'The right care at the right time': the team helping patients leave hospital

“From the minute a patient comes through the door – be that via A&E or one of our admission wards – we’re starting to think about how we can get [them] home,” says Rachel Blackmore, an operational manager at University hospital of North Tees in the north-east of England.

Delayed discharge from hospital is a widespread issue for the health service. Latest NHS England data reveals there were 145,000 delayed discharge days in April.

Pressure on the NHS is also leading to some patients being discharged before they are ready and without the right care and checks in place, a British Red Cross report warned in February. It said frail and vulnerable patients were becoming trapped in a cycle of avoidable hospital readmissions.

Now an award-winning partnership is transforming care for patients in Hartlepool and Stockton. The Home Safe, Sooner initiative supports patients who are medically fit to leave hospital, linking them with reablement and community services to help them remain well at home.

Prompted by increasing numbers of delayed discharges in the area, health and social care leaders came together in 2017 to look at how they could do things differently. The partnership between North Tees and Hartlepool NHS foundation trust, Hartlepool and Stockton-on-Tees clinical commissioning group (CCG), and Hartlepool and Stockton-on-Tees councils involves an integrated team of about 15 staff based at the North Tees hospital. The team works closely with the hospital’s physiotherapy and occupational therapy services and local voluntary organisations.

“Historically, local organisations often worked in silos and weren’t always connecting with one another,” says Paula Swindale, head of strategy and commissioning at the CCG. “At times, this would result in patients being discharged then readmitted if community services were not in place or there were delays in setting up support. This initiative has transformed the discharge experience for patients.”

The project has evolved from a pilot last year, developed with leadership and coaching support from innovation foundation Nesta. It led to a 35% drop in delayed discharges and was named best integration project at the North East, Cumbria and Yorkshire and Humber commissioning awards.

“The challenge ran from January to May 2017 and the outcomes from that have shaped how we now deliver care,” says Jill Foreman, senior clinical professional in physiotherapy at the hospital. “A social worker from one of our partner local authorities is now based within the integrated team at the hospital.

“In Stockton, we’re now able to receive a referral, see a patient on the same day and provide a package of care within two hours. Working as an integrated discharge team means we’re able to access the right care at the right time to facilitate same-day discharge for less complex patients.”

Blackmore adds: “There is a lot more information sharing between systems and teams now so that we can get the information we need at the beginning. We’re no longer finding things out that could delay discharge at the 11th hour.”

The result has been a cut in delays. The CCG’s data for 2017-18 shows a 12% reduction and savings of £900,000.

In March, the initiative received further acclaim, winning the most effective approach to integrated new models of care award at the Skills for Care Accolades. Judges said it was a model that could potentially be replicated in other parts of the country.

“The Home Safe, Sooner initiative has had such a positive impact on the ward staff,” says Nanette Parkin, a staff nurse at the hospital. “You no longer have tunnel vision where you are focused on your area alone. We’re all familiar with one another so when we make contact, it’s more than just a voice at the end of the phone. It has changed how we work for the better.”

Jill Harrison, director of adult and community-based services at Hartlepool council, agrees: “Working as part of the co-located team is empowering for our staff – they are involved in patient discharge arrangements on a daily basis. They really are seeing the benefits of working in this integrated way.”

She adds: “It’s making a difference to patients as it provides joined up care. There are no longer those delays and hand offs that result in patients having to wait for nursing or social care assessments – people are no longer referred from one agency to another.”


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