Innovation Exchange

Integrated Discharge Hub

Introduction

Key activities

Benefits and impacts

Learning

The NHS Dundee Discharge Team and Dundee City Council’s Hospital Social Work Team have integrated to create a joint Discharge Hub. All referrals from Ninewells and Royal Victoria Hospitals now come to the hub where they are jointly screened and a decision made about which professional is best placed to assume responsibility for the piece of work.

 

This is reducing duplication, and further building on the existing multi-disciplinary relationships within both teams. The patient's journey through the hospital system is streamlined with the ultimate aim being timely discharge to a community setting. The aim is to minimise unnecessary moves for patients, and to ensure they see the right person with the right skills at the right time for them. By improving the discharge pathway, we are also contributing to the reduction in unnecessary bed days in hospital which in turn addresses the Scottish Government's delayed discharge targets.

Theme: Health and Social Care

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We are working in the context of wider health and social care integration and, as two teams within a hospital setting, the opportunities of integration were obvious.

 

Both teams were tasked with ensuring the Scottish Government's targets for reduction in bed days lost are met, but have a commitment to ensuring this is done in the context of service improvement. By reducing both the overall time the patient spends in hospital (and therefore away from their own home) as well as the numbers of unnecessary moves for each patient, we can improve each patient's experience and maximise their opportunity to achieve better outcomes, as well as meeting the overall organisational objectives.

 

A range of stakeholder consultation was undertaken, both across the two teams, but also in the wider community and hospital service interfaces. A service user consultation was also carried out, which highlighted that people valued being fully involved in their own discharge plans, and that having a single consistent person who was their contact made a positive difference to their experience. A test of change was then undertaken in one area of the hospital and further consultation undertaken to compare service user experience. The project then expanded gradually, taking on board the continuous learning from the test, and has now been formally launched across the two hospitals. The hub now also includes Liaison Psychiatry and Mental Health Officer team input.

With the pooling of resources, our integrated hub is able to deploy staff resource more widely across multidisciplinary meetings in hospital wards. A key role of the hub staff is to ensure good communication between the wards and the community health and social care staff in order that any care plan put in place to facilitate discharge is as accurate and efficient as possible. This promotes better use of resources as community knowledge is better applied to the hospital assessment.

 

We are currently collecting information on readmission rates, in order to explore whether we are enabling people to remain at home for longer. We continue to monitor our delayed discharge results in terms of bed days lost, and note that for those people who are returning to their own homes, bed days lost is reducing month on month. As a result of improved communication between hospital and community, 85% of people in Medicine for the Elderly wards in January had an agreed planned date of discharge which community resource providers were able to aim for in terms of planning for discharge. Our aim now is to measure across the hospital as the new system rolls out, and to continue to improve our performance.

 

In terms of continuous improvement, the bed days lost statistics continue to be monitored, and a discharge questionnaire tool is being developed to enable us to continue to measure patient satisfaction. Our aim is that as the hub develops and enables us to increase capacity, we will be able to continue to transfer staffing resource into a community setting in order to focus our services on the communities where service users actually live.

Although many teams are already co-located, there are fewer examples of services from different professional groups who have fully integrated and who are working together from a starting point of joint decision making and professional trust. Work is ongoing to continue to develop our understanding of how much overlap there can be in terms of professional roles and responsibilities, and our aim is to continue to improve the service to the public while increasing capacity within the system by utilising economies of scale. As our services across health and social care move towards more integrated forms of working, our experience of setting up the integrated hub can be shared with our colleagues. We have also worked alongside our community social work colleagues to realign some of our staffing resource away from the hospital and into the community in order that more support is located as close to the individual service user's home as possible while we focus our specialist knowledge on ensuring the discharge pathway is as efficient as possible.

Contact details:

To find out more about this case study, please contact:

 

Lynne Morman

Resource Manager

Dundee City Council

01382 438317

Case study added to site: June 2016

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