coronavirus at all. He was medically fit for discharge but was not fully back to his baseline mobility and we were concerned that he was at high risk of delirium if he stayed in hospital. So, we discharged him to his home and the Trust’s care home liaison nurse reviewed him on a daily basis. A geriatrician was also available to help with his complicated mobility issues. We reviewed his medications and supported the home to keep him moving – preventing him deconditioning and monitoring for early signs of deterioration. As part of the process we were able to hold family discussions and complete multidisciplinary team care planning sessions, and he has remained out of hospital for the past five months.
Imperial College Healthcare has started to roll out remote monitoring so that we can keep patients in their normal place of residence and still monitor their vital signs by using the Care Information Exchange (our secure, online patient records system) and Current Health. Current Health, a patient monitoring platform, combines vital-sign sensors and connectivity with other devices, enabling remote diagnosis and treatment. It has been trialled previously for post-surgical monitoring but this is quite a novel way of using the technology - staff from the homes have been trained and shown how to use the equipment. We focused initially on residential homes as they do not have access to vital signs monitoring. This training and technology enables us to remotely monitor, between the hours of 8.00 and 20.00, any residents we are concerned about. Trust staff can access a live feed of observations and video call the residents and staff which helps inform the clinical decision making remotely.
The role of technology has been key for other areas during the pandemic and we're working to ensure that this is part of planning for the future. With an improved knowledge of symptoms in elderly people and digital advancements, we hope that we can be even more innovative in our work with local care homes through flexible clinical advice and support.
Amongst the huge challenges globally and locally, the pandemic has provided an opportunity for both the Trust and the council to build relationships across the sector, not only with the care homes but also with CCGs, GPs and other local partners. This collaboration and co-ordination continues to highlight areas where preparation for outbreaks could be improved and it is only by understanding these challenges that we can ensure we have everything we need in place for the future. We are committed to building on what we have learnt as we move to a longer-term response to Covid-19, providing the best for our patients, health and care workers and the wider population.
The Care Information Exchange gives patients and providers in north west London access to digital health records. Find out how you can gain access.