More patients are experiencing delayed discharges from hospitals, but integrated care boards are working with system partners to develop new and innovative ways to address this. Mid and South Essex ICB and Mid and South Essex NHS Foundation Trust are approaching this longstanding issue with a home-first ethos as Kathy Oxtoby explains in the third of four case studies.
High demand for services, more patients with complex care needs, and making sure there is sufficient flow in discharge services, are some of the main challenges facing the integrated care board (ICB) and hospital trust when managing patient discharge.
The hospital trust works jointly with the three local authorities to promote a home-first ethos.
System challenges are being addressed through ‘shared thinking, shared responsibility, and putting patient outcomes at the heart of all decision making’, the ICB and trust say.
In Mid and South Essex, there is an established Stewardship programme, which is about forming teams that bring together perspectives from the whole cycle of care – from across all services supporting residents moving through the health and care system, from before they enter, to after they step out.
Ageing Well stewards have co-designed a common assessment tool to help identify and meet the needs of older people who often have complex needs. Results have seen more than 12,000 new people with frailty/dementia/end of life needs identified in the first year alone, and more than a 50% reduction in older people with more than three unplanned hospital admissions in their last 90 days of life.
Schemes such as Urgent Community Response Teams, can provide two weeks of intensive treatment in a person’s home or care home, are ensuring more urgent care in the community.
Supporting people to get home and become as independent as soon as possible has also been a focus. This has been done through continued partnership working with system partners to offer ‘at home’ reablement and virtual ward services to support people to go home if they are able for ongoing assessment.
Transfer of care hub teams have been working on making sure community services information can be accessed by wards – which is being trialled in a small number of wards on two of the hospital sites – and with support from community matrons to highlight what support community teams can provide on discharge. ‘This is having a positive impact on ward teams’ confidence in discharging residents with complex issues to home, rather than to short term bedded care,’ the ICB and trust say.
Home-first funds
Charis Shop provides hospital discharge teams with immediate access to funds to help them discharge a person safely home. The scheme came about to support the delivery of a one-off discharge support package that could help reduce unnecessary discharge delays. It allows those with low level needs to be supported with essential items such as food and fuel vouchers, bedding, small appliances and phone top ups.
Using the fund in this way supports people – who might otherwise have had an extra day or two in hospital waiting for assessment or support from other agencies – to be discharged and receive a follow up from statutory or voluntary services if needed once they are home.
Within the last year, the Integrated Discharge Teams have supported the distribution of more than £19,000 of grants to 155 people through the Charis fund.
From admission to discharge
Michelle Stapleton, integrated care operations group director for Mid and South Essex NHS Foundation Trust says: ‘We now focus on a patient’s discharge journey from the moment they are admitted. Using same day emergency care services has enabled us to treat and transfer or discharge at the front door, reducing the need for stays in hospital. Work to reduce length of stay is important in increasing flow across the hospital and we can only do this by working in an integrated way with our wider health system partners.
‘There have been some bumps along the way, but we must remember our ethos of home first. Patients will always feel better if they can recover with support in their own homes,’ she says.
Dr Matthew Sweeting, executive medical director for NHS Mid and South Essex, says: ‘Supporting effective discharge is not a one-size-fits-all process, and as a system we are focussed on ensuring smooth and timely discharges that consider the holistic needs of patients and maximise health outcomes.
‘We know that beds in residential settings are not always the answer to supporting people to get home at the right time. We need to continue to support our community teams across health and social care to work together and have strong networks to help our residents to remain or regain independence after a stay in hospital. It’s important to reduce unnecessary admissions by having care at home and using community home-based services such as our Urgent Community Response teams (UCRT) and virtual hospital.
‘We recognise that discharge planning starts on admission and that in working with our partners across the system, we need to ensure our discharge pathways flow well and that teams can work together to problem solve and support our residents. One team cannot solve this on their own,’ he says.
Further analysis and case studies
Read more about tackling delayed hospital discharge and improving patient flow in this analysis, and discover some of the other inspirational work being done across England in the other case studies in this series:
- Case study 1: Virtual ward and Quick Start initiatives from Central London Community Healthcare NHS Trust
- Case study 2: Improving the discharge lounge at the Royal Free London NHS Foundation Trust
- Case study 4: A person-centred HomeFirst model
This case study was originally published by our sister publication Healthcare Leader.
