PROJECT Simplified discharge

Creating an integrated approach to discharge

Feedback from local people echoes that of national evidence. This is that people only want to be in hospital when they really need to be and where possible they want to be treated at home. Evidence from audits carried out at both Guy’s and St Thomas’ and King’s College hospitals have shown there are people in hospital when they don’t need to be for medical reasons. Often the reasons they are there are because they are waiting for care to be set up in the community or they are waiting for assessments about what care they need at home.

Southwark and Lambeth Integrated Care has created Integrated Hospital Discharge Teams at both hospitals. The teams will test how health and social care professionals work together when they are planning to transfer care from the hospital to the person’s home (discharge). This will help make the process more effective, avoid duplication and minimise delays, so people can return to their homes as soon as they are fit to.

Clinical staff talking next to whiteboard

The Integrated hospital discharge teams are multi-disciplinary teams of health and social care professionals. As a team they will:

  • Review the people on the test wards on a daily basis
  • A member of the team will take lead responsibility for overseeing each discharge, acting as a point of contact for patients and carers
  • Manage the referral and discharge process in a joined up way
  • Ensure there is a person-centred approach to discharge with better outcome, minimised risks and better involvement (for carers / families as well as patients)
  • An administrative assistant will be a key member of the team and will work with the care managers to ensure that all actions and activities required to support discharge happen in a timely way, for example equipment is ordered and the correct paper work is completed and shared.

The test is currently running for six months. During this time we will be looking at how the process can be improved on a weekly basis. A key part of the improvements will be feedback from patients on the wards where the test will be taking place and their carers.


Project update - August 2015

The test at King’s College Hospital is currently in its final month and in its penultimate month at St Thomas’ Hospital. Both test sites have responded to local needs and challenges by changing the way they work and the way the initiative is tested. To date, the impact highlights and benefits include:

  • An overall reduction in hospital length of stay (when compared to 2014 data)
  • Improved communication between different professionals, which leads to more efficient execution of discharge planning
  • Staff feel more confident with their role and responsibilities as they take on the key worker role, often through joint working and cross-learning with different professionals
  • Reduced the time taken to complete London Health Needs Assessment and other relevant activities throughout an assessment.