hospital discharge:

The general and emergency medicine directorate at Barts and the London trust introduced the role of interprofessional care co-ordinator in 1997. Research by City University has produced some valuable lessons for other hospitals thinking of establishing similar posts.

What is a care co-ordinator?

Our directorate has 20 consultants, runs six wards and admits more than 8,500 patients a year. Three inpatient care co-ordinators work in the directorate, each linked to two or three medical specialties. We have now introduced a fourth post, with plans to extend the role into accident and emergency.

The care co-ordinators' main purpose is to ensure that the patient's stay in hospital is only as long as clinically necessary. They generally meet patients the day after admission and consider them for occupational therapy and social work services. Referrals are authorised by a professional. The care co-ordinators attempt to clear any obstacles in the path of patient care and discharge. They identify patients who are likely to benefit from their input early in the admission process and gather detailed knowledge about the patient's living situation, clinical problems, investigation needs and any likely discharge delays. They try to kick-start investigations and co-ordinate the discharge.

Throughout the patient's stay, care co-ordinators play a key role in prompting planning and are recognised by the multidisciplinary team as the person who knows 'what's going on' with a particular patient. They liaise with patients, families and carers and may also act as advocates, accompanying patients to nursing homes.

Gathering and communicating information is key to the job. But evaluation has shown few instances of care co-ordinators making decisions independently - information is more likely to be used to prompt action by other staff. Over time, the role has developed to focus more on discharge than inpatient processes. Care co-ordinators have retained a key role as problem-solvers but they work flexibly to enable them to do whatever may be needed to move a patient through the system quicker.

As one described it, the work 'can be anything from trying to sort out transport problems, to getting a patient transferred back to another hospital, to chasing up results, getting in touch with a relative... to getting a vest and pants for a man who couldn't go home unless he had these'.

Care co-ordinators have developed particular skills in understanding the administrative difficulties in discharge and identifying the right person or service to deal with them as quickly as possible.

They keep a record of patients whose discharge is delayed and the reasons for the delay. At a weekly meeting of the care co-ordinators, the directorate operations manager and the hospital social services team leader, cases where discharge has been delayed are reviewed and actions are agreed to resolve the problem. System problems which may need to be tackled at a different level are also identified. The bed manager is an important link for this. The data is also used for directorate reporting on discharge delays to trust managers and the health authority.

What are the benefits of the post?

Because of the complexities of interprofessional working and the size of the directorate, the care co-ordinators make a valuable contribution to patient care. The number of delayed discharges has decreased from a maximum of 40 patients (winter 1995-96) to a maximum of 15 patients (winter 1998-99). The average length of stay has also fallen from 8.5 to 5.9 days in two years. The directorate team attributes these changes to a number of initiatives, particularly the introduction of care co-ordinators.

Introducing and negotiating the role

Care co-ordinators have been in place for over two years and were initially introduced through a joint effort between the directorate's clinical director, operations managers and lead nurse. Other team members (particularly in social work, occupational therapy and physiotherapy) have been involved in reviewing the post's role. Evaluation has highlighted some tensions between the care co-ordinator role and some other staff. Early evaluation highlighted a 'boundary overlap' with nursing and, although few tensions are now apparent, it may be that the current smoother working represents a 'take-over' by the care co-ordinators of work traditionally the responsibility of nurses, particularly discharge planning.

The greatest remaining tension is with social workers. Some social workers and care co-ordinators work together in a complementary way. But given the care co-ordinator focus on social issues and discharge planning, the flexible boundaries allowed by their role and their remit to move patients through the inpatient system as quickly as possible, it is not surprising that tensions exist. More work is planned in exploring the nature of the boundary overlap and creating opportunities for role negotiation, enhancing mutual understanding and effective joint working.

Recruitment The specification states that a detailed working knowledge of the hospital environment is more important than a professional qualification. As one senior registrar stated: 'The success of the role is more about the individual in it than the role itself.' All those who have held the post were working at the Royal London Hospital at the time of appointment and, between them, their backgrounds included ward clerk, administrator for diagnostic imaging, bereavement and convalescence secretary and healthcare assistant. A detailed knowledge of the hospital environment and systems have proved to be of great benefit.

The specification indicates that a professional qualification is desirable but not essential. Most members of the team and the care co-ordinators themselves feel that the type of duties involved do not require a professional qualification. It may be, however, that such a qualification would lead to a different interpretation of the post.

Induction and training

As post-holders came from different backgrounds, training has had to be tailored to individual needs. Shadowing someone already in the job has been identified as one of the most effective introductions.

Staff and managers in the directorate have made several suggestions for training (see box, above). Trends in national training and education policy may now prompt the development of a more formal training pathway for care co-ordinators.

Management

The care co-ordinators were originally managed by the directorate's lead nurse, but over time it became clear that a more direct line was needed to enable system problems identified through the role to be tackled. The directorate's operations manager then became the care co-ordinator's manager.

Conclusions

The care co-ordinator appears to have an important contribution to speeding up in-patient processes. But more evaluation is required to determine the post's unique contributions and the implications for patients of unqualified workers taking on responsibilities previously carried out by professionals. Within the directorate, the care co-ordinators are clearly valued. For an information pack on care co- ordinators write to Dr Michael Glynn, clinical director, general and emergency medicine directorate, Clock Attic, The Royal London Hospital, London E1 1BB.£5.

Jackie Bridges is research fellow and Julienne Meyer is professor in adult nursing, St Bartholomew school of nursing and midwifery, City University. Debra Davidson and Julie Harris are operations managers, and Michael Glynn is clinical director, general and emergency medicine, Barts and the London trust.

Key points

The introduction of care co-ordinators into a medical directorate two years ago has reduced bed blocking and cut length of stay from 8.5 to 5.9 days.

All those appointed were already working in the hospital.

There have been some tensions over boundaries with nursing and social work.

Do you need a care co-ordinator?

Are significant numbers of patients staying longer than clinically necessary?

Do the patients going through your service have input from several different professionals?

Do your patients have contact with several other hospital departments?

Do you often think: 'This test/treatment/ discharge plan seems to be taking a long time to arrange or to carry out'?

Do you often think: 'We have a lot of patients going through with similar problems - isn't there a way of learning how to do these things better'?

Are there 'trivial' issues which add up to a big problem because no one takes responsibility for them?

Does a lot of the expertise to solve this type of problem lie with doctors- in-training who change frequently?

Do you need to gather regular reporting information on reasons for delayed discharges?

Training topics for care co-ordinators

Contributions of other multidisciplinary team members

Interpersonal skills

Team building

Assertiveness

Managing priorities

Confidentiality

Working with ethnic minorities

Ethical issues

Counselling

Loss and bereavement

Domestic violence

Substance abuse

Homelessness

Community Care Act

Changing role of health authorities

Primary care groups