Facilitating early and well managed discharge from acute care is very important, as is supporting older people to live well at home, preventing early admissions to long-term care. NHS Providers has launched a Commission to capture good practice with regard to transfers of care in all settings across acute, community, mental health and ambulance services.

The three Health Foundation funded projects below were highlighted in submission to the Commission. They all aimed to improve the transfer of care process for older patients moving from acute to community settings. They show how introducing more person-centred approaches to care can improve patient experience while also helping to bring down repeat admissions to hospital.

1. Discharge to assess for frail older patients

Discharge to Assess (D2A) is an innovative new approach to managing the care of frail older people which has had a striking impact on outcomes and length of stay. The first ward to introduce D2A saw a seven day reduction in length of stay, no increase in readmission and a lower number of patient falls.

The Discharge to Assess model (D2A) in Sheffield was developed as part of Sheffield Teaching Hospitals NHS Foundation Trust’s wider work to improve patient flow through the emergency care pathway.

The model ensures frail older patients are discharged from hospital as soon as they are medically fit, with assessment and care packages put in place in their home. Prior to this, people who were clinically well but would have found it difficult to manage at home were usually kept in hospital for an assessment of their needs.

Sheffield’s Flow Cost Quality project team worked closely with stakeholders involved in each step of the assessment pathway to redesign the process and ensure that appropriate support packages could be made available in the community as soon as they were needed. As a vertically integrated trust, it is able to call on community based care teams to give immediate support to patients at home once they are medically ready to be discharged.

Read more about Discharge to Assess, part of our Flow Cost Quality programme.

2. My Discharge – Royal Free London NHS Foundation Trust

My Discharge is an innovative case-management model for people with dementia which achieved some dramatic results when introduced by a team at the Royal Free Hospital in London. During its first nine months, the project managed to reduce length of stay by 2.6 days, reduce re-attendance to A&E by a quarter and save nearly £50,000.

The model gives every patient with dementia a safe, dignified, timely and sustainable discharge, bridging the transition from hospital to community care. It offers a personalised service, working in partnership with patients, their care support network and community providers, including flexible post-discharge management and one-to-one training and support.

More recently, the project team has used the learning from the project to date to design a model of care that can be embedded in the organisation and disseminated to all staff involved in the care of people with dementia. To help implement this model, the project has received further funding from our Spreading Improvement programme.

Read more about the original ‘My Discharge’ project, part of our Shine 2012 programme.

3. Improved communication during transfer of care

A team at East Kent University NHS Foundation Trust significantly improved communication during transfer of care processes for frail older patients. Their results were impressive. The trust reported that readmissions from care homes had reduced from 25% to 15% at 30 days, without a rise in length of stay. Ashford CCG also reported a reduction in total admissions of older people, leading to an estimated saving of £500k in the first year.

The solutions introduced by the team focused on streamlining the handover of information when frail older people left hospital. They developed a two-sided form to accompany the patient – one side for the care home to fill in when sending a patient to hospital, the other for the hospital to complete on discharge. They also set up a community geriatric team and 24-hour telephone service, which helped to reduce readmissions from care homes.

They established that problems using the Electronic Discharge Notification (EDN) system meant that crucial information was not being passed on to primary care. Failure to set an Estimated Date of Discharge (EDD) was associated with an increased length of stay and could lead to a discharge without appropriate assessments or adequate care planning. They made changes to the EDN system and introduced training on EDN and EDD.

Read more about this Safer Clinical Systems project.

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