Reducing hospital stays through integrated care

The length of time patients are staying in hospital has been reduced on two wards at St Thomas’ and King’s College hospitals, thanks to the Integrated Hospital Discharge Teams being tested.

The teams have also been able to reduce the time it takes to complete a health needs assessment with patients. These assessments identify whether patients are eligible for continuing healthcare and/or NHS-funded nursing care when they leave hospital.

The teams are working to improve communication with patients and their carers; and encourage more collaborative working between health and social care professionals when they are planning to transfer care from the hospital to a person’s home or to a care home. They are currently being tested on two older people’s wards; on Anne Ward at St Thomas’ Hospital and Donne Ward at King’s College Hospital.

The teams aim to help make the hospital discharge processes more effective, avoid duplication of work and minimise delays, so people can return to their homes as soon as they are medically fit. Each patient is allocated a member of the team who is their main point of contact for information and support regarding the discharge planning.

In July, the Integrated Hospital Discharge Team on Donne Ward has seen the average length of stay reduced by four days (when compared to 2014 data on the same ward).

Sue Bowler, Director of Integrated Care and Partnerships at King’s College Hospital, said: “This is a significant reduction in the amount of time people stay in hospital for, which is fantastic for our patients. It also means that we can give the beds to people that really need them.

“The test has now been running for five months, and we have learned a great deal about how we can improve our hospital discharge process. The inclusion of a ward-based social worker has made a huge different to how we coordinate support for patients when they leave hospital.”

On Anne Ward, the team were able to significantly reduce the time needed to complete a health needs assessment, in one case it was completed in just two days.

Previous audits show the average time it took to complete an assessment has been 22 days.

Teresa Meldrum, Clinical Specialist Occupational Therapist, said: “A better understanding of each other’s roles in the discharge process has resulted in improved communication between the team members and helped to break down the barriers between health and social care.”

The Integrated Hospital Discharge Team on Anne Ward also includes a Discharge Facilitator who has been seconded from the British Red Cross.

Teresa explained: “The test has been really interesting, especially having someone from the British Red Cross on the ward with us. They have been able to identify and access voluntary and community sector services promptly to support the patient to return home.”

Following the test, which finishes in September, an evaluation will be undertaken to decide how the learning will be taken forward to continue to improve the discharge process at both hospital trusts.