This integrated pathway (Red Bag Pathway) is designed to support care homes, ambulance services and the local hospital meet the requirements of NICE guideline NG27: Transition between inpatient hospital setting and community or care homes.
A red bag is used to transfer standardised paperwork, medication and personal belongings and stays with the resident throughout their hospital episode and is returned home with resident. The standardised paperwork will ensure that everyone involved in the care for the resident will have necessary information about the resident’s general health, e.g. baseline information, current concern, social information and any medications, on discharge the care home will receive a discharge summary with the medications in the red bag.
The pathway enables a significant reduction in the amount of time taken for ambulance transfer times and for A&E assessment times and reduces avoidable hospital admissions.
This example was highly commended in the 2016 NICE Shared Learning Awards.
Aims and objectives
- To improve the experience for the resident by ensuring that the medical teams have the relevant information to assess and provide the appropriate treatment plan and that on discharge the care home has the relevant information to enable continuity of care.
- To ensure the resident has their personnel belongings i.e. their own clothes for discharge, glasses, etc. with them at all times during their hospital stay.
- To reduce the length of stay for the resident by enabling the care home to be actively involved in the decisions of care as part of the resident’s hospital stay, therefore avoiding unnecessary assessments to be made by the care homes which delay discharge back to the care home.
Reasons for implementing your project
Prior to implementation of the Hospital Transfer Pathway (Red Bag Pathway), there was no standardised handover process or paperwork between care homes and the ambulance service.
Crews would be delayed while care home staff, collated a variety of different types of paperwork for the ambulance crew to take with the resident. Resident’s personal belongings were often either not conveyed with the resident or lost during the residents stay in hospital. Medical teams did not have baseline, details of medicines or social information to make decisions on whether to admit or order further tests and would spend considerable time ringing the care homes to obtain relevant information needed to carry out a comprehensive assessment and decision on whether to admit or discharge.
Whilst in hospital, many care home residents were not visited by the care home staff and therefore the care home was not included in the treatment plan or discharge planning and would not accept the resident back to the care home until an assessment had been made by a named member of the care home team.
The care home resident often had to be transferred back to the care home with clothes from the hospital charity box as did not have their own clothes for discharge. Many residents arrived back at the care home without medications, or information for the care home to continue with the treatment plan and were unaware of any changes in the residents care plan. Regular care home forums with care home managers identified there were many blockages in the pathway, this included that the hospital would not discuss the resident with the care home as consent to do so had not been obtained.
A task and finish group consisting of representation from care homes, ambulance service, local hospital, clinical commissioning group and community nursing was set up, to design an end to end integrated pathway to remove the blockages that had been identified. The benefit from putting this NICE guidance into practice is this has provided a neutral ground to enable a framework for action.
How did you implement the project
The steps used where to identify key leaders within the various organisations involved in the pathway, including care home managers. These identified leaders act as change agents within the organisations they represent. Task and finish groups were held in a number of care homes, to include care home staff to be part of the co-production of the products in the pathway, these are: the red bag, care handover process, older persons assessment form (baseline information), care escalation report (acute episode), MAR sheet, 'about me' form, 'cleaning the bag' information sheet, poster and training film. A senior executive along with key staff was involved in the communications of the red bag pathway within the hospital, providing the leadership promoting and refining the pathway as required. The film can be accessed on YouTube here: https://www.youtube.com/watch?v=XoYZPXmULHE
A member of the service improvement team within the hospital oversees the communication and promotion and has been key within the hospital developing and implementing screen savers with the red bag pathway with links to the training film and a brief on the pathway. The communications leads from all organisations in the pathway have promoted the in newsletters and staff bulletins.
- Consent for the care homes and hospital to discuss the resident, we overcame that by including a consent box on the older persons assessment form, these are now used for all residents whereby either the resident is able to consent or a best interest decision is made as appropriate.
- Hospital would not accept the MAR sheet without all the residents’ medicines - we overcame this by sending in all the medications with the red bag.
- Discharge summaries are sent to the GP so the care homes do not receive information on any changes to the residents care needs – we overcame this by an agreement that a nursing summary is sent with the red bag and TTO’s on discharge – we are currently setting up all our care homes on NHS net email addresses so the discharge summary will be able to the GP and the care home automatically.
- Concerns were raised that the red bags will go missing in hospital – we overcame this by each bag having its own serial number and a log kept of which serial number is with each home. A check list was also designed and when the resident returns home, the check list is returned to the project team to monitor and identify areas in the pathway that require a review. The costs involved were purchase of the red bags, training film and posters and printing costs.
Initial reports show that by putting the NICE guidance into practice within the red bag pathway has made significant improvements in the communications and relationships between the hospital and care homes.
The ambulance service have reported smoother transfers from care homes since the start of this project saving valuable resource time by enabling crews to transfer residents quicker without being delayed at the care home waiting for handover. Early findings from the hospital are that by being able to identify a resident from a care home and having the information on the standardised paperwork that it is extremely valuable and enables a more timely medical assessment to take place.
This project developed further as we worked to have red flags on the hospital system to identify the pathway, this will enable the pathway to be evaluated in more detail. One of the elderly care consultants who has presented at our care home forum and who is a champion for this project is keen that her team help with the evaluation and that the medical team have a regular presence at our care home forums to network with the care home managers.
We have involved residents and families by engagement events within the care homes and as part of this present the Red Bag pathway and film, all care homes display the poster which details the pathway in detail ‘The Journey of Betty and the Red Bag’.
The care homes have embraced this initiative and rolled the pathway out to our learning disability and mental health care homes during the summer 2016 as they have asked that they be included in this pathway.
A final evaluation report of the Sutton Homes of Care Vanguard was published in April 2018 and can be accessed here.
Key learning points
- Meet in a neutral place and have the initial meeting as a fact finding meeting, setting out objectives and rules for the meeting in advance.
- Involve senior decision makers in the pathway who can act as change agents and influencers to ensure the pathway is embedded and communicated to all teams.
- Involve the care homes at every stage and ensure they are key to the design and test of the pathway.
- Keep meetings short and action points delivered in quick timescales
- Keep the project alive by regular updates.
Further resources on the hospital transfer pathway can be accessed on our website here.