The role of a dietitian in Hospital at Home

With a strong interest in improvement, dietitian Aaron Fraser in NHS Forth Valley, found a place for his skills in the Hospital at Home (H@H) team.

Before H@H

After graduating from Queen Margaret University with a degree in Dietetics, I took up my first post in NHS Forth Valley. In this post I developed an interest in frailty. While working in nursing homes and community hospitals (amongst many other roles), I developed a keen interest in service improvement.

I moved on to a role in Forth Valley Royal Hospital covering Aging and Health and General Medical Wards. This role allowed me to really stretch my improvement muscles on the wards. I worked with the Scottish Hip Fracture Audit Steering Group, where I helped develop the nutritional care standard for Scotland. I then supported implementation of this locally.

When I moved to my first band 6 role, with Forth Valley’s Rehabilitation and Assessment in the Community and at Home (ReACH) team, I was working with a large number of malnourished patients. I redesigned the Dietetic Service, supporting phone calls to help capacity by reducing travel time to home visits, this made our service more flexible.

An opportunity arose to work on tests of change, with the Frailty Intervention Team, to improve the early identification and treatment of malnutrition in the Forth Valley Royal Hospital Acute Assessment Unit. Along with my team, I wrote a paper about our progress which helped to support our Dietetic H@H bid.

In December 2021 I began working with the NHS Forth Valley H@H team.

Improving quality of life for H@H patients

Malnutrition is common within the frail older adult population. Our H@H team aim was to provide early and meaningful dietetic input to improve people’s outcomes and quality of life.

A lower threshold for dietetic referrals was introduced. This supported early identification of nutritional issues in a patient-centred way and helped address concerns with a ‘what matters to you’ approach. The lower threshold created a higher demand on the service. To increase capacity I use telephone assessments where possible, and I link with our Multidisciplinary Team (MDT) to help identify who might need an in-person assessment.

With this approach, I have been able to identify which patients I need to visit, which ones to contact by phone and what is the priority for the day. This approach, especially as the lone dietitian in the team, has allowed me to ensure that my queue sits at zero.

No average day in H@H

There is no average day in my role. I start the day screening the caseload to identify patients admitted with nutritional issues or developing nutritional issues during admission. Depending on the day’s screening the role can vary, it may lead to a telephone call to provide advice for someone losing weight, a home visit to review a tube feed or a joint visit with another team member to support what is often a multifactorial presentation. MDT working is a key part of the role within H@H and I attend a daily ward round, at least once per week, to discuss each patient on the caseload.

The best of both worlds

As I'm the only dietitian in the team, I base myself between the H@H base and the main Dietetic Department in Forth Valley Royal Hospital. Having a split base allows me to have all the benefits of being imbedded within the H@H team but maintain dietetic supervision and provides the opportunity to peer review patients when needed.

The other Allied Health Professionals (AHPs) and I continue to work with patients after they have been discharged from H@H. This follow-up can often be for eight to twelve weeks. It allows for better continuity of care, minimal impact on other community services and decreases the likelihood of readmission to H@H.

I loved working in the wards, but felt that there were a lot of patients that did not need to be in hospital. Some of the patients, particularly those with conditions such as dementia, may be better off if they could be treated at home. This was what drew me to H@H, as well as the opportunity for early dietetic intervention. I feel like I have a real opportunity in H@H to makes people’s lives better.

For me, the multidiscipline nature of H@H is great. I really enjoy learning from others in the service and how to organise my work in the context of their roles and the patient’s needs on the day. I have a good level of autonomy and the work in H@H is streamlined. The team in NHS Forth Valley are supportive, helpful and an excellent team to work in.

The rewards of working in H@H

One of the most rewarding aspects of my H@H role is helping people stay at home when they are acutely unwell. Patients being at home highlights the importance of their family and carers, they are an important link for me. As everyone is involved in the H@H environment, there can be meaningful change with a greater impact.

As I keep patients on after their discharge from H@H, I get to hear months later the difference it has made to people. Quality of life is so important and it is always great to hear how my team and I have made a difference.

I appreciate that I am in a role where I can get in early within a patient’s journey, allowing me to support people better. It allows me to build better relationships and trust with my patients. I am now gathering evidence to demonstrate the impact of having a dietitian within H@H.

The future for Aaron and H@H

As far as career progression, I am eager to keep doing what I am doing. I am completing an advanced clinical examination masterclass to develop the competencies to assess patients, which will help the H@H team’s capacity. Recently, I sent out care experience questionnaires, I am waiting for the responses before planning my next improvement steps.

As for what I'd would like to see next for H@H in Scotland, I'd say more of it! Perhaps unsurprisingly, I would suggest there should be a dietitian in every H@H service. For me, H@H works in terms of what matters. I am interested to see if H@H will be expanded into other patient cohorts.

Working in H@H

For me, you need to have passion for the role and understand the mission and goal of H@H to work in the service. H@H brings quality of life. You need to have confidence in your own skills but know your limitations and when to ask for help too.

For anyone looking to work in H@H, I say to do it!