Faced with high delayed transfers of care, Medway Clinical Commissioning Group identified four discharge pathways a year ago and things started turning around, explain Stuart Jeffery, James Lowell, John Britt, and Helen Martin

Elderly woman in bed

As I write this in late November, Medway Foundation Trust has just two patients on the delayed transfers of care list. They closed an escalation ward last week that had been open for three years, there are 32 empty community beds and last week’s accident and emergency performance was just a whisker under 95 per cent. 

Twelve months ago, we had 47 DTOCs and A&E performance was in the mid 70s. It has been a long struggle to get patients moving and we have thrown everything we can think of at the problem but it seems to have worked (touches wood, crosses fingers and prays that it continues through the winter).

Twelve months ago, we had 47 DTOCs and A&E performance was in the mid 70s. It has been a long struggle to get patients moving

The Medway health economy is helpful. The clinical commissioning group and unitary council are co-terminus and have an excellent working relationship, including a shared commissioning team. Medway CCG and Medway Council serve 75 per cent of the acute trust too.

The CCG and Council had put reablement and intermediate care monies into our Better Care Fund and we were planning how we commission services from this joint pot. Neighbouring Swale CCG, which has the other 25 percent of Medway FT’s patients, is working closely with us.

Discharge pathways

Starting in 2016, four discharge pathways were identified. Pathway 0 was the easy one, patients discharged who need no ongoing support from any other agency.Sorted!

Pathway 1 commenced in April 2016. “Home First” takes five patients each day who need support at home. They are identified as having this need in the morning and arrangements are made for the patient to be discharged in the afternoon. They are visited at home within two hours of arrival by the Home First team and a package of care is put into place provided by them. 

The package is assessed after a few days and either stopped if the patient has recovered sufficiently or a longer term package of care is arranged through social services. There is a further review after six weeks and around three quarters of patients are discharged without a need for an ongoing care package.

Pathway 2 started in September 2016. Our intermediate care / reablement / rehabilitation beds were moved and refocused on getting patients back on their feet and home to their usual place of residence. 

We quickly adopted the premise that an acute bed was almost always the worst place for a patient who was otherwise fit to go home

We reduced the overall number of inpatient beds by 10 and increased support for care packages at home to compensate. Our Integrated Discharge Team controlled the flow of patients to these beds and we aimed for an average LOS of 21 days. We were still struggling with DTOCs though, despite Pathway 1 and 2 being in place.

Pathway 3 commenced in May 2017. We used the iBCF money to purchase nine residential beds to do discharge to assess and DTOCs immediately fell below 30 for the first time in nine months.

We put into play a number of pilots in October 2017 based around discharge to assess and getting care homes to accept assessments, ie the trusted assessor model. 

Then in mid October we started daily conference calls with partners going through the DTOC list.

The daily calls were based on a model plagiarised from Brighton and the hope was that we could identify some further themes to focus our next area of work on. The first call had 28 patients on the list so we went through them one by one, challenging each other for solutions. 

We quickly adopted the premise that an acute bed was almost always the worst place for a patient who was otherwise fit to go home so if we found even a short term hop to home it would be better for them.

There were real concerns that we would just block community beds with patients on a different DTOC list so we agreed to discuss them on the calls too.

Efforts bear fruit

The DTOC list fell week by week, from 28 down to just two patients over the five weeks and yet the community beds did not increase their DTOCs.

We found that teams were trying to get discharges completed before patients became DTOC rather than simply dealing with them once this had happened.

They became far more proactive in identifying medically fit patients and getting them discharged. It felt like they were trying to keep up with us.

We found that teams were trying to get discharges completed before patients became DTOC

We have still got some tests of change happening in Pathway 3 but the bulk of our pathways are now running hot and efficient. Our next step may be to go through the medically fit patients each day too and we may not need to have so many beds open either. 

We couldn’t have managed it without the close co-operation of our partners and teams at the councils, the Trust and community providers Medway Community Healthcare and Virgin. 

Long may it continue.