Innovation Exchange

Facilitating Hospital Discharge

Introduction

Key activities

Benefits and impacts

Learning

West Dunbartonshire Health and Social Care Partnership Community Hospital Discharge team (WDCHDT) provides an integrated approach to care which optimises independence and maximises opportunities for recovery at home. It identifies the need for ongoing support and ensures timely transfer to appropriate services.

 

By organising the integrated services effectively, the team has been able to deliver a significant improvement in avoiding delays within the hospital discharge planning process; and an overall reduction in unnecessary emergency admissions to hospital.

 

In 2015 WDHSCP developed Hospital Discharge Liaison Workers, who promote early referrals and discharge planning; promote awareness with Consultants and ward staff; work in parallel with medical treatment; assess need at the earliest opportunity, with referral/information shared from the point of admission; and identify people who cannot return home/lacking capacity.

 

Theme: Health and Social Care

The Community Hospital Discharge Team is part of the HSCP’ Community Health and Care service for older people and is designed to ensure that people receive the support and care they need when they need hospital, and that they continue to receive the right service once they are home. Incorporating Health and Care professionals across Physiotherapy, OT, Social work, Speech and language Therapy and nursing staff, this team works closely with Care at Home, Care Home and HSCP Care at Home Pharmacy service to provide integrated and planned discharge from hospital at the point a person is medically fit to return home.

By focusing on timely and appropriate hospital discharge WDHSCP achieved the Scottish Government’s target of 0 patients delayed for more than 14 days in all but one (the last) month during 2015/16.

 

Chart shows the number of delayed discharges, more than 14 days

 

Chart shows number of acute bed days lost to delayed discharge

 

People leave hospital to integrated support packages which meet their needs. This has worked because the service thought ‘out of the box’. Managers analysed why the process of people leaving hospital was not always working and saw that they needed to change tactics and step into a different environment. They recognised that they needed to influence how and when hospital staff started to think about patients’ needs when they were discharged.

As the success of the integrated Hospital Discharge team has developed, learning led to identifying key points of delay, not always accountable, but impacting on the HSCP. Redesigning services through the development of the Hospital Discharge Liaison Workers to improve influence and practice at key points has improved provision across the service.

Contact details:

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

 

Heather Irving

Improvement Lead

West Dunbartonshire HSCP

01389 776866

Case study added to site: June 2016

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