PROJECT

Simplified discharge

Our Simplified Discharge work aims to resolve the issue of people remaining in hospital longer than needed. Many local people have told us they would prefer to be cared for in their own homes whenever possible, but sometimes there are delays that stop them going home quickly. These issues can be caused by delays in the discharge process across the health and social care system, such as waiting for:

  • assessments to be completed
  • clinical decision-making
  • referrals
  • transfers to appropriate places of care
  • people (and carers) to make informed choices about their care.

These delays can have an impact on a person’s hospital experience, but can also cause physical decline and can lead to people needing long term care to support them in their own home or a care home.

Also delays in people returning home or to a place of care have knock-on effects on the flow of patients through hospital, with consequences on:

  • hospital bed availability
  • A&E performance
  • demands on staff, which can result in reduced staff morale.

 

Organisations around the country are looking at how they can improve the way people are transferred from one care setting to another or back to their own homes. We are learning from these organisations as they also develop models that integrate hospital, community, social care and general practice. Many, like us in Southwark and Lambeth, are looking at how to assess the needs of older people outside the hospital walls. Evidence shows that this increases independence and reduces the number of people placed into long term care, for example care homes. It also helps to ensure more beds are available in hospital and reduces the number of days people spend in hospital beds; therefore, potentially saving money that can be used to provide other aspects of care.

Evidence highlights a clear need to change the way services work together and with older people, their families and carers. However, improving the discharge process is extremely complex, and requires changes to be made and learning to be gained from them.

The Simplified Discharge project has already trialled two significant changes: extending the Enhanced Rapid Response (ERR) service and providing additional social worker support for older persons’ wards. Both of which have led to improvements, and have provided building blocks for further improvements to the discharge process across the health and social care system.

In Lambeth and Southwark, patients aged 65 and over who stay in hospital for 14 days or more contribute to a staggering 69 per cent of all the days 65+ year old patients send in hospital.

The overall vision for the project is that people receive the right care, in the right place at the right time. This requires a significant number of changes to the way staff work, finances and the culture of the organisations involved. With this in mind we have set out a number of stepping stones in the process to improve the quality, safety and efficiency of the process of people returning home or to a place of care. They are:

  1. Creating an integrated approach to discharge
  2. Building knowledge of community services
  3. Creating a trusted assessment process and simplifying the referral process
  4. Time sensitive assessments at home and standardised packages of care
  5. Training staff to support older people, their families and carers to prepare for returning home.