Thanks to the launch of a new national scheme, 235 patients across Morecambe Bay have been able to leave hospital earlier to receive their follow up assessment and care in a more suitable environment.
The scheme, called Discharge to Assess, is currently being rolled out across the country, aiming to support people to leave hospital as soon as well enough to do so.
Bay Health and Care Partners began a pilot implementation of Discharge to Assess in Morecambe Bay in March 2018, and the approach is working well so far with 235 patients being discharged from hospital earlier than they would have previously.
Foluke Ajayi, Chief Operating Officer, University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT), said: “For older people, we know that longer stays in hospital can lead to worse health outcomes and can increase their long-term care needs. The last thing they need is to be kept waiting unnecessarily in hospital for an assessment to determine their long term care needs.
“Discharge to Assess aims to ensure that patients who are ‘medically optimised’, and no longer need a hospital bed, are able to leave hospital and have their assessment in the most suitable setting - usually their own home.”
When a patient is being discharged from an acute hospital, there are typically four pathways (or routes) that the patient may follow:
0. Patient is able to leave hospital to go home without any additional support,
intervention or assessment
1. Pathway 1 (‘Home First’) - for those patients who would benefit from
reablement support and / or therapy care input to help them live and manage
safely at home
2. Pathway 2 - for those patients who require further rehabilitation in a
community setting with short term therapy input
3. Pathway 3 - for those patients who will require 24 hour care in an appropriate
Discharge to Assess focuses on patients being discharged on pathways 1, 2 or 3, who require further support.
It does not apply to patients leaving on pathway 0 who require no further input or support.
Patients can also move between pathways to ensure appropriate interventions.
When a patient is identified as needing to follow either pathways 1, 2 or 3; hospital and community staff work closely with social care colleagues to discharge the patient to the most appropriate setting. It is whilst in the most appropriate setting that the person will have an assessment to determine what their needs are to help the person remain living safely in the community.
For people being discharged on Pathway 1, a team of healthcare professionals supports the person being discharged to their own home for an interim, short term period, whilst the assessments are taking place to agree the best interventions needed to allow the person to continue to live safely at home.
Hilary Fordham, Chief Operating Officer, Morecambe Bay CCG, said: “We are extremely pleased to see activity levels through the Discharge to Assess and Home First schemes improving. It is a great testament to all of the hard work that has gone into this pilot.
“We are committed to supporting this process through its pilot phase and are working closely with all stakeholders to improve the patient experience whilst delivering quality services.”
There are many benefits of Discharge to Assess, including:
Determining a person’s needs is best done in the person’s own home in
familiar surroundings, which results in improved health and wellbeing
People will be in a better position to need less ongoing care and support
because they have left hospital at a time when they are best able to recover
People’s length of stay in a hospital bed decreases due to longer-term
assessments taking place in a more appropriate setting. Evidence suggests
this should improve outcomes significantly, since ten days in hospital (acute
or community) can lead to the equivalent of ten years of muscle wastage in
people aged 80 and over
Encourages partnership working between colleagues in primary care,
community, hospitals and adult social care for the best outcomes and
experiences for people
Improves patient flow across the health and social care system by enabling
patients to access urgent care at the time they need it
Reduces duplication and unnecessary time spent by people in the wrong
Allowing patients and their families or carers to be involved in the process
from the very beginning to ensure they understand what is happening and
County Councillor Graham Gooch, Lancashire County Council’s cabinet member for adult services, said: “We’ve worked very closely with our partners to improve support for patients who may need social care when they leave hospital. Despite the challenges the NHS and local government face and the high demands for our services, through developing Discharge to Assess pathways like these for patients
in UHMBT, we have been able to reduce the number of days people have to stay on hospital wards because of delays. These are known as Delayed Transfers of Care and we’ve been able to reduce the number of days awaiting social care assessment by 83% between April 2017 and July 2018 for Lancashire residents.
“Our social workers who support patients after a stay in hospital do a superb job.
They’ve worked tirelessly to make improvements and this scheme is a great example of the work we do together with the NHS to improve people’s health and wellbeing.”
Regular updates on the implementation on the scheme, including staff and patient feedback, will be shared on: https://www.uhmb.nhs.uk/patients-and-visitors/supporting-patients-when-leaving-hospital/.
More information about discharge to assess can be found at: https://www.england.nhs.uk/urgent-emergency-care/hospital-to-home/improving-