What happens at the end of a hospital stay? Are patients forgotten the moment they leave the ward? Sadly, it is often a case that once patients are out of sight they are also out of mind.
We do things differently at Spiral Health. At our Bispham rehabilitation unit we’ve been introducing a pioneering approach to patient care. Our patient-centred journey begins before a patient even arrives in our unit and it doesn’t end until the patient is fully settled at home. Having invested so much effort in getting to know our patients as real people with unique needs, how could we turn our backs on them the moment they leave our unit?
We have one dedicated nurse in charge of pre-arrival assessments and post-departure follow up. When patients are discharged, Zandra puts their name and phone number into a diary. Seven to ten days later she calls them at home to ask how they are doing. This is Zandra’s chance to give advice and pick up on problems and she doesn’t miss a trick.
Recently, Daisy stayed with us to recover after a series of falls. Her main carer was her son, Richard, but he was also unwell. After Daisy was discharged, Zandra phoned her at home and Richard answered. “I’m worried,” he said. “Mum’s confidence has gone, she’s having problems with her mobility and she’s not eating. And I’ve got to go into hospital next week myself, so I don’t know how we are going to cope.”
Zandra suggested that Richard contact Daisy’s GP to see if she could be re-admitted to Bispham for more physiotherapy – and to see if this could coincide with the time he was in hospital. Zandra also spoke to Richard at length about claiming his carer’s allowance: he’d had no idea he was entitled to it.
The plan worked like a dream. Daisy came back to us and we gave her lots of care and attention and fed her up – and Richard went into hospital as scheduled.
Calling patients at home is also a good way to check that they are receiving continuity of care. We’ve recently discovered that a few of our patients are missing their first few days of physiotherapy once they return home, because they are waiting for the community physiotherapist to visit them. A gap in care could mean that they sit, immobile for several days and this will undermine their long-term progress. To stop this happening, we’re trying to instigate a new procedure whereby one of our own physiotherapists makes home visits, when needed.
With follow-up calls, sometimes it is just a case of giving advice on the phone. Perhaps a patient has been struggling to use certain equipment or is wondering if they can contact their GP about a certain issue. Zandra has a calm way about her and even if the patients just want a chat, she’ll make sure she has the time to listen. She’ll pick up the phone and tell them, “I’m the little one with glasses; you met me before you were transferred to Bispham.” They’ll say, “Oh I remember you,” and then they’ll talk.
At Bispham every aspect of our work is dedicated to the moment when a patient returns home healthy and happy. Zandra’s role is to provide what some may call customer service, but what we like to think of as a human touch.
“It’s satisfying,” said Zandra. “I feel as if I make a real difference. It’s nice to know that our patient-centred journey begins and ends with me.”