South Warwickshire Foundation Trust set up three discharge-to-access pathways that cut down the length of hospital stay for older patients
Following the transfer of Warwickshire community services to South Warwickshire Foundation Trust in 2011, the trust embarked on a transformation journey with our clinical commissioning group and local authority colleagues to integrate services to best meet the needs of older people.
There was an urgent need to develop and implement an innovation to manage the demographic, financial and urgent care performance challenges.
The trust acknowledged that organisational boundaries and traditional financial flows were getting in the way of providing the right care in the right setting and explicitly recognised the findings of the King’s Fund and Nuffield Trust integration report.
The trust found that that in changing the design of the patient discharge pathway, benefits do not always accrue where the cost is incurred; that organisational development can hinder development of shared care; and that frank discussions about risk share and gain share would be needed to ensure that resource could follow the patient.
Clinicians and practitioners adopted the principle that no decision about long-term care needs should be made in an acute hospital setting – they should discharge to assess (D2A) and establish a shared purpose between the partner organisations.
From 2012-14, we have established three D2A pathways to support discharge from acute hospital care based on this shared purpose and three underlying principles (see box).
Principles for day-to day running of D2A pathways
- Patients should always be cared for at the lowest level and least dependent pathway that can meet their needs and the focus should be on improving and maintaining independence
- An electronic trusted assessment was developed by practitioners in the field, delivering one single assessment prior to discharge, and which was completed by trusted assessors. This was accepted by practitioners in the community and it has vastly reduced re-assessments in hospital.
- No adult patients should be excluded from access to improve their independence and all patients will formally consent to the discharge pathway.
The D2A pathways
Pathway 1: supported discharge at home
This pathway lasts for a maximum six weeks. Care is fluidly provided between re-enablement and the community emergency response team. The pathway is resourced to discharge 40 patients per week in South Warwickshire.
Pathway 2: re-enablement and rehabilitation in a bedded facility with discharge being the intention
Care is provided in community hospitals or care homes, with rehabilitation or re-enablement support depending on the patient’s need. The pathway is set for a maximum of six weeks but most patients are discharged within four weeks. The rehabilitation pathway has been redesigned to discharge 20 patients per week.
Pathway 3: for patients who are likely to require ongoing care at home
Here, beds have been commissioned in nursing homes through the local authority; medical care is commissioned through GPs and care coordination and rehabilitation is provided through South Warwickshire Foundation Trust as the local acute and community provider. The pathway has 30 beds and can support five discharges per week with maximum stay of six weeks.
The implementation of the redesign has been through a programme board, directing the work of jointly chaired operational planning teams. Successful implementation is because of the quality of the conversation with patients and their families, setting clear goals and ensuring a clear end point to D2A through the consent process. As a result,
- For older patients, acute hospital length of stay is reduced by three days; community hospital length of stay is reduced by 17 days
- Fewer patients admitted to long term care
- Standardised hospital mortality indicator is reduced from 1.11 to 1.05
- Accident and emergency target achieved every month over the winter period for the first time since 2009-10
- 18 acute hospital beds closed
- 26 community hospital beds closed
- Reinvestment in community services nearly tripled community capacity from 25 to 71 patients discharged a week
Health and social care commissioners
- The new pathway 3 released £527,000 net savings from excess bed days to the other new pathways (at 30 per cent marginal tariff)
- The growing trend for community health centres and local authority residential nursing home placements has halted, and may be starting to fall. However, more analysis is required as this is based on small numbers
The redesign of health services to meet the needs of older people is complex. More integrated care is correctly seen as the way forward. Drawing on practitioners’ views and ideas as well as collaborative working at the point of care can transform service and system delivery while the processes should be re-assessed more often.
The D2A pathway is not a quick fix and does require sustained leadership and good working relationships at all levels. However, the benefits vastly outweigh the efforts required en route to good healthcare.