Alcohol and hospital readmission (3)

Shalchi et al are to be congratulated on their paper on hospital readmission rates (Clin Med October 2009 pp 426–30). This concentrated on the medical factors which might have influenced readmission and thus contrasts with previous work which derives from the same catchment area and the same hospital, albeit 20 years earlier.¹ Their definition of ‘readmission’ was within a period of two weeks, whereas we reported on readmissions up to three years. Our sample was limited to those aged 75 or more. Our objective was to assess the effects of a social service run ‘care attendant’ scheme in which the health concepts of rehabilitation – a planned withdrawal of support – were melded with the need for care. The service was provided by Harrow Social Services trained care attendants incorporating the rehabilitation ethos.²

Like Shalchi et al, we found that common medical diagnoses at the initial episode were cardiorespiratory, but that readmission was reduced in the care attendant group. Likewise, older patients were more likely to be readmitted as emergencies. Those patients whose original admission was an emergency were more likely to be readmitted as an emergency. Emergency admissions were significantly more likely for elderly patients living alone.

Shalchi et al did not detail the nature of the social support post discharge. However, specific care assistant (as currently named) support targeted at frail elderly emergency admissions, particularly if living alone, would probably be cost effective as our scheme saved money by reducing readmissions even though the scheme provided potential support for many who were not at risk. Care assistants could check that medication was taken appropriately, for example.

Although the scheme was reproduced elsewhere, it was withdrawn by Harrow Social Services at the end of the controlled trial as the savings accrued to the NHS while the investment was made by Harrow Social Services (the monies in fact being spent on other community care projects needing care attendants in the borough).^3,4

The lessons learned then were that:

1. Hospital and social services had to have trusting relationships.

2. Joint funding across health and social services was appropriate (utilised by the community-based hospital discharge scheme² and the care attendants supporting younger people⁴).

3. Social support after discharge utilised the rehabilitation approach – facilitating optimal independence at home thus reducing readmissions.

• © 2010 Royal College of Physicians