Rotherham’s Delayed Transfers of Care (DTOCs) were increasing. Benchmarking against the High Impact Change Model evidenced issues with conflicting health and social care models, ill-defined pathways and inconsistent processes and reporting. An MDT review of 50 patient discharges indicated that there was potential for 57% of patients to be discharged home but only 25% were in practice.
The project goal was to develop an integrated health and social care approach to discharge, with home as the default pathway to:
i. Improve the patient experience with over 80% of over 65 non-elective patients discharged home
ii. Reduce DTOCs to within the national standard of <3.5% and
iii. Improve efficiency and effectiveness through streamlined pathways and processes.
• Formation of a health and social care Integrated Discharge Team (IDT)
• Streamlining 23 destinations to 3 pathways, with home as the default
• Simplifying discharge processes
• Developing standard reporting Improved integrated working resulted in:
• Reduced DTOCs, mostly sustained at <3.5%
• Over 80% of the cohort discharged home from Q1 2018
• Greater efficiency
Rotherham’s DTOCs were rising, peaking at 8%. Benchmarking against the High Impact Assessment Model and sector learning including North Midlands NHS and the Local Government Association indicated issues with:
• Conflicting health and social care models, with no overall ownership
• Ill-defined pathways based on destination not patient need
• Paper-based data sets and
• Manual processes
Social care notifications were higher than discharge notifications preventing effective planning. Most patients want to return home, as soon as possible. Delays cause distress with in-patients more at risk of infection, loss of mobility and independence. An MDT review of 50 discharges indicated that there was potential for 57% of patients to be discharged home but only 25% were in practice. Discharge planning was poor.
The project goal was to develop an MDT approach, with home as the default pathway to:
i. Improve the patient experience, with over 80% of over 65 non-electives discharged home
ii. Reduce DTOCs to within the national standard of <3.5% and
iii. Improve efficiency.
Risk was managed by improved MDT working to ensure patients were ready and safe to return home. Complex discharges were allocated to a specialist according to patient need ensuring discharge to the right level of care/destination.
The project goal of an integrated health and social care approach to discharge to improve the patient experience, reduce DTOCs and be more efficient was achieved by: Integrating Health and Social Care
• Establishing an Integrated Discharge team (IDT), with a single joint service lead
• Therapy and community nursing working into the team
• Appointment of ward co-ordinators to manage the interface Process Improvement
• Streamlining 23 discharge destinations to 3 pathways
• Defining simple (ward) and complex, MDT, discharges
• Implementing a single electronic referral process replacing 7 manual forms
• Allocation of a specialist Trusted Assessor according to patient need
• Co-ordination of MDT support for discharge home, or to the right level of care
• DSTs conducted outside of the acute setting for more accurate outcomes and reduced delays
• Working with the voluntary sector to support patients home Outcomes Improved patient and system outcomes
• DTOCs were reduced, and mostly sustained, within the national standard of <3.5% see Tables 1&2) resulting in patients being discharged quicker, avoiding risk in the acute setting
• Discharge home target of over 80% of over 65 non-electives, reached and surpassed from Quarter 1 2018
• Better communication
• Process improvement, including digital released capacity
Following successful outcomes from the Trusted Assessor/MDT approach to discharge, the role of the team has been extended to co-ordinate all complex discharges including winter pressure beds. A GP practice that had previously chosen not to support winter beds notified the Trust that they would now be willing to, following positive feedback from a Practice Manager, who had experienced the new working practices. The initiative has been spread locally through the development of a therapy Trusted Assessor role working into A&E and AMU for admission avoidance.
The Intermediate Care and Reablement team have now adopted the approach to manage flow out of community beds. Outcomes are informing the Rotherham Place Plan’s review of Intermediate Care and Reablement including the development of a Home First community team and re-configuration of community beds. Regionally and nationally the team have shared learning with:
• NHSI’s Action on A&E
• the Allied Health Practitioners Patient Flow Collaborative and
• NHS England’s North Region Integrated Care Learning Event
The National Audit Office (2016) evidenced an ‘alarming growth’ in DTOCs with poor patient experiences and financial pressure equivalent to a gross national annual cost of £820M. Table 1&2 evidence how improved integrated working has reduced Rotherham’s DTOCs to a sustained rate of c <3.5%. Patients had a better experience, with discharges home for over 65, non-electives rising from 75.9% pre the intervention to a sustained level of over 80%.
Communication improved through better discharge planning. A patient commented ‘knowing I’m going home in 3 days keeps me going’ By promoting home as the default pathway short term packages reduced the need for long term care. DSTs conducted in the acute setting reduced from 10% to 2% between Q1 and Q2, providing a more accurate assessment.
The Head of Continuing Health Care commented that the integrated team is ‘a fantastic team, working really hard on positive relationships. It makes such a difference that barriers have gone down - now it’s ‘nobody’s fault’ New ways of working save time. In January 2017, 37 discharge notices were denied as alternative pathways were not considered, causing repeat work and delays to patients. Now IDT carry out this work, on the same day.
The project is part of the Rotherham Place Plan which has conducted a range of whole system events with stakeholders. This includes patients and carers, health and social care professionals, Commissioners and the Voluntary and Community Sector. More specifically to this project discussions have been held with members of the Carers Forum.
Patient experiences, including a review of 50 patient discharges, have informed developments. A cross-system Winter Pressure Workshop included practitioners, Commissioners, Continuing Health Care and the voluntary and community sector. A wide range of engagement events have been held with health and social care colleagues to plan and implement the change.
The outcomes informed development and prioritisation, including development of the single referral process, which was reworked to address therapy concerns. As the home first ethos has taken root more specialisms have become involved. Therapies and community nurses now work into the Integrated Discharge Team, with acute therapies covering the community Trusted Assessor roles in ED and AMU when they are not available.