Learning in the snow

By Fiona Martin, Project Portfolio Manager, SLIC Core Team

Late last year I was at my Mum’s house and a friend of hers popped in for a cup of tea. Mavis asked me what I did. Describing Integrated Care is always a fun experience. I explained about how we were working towards making sure people only spend as long in hospital as they need to and that they are then supported by the right people at the right time at home and described our vision of an integrated discharge team. My Mum then said: “Oh, that is what they do here.” I thought ’Yes Mum, of course they do.’ But there was that nagging feeling in my head, you know the one, that your Mum is always right. Just like all those times when you were little and she said ’take your coat, it’s going to rain’ and then it did. I did a bit of research and found out that Doncaster and Bassetlaw Hospitals NHS Foundation Trust do have an Integrated Hospital Discharge Team. So, for the one billionth time in my life, my Mum was right, although I haven’t actually told her that! After a few phone calls I arranged a visit to the hospital, after a learning event in Sheffield.

A couple of years ago Sheffield Teaching Hospitals NHS Foundation Trust started to develop a ‘Discharge to Assess’ model, so we also wanted to know more about. On a cold winters day me and a few colleagues working across Southwark and Lambeth headed north, to find snow and find the answers to our discharge questions…..

Over 140 people gathered at the Novotel in Sheffield to hear about the work they have been doing to develop a Discharge to Assess model. We met staff from the social care, community and acute services who have all been integral to designing and testing their Discharge to Assess model. The model builds on the evidence that people are staying in hospital too long and they should go home as soon as their acute needs have been met. That is all very well, but some people need additional support to live at home after they have been in hospital. Traditionally many patient needs assessments are completed in hospital, but in Sheffield they have developed an Active Recovery team. This team is based in the community and is made up of nurses, occupational therapists, physiotherapists and rehabilitation assistants. So in Sheffield patients now receive a detailed assessment of their immediate needs in the hospital, to ensure they are safe to go home and any further needs are assessed at home on the day of their discharge.

We heard about the challenges of developing this model; for example having to overcome problems when patients were due to go home, but the medication wasn’t ready, the doctors were in a training course or the fax machine wasn’t working so they weren’t able to send the 14 page document over to the community team in one go. The team used a ‘Big Room’ approach and a ‘Plan Do Study Act’ method to bring about the changes and resolve problems. The benefits to the model included; reducing length of stay, reduced risks of vulnerable patients returning home, increased patient flow through the hospital. The patient needs assessment have shown that people need less support at home than was predicted.

One of the most striking things for me was the fact that the Trust uses a private taxi company to take people home rather than using an ambulance. The taxi drivers were paid extra to provide an enhanced service that included taking the patient into the house and making sure they were settled.

The teams were open about their learning and challenges they faced. We were reminded that putting a Discharge to Assess model in place is a marathon not a sprint and takes a lot of effort to make the organisational and cultural changes necessary. 

With the snow falling we headed from one South Yorkshire city to another, this time Doncaster to learn about their Integrated Hospital Discharge Team.
The Integrated Discharge Team is based at Doncaster Royal Infirmary and works with any patients who need additional health or social care support. The team is made up of therapists, nurses and social workers. They have a system of trusted assessment, which means that any member of the team can go and do an initial fact finding visit with a patient on a ward. The fact finding form covers health and social care needs. Once completed the most appropriate discharge route is chosen and communicated to the ward staff. The wards all have a discharge facilitator who work with the discharge team to ensure the patient has medication, transport and all activities related to the discharge are complete. 

The team were really welcoming and explained how it has taken two years to get the team in place and the processes working well. Doncaster has a lot of community rehabilitation beds where decisions are made about long term care – e.g. nursing homes. Now people rarely make a decision about the need for a long term care placement from the acute hospital as they are made in the community. This model is very different to the model we have in Southwark and Lambeth, where we have very few community rehabilitation beds. We have used some of the learning we gained from the trip to Doncaster in the design of our Integrated Hospital Discharge Team test that is taking place at King’s College Hospital and St Thomas’.

Our trip to the North may have been cold, but we received a warm welcome and learnt a lot about the challenges and opportunities of implementing different discharge models.