Community nurses to be alerted to hospital moves for elderly patients in Yorkshire pilot scheme

The new approach aims to provide better and more joined-up care and stop patients from “falling through the cracks”.

It is the result of a collaboration between Harrogate-based Inhealthcare, City Health Care Partnership in Hull (CHCP), Humber and North Yorkshire Integrated Care Board and the Yorkshire and Humber Care Record (YHCR).

The YHCR is a digital shared care record that enables citizen information from multiple sources to be accessed securely and updated in real time, when it is needed, by appropriate health and care professionals.

Inhealthcare, a UK leader in digital health and remote patient monitoring, has developed a subscription service within the shared care record to automatically alert CHCP every time a patient is admitted to, discharged from, or transferred between hospitals.

The service will be piloted with patients under the care of CHCP’s frailty team in Hull with a view to rolling out more widely to other frontline teams.

Bryn Sage, chief executive of Inhealthcare, said the scheme had the potential to be hugely positive for patients.

“This is the first project of its type across Yorkshire and the Humber and it has the potential to dramatically improve outcomes for patients, by making health information accessible at the right place, at the right time, so clinicians can provide more timely care.”

Dr Dan Harman and Dr Anna Folwell, Frailty Leads at CHCP, said in a joint statement: “If an elderly or frail patient has a fall at home and suffers a broken hip, she would be taken to hospital and admitted to a ward.

"This could happen without the knowledge of community care providers.

"A nurse could visit the patient’s home for a routine check-up but find no-one is there. Later, the patient could be discharged from hospital to home without the knowledge of community care providers.

“The patient would not have the best experience. He or she could be confused.

"Inevitably the risk rises of readmission to hospital and a poor health outcome.

“With this new subscription service, the opposite happens.

"Community care providers are alerted at the point the patient is admitted; they would know which hospital site and which ward; they would be able to stand down their service until they know the patient is discharged and they could resume care for the patient at home.

"Data is flowing back and forth throughout the system.”

Lee Rickles, Programme Director at the YHCR, said: “This is about making sure that clinicians are fully informed and able to be there when our patients need them.

"The project also has the potential to increase capacity by reducing the number of unnecessary home visits when a patient is in hospital.

"It is a great example of the YHCR approach.”