Good practice case study: rehabilitation and older patients

Hospital related functional decline in older patients is an understated problem. Elderly patients often experience reduced mobility and their activity levels accelerate bone loss, sensory deprivation and isolation, while a lack of stimulation means reduced cognitive functioning. On discharge, these patients’ functional level and confidence in their abilities can be significantly reduced, compared to their previous functional status.

• HSJ/Serco Commission on Hospital Care for Frail Older People: main report

For patients, rehabilitation provides an intervention to prevent functional decline and maximise functional independence.

Traditionally, rehabilitation is the domain of the allied health professions such as occupational therapy, physiotherapy and speech and language therapy. These professionals are integral components of the multidisciplinary team; however, they are not available around the clock. Also, by the nature of their professional expertise and culture, they aim to pass responsibility to the patient and carer for the management of the former’s condition. We are keen to explore and develop their practices within the ward team.

The goal

The ethos of rehabilitation is about enabling maximum physiological, psychological, emotional and social potential of the patient and improving quality of life.

NHS Lanarkshire piloted a rehabilitation and enablement team through support via Reshaping Care for Older People, in order to promote a culture of rehabilitation and enablement within older people’s associated hospitals.

This team aimed to develop a culture of enablement within the wards, which would impact on the patient’s function and cognitive state through increased stimulation.

The overall outcomes set included reducing length of stay; reducing care home admissions; reducing readmission rate and increasing the number of patients discharged home; enhancing bed occupancy rate and improving patient activity.

Training methods

A small team (occupational, physiotherapist and generic clinical rehab support workers) developed a training and development package for the nursing teams within these wards and units.

The renablement ethos was initiated via formal teaching and clinical support. Measures taken included buddying and staff rotation between team and activity sessions to increase and promote a normalisation of approach and increased overall activity within the wards.

The baseline learning need analysis of nursing staff and clinical support workers informed the topics for teaching and development sessions. Sessions included chair based exercise, enabling sessions, falls awareness, mobility, seating and positioning and activities of daily living and more.

An audit data collection over the five sites provided a baseline on falls, access to mobility equipment, instigation of exercise and stimulation activities, use of the “getting to know you” document and enabling approach by the staff.

Constructive results

Post team intervention, outcomes included an increase in the number discharged to the patients’ homes rather than to a care setting; 20 per cent reduction in falls; 100 per cent increase in activity and stimulation sessions; very positive patient and carer response and an increase in improved use of the environment to support normal activity.

There were variations between the sites, with areas having higher static workforce and dynamic leadership, enjoying the most impact. The sustainability of this enablement culture has been supported by instigating enablement champions per ward area, to enhance, promote and challenge practice, with support from the AHP team. This has also highlighted areas of focus for AHP intervention within the wards’ management plans, utilising the wider team to promote the rehab interventions.

Melissa Murray is a specialist physiotherapist, Anne Close is a specialist occupational therapist, Lynn Flannigan is a physiotherapist for lead care homes and Susan Kennedy is team lead occupational therapist for NHS Lanarkshire. Lesley McCreaddie is the senior charge nurse at Coathill Hospital