Sheffield Teaching Hospitals Foundation Trust brings discharge duties home when needed for timely service delivery.
It is well documented that the average length of hospital stay increases directly with age. An aging population means that over the next few years, there will be an increase in the number of frail elderly patients admitted to hospital.
Once their acute and immediate needs have been met, it is important that patients are discharged in an appropriate and timely manner. The risks of prolonged length of stay are infection, worsened state of confusion/disorientation, physical deterioration, institutionalisation and reduced independence.
At the Sheffield Teaching Hospitals Foundation Trust, a regular meeting called ‘The Big Room’ was started to improve patient care and flow. This is where staff across health and social care who work with elderly patients come together to discuss, plan and implement tests to improve patient care.
These meetings take place every week for one hour, they are non-hierarchical and everyone’s opinion and roles are respected. It looks at problems and uses plan, do, study, act cycles to work towards solving issues and moving ahead.
Discharge to assess model
Under the discharge to assess model, we now have access to active recovery (AR). This is a community team of nurses, occupational therapists, physiotherapists and rehabilitation assistants. The patients receive a detailed assessment of their immediate needs in the hospital, and any ongoing needs are assessed on the day of discharge at home. Subsequently, any patient services are supplied in a timely manner.
Discharge to assess brings a number of benefits for the patient and the family, and removes many barriers that have delayed discharge in the past. It has allowed the establishment of closer links with community colleagues, and facilitates a timely and safe transfer of care between hospital and home as soon as patients no longer require acute hospital care.
Under this model, a short assessment is completed prior to deciding if the patient is appropriate to be discharged home. Previously, referrals were made for equipment, home care, and community therapy if needed. These referrals often contributed to delayed discharges with no benefit to the patient. The assessment is condensed to initial interview, transfers and mobility assessment, toileting and night needs. This is often done jointly with physiotherapists. Key information is passed to community staff and the remainder of assessments are completed at home by AR.
This approach still requires therapy skills to identify immediate needs on transfer; however, it moves further occupational and physical therapy assessments and timely provision of services in the community setting. AR meets the patient at the property; can deliver and fit small pieces of equipment. They will assess and set up a care package to be carried out by rehab assistants, and will continue to work towards therapy goals set by hospital therapists and the patient.
Benefits of this model:
- Assessment is ‘context specific’ and the patient’s immediate and long term needs can be more appropriately evaluated at home
- Issues which may have been developing for some time which precipitated an acute admission will be assessed and plans put in place while the patient is still at home
- A patient’s needs have been frequently found as less resource intensive than predicted in a hospital environment, saving demand on social services resources
- Patients and relatives report increased satisfaction. AR work until 8pm and are happy to accept evening discharges. This works well with families who want to be there on the day of discharge but are unable to take time off work
- Removal of steps, processes and delays in the discharge process which consume valuable resources and do not add value for the patient
- Reduced length of stay
- Reduced risks associated with vulnerable patients remaining in hospital
- Increased discharge rates
- Hospital beds are freed which reduces medical outliers
- Increased patient flow through the hospital
Challenges in the early stages
- Managing administrative issues (phoning, faxing, photocopying)
- Delays in medication for discharge
- Capacity in community
- Handling patient/carer concerns
- Gaining access to property
- Time constraints
- Establishing roles and responsibilities
- Lengthy referral process
- Changes in roles and assessment processes
Overcoming the challenges
- Introducing flow nurses to coordinate the discharge, thus freeing up therapy time to assess patients
- Encouraging doctors to complete ‘to take outs’ as soon as the patient no longer requires acute medical care
- Employing rehabilitation assistants as part of community services to review the capacity needed to meet a patient’s requirements on discharge
- Improving all team members’ knowledge of AR and patients/carers are informed about AR on admission
- Location of house keys is discussed as soon as possible on admission
- Shortening the therapy assessment process has been shortened but still relies heavily on clinical knowledge and reasoning to plan safe discharge
Before discharge to assess, patients could wait on average 10 days for community services. Following a successful trial period, the time frame for a patient no longer requiring acute hospital care to discharge is reduced to 0.6 hours
Discharge to assess continues to be work in progress. Plans have already begun to extend the model from geriatric and stroke medicine wards to other trust directorates.
Laura Evans is head of occupational therapy; Helen Miller is a clinical specialist occupational therapist in long term conditions and falls; and Claire Doran is senior occupational therapist at Sheffield Teaching Hospitals Foundation Trust.