Discharge to assess: home in a day

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A case study examining a 2016 collaboration between health and social care teams within Pennine Acute Hospitals NHS Trust, to facilitate timely discharge from hospital.

What was the aim?

Increasing numbers of patients were waiting in hospital for assessments, leading to long lengths of stay.

The trust wanted to develop a multidisciplinary team to assess patients holistically in the most appropriate environment and at the most appropriate time. The team would typically assess and discharge patients from hospital on the same day.

What was the solution?

Discharge to Assess - Home in a Day (D2A) was launched as a pilot in October 2016. It was (and is) a collaboration between health and social care to facilitate timely discharges from Rochdale Infirmary and Fairfield Hospital in Bury.

The D2A team consists of an occupational therapist, physiotherapist and support planner (adult social care). Members have become trusted assessors, working across professional boundaries in line with agreed competencies.

The service identifies patients suitable for discharge within 24 hours of referral. Once they are 'medically optimised', they are assessed at home and maintained there with support from the Short Term Assessment and Re-ablement Service (STARS), equipment and voluntary services.

What were the results?

Evaluation of the first 12 months showed:

  • discharges through D2A tripled within a year and now average over 50 same-day discharges per month
  • length of stay has been halved on the Rochdale site along with reductions in delayed transfers of care
  • closer working relations with social care staff, NHS and urgent community care team
  • true integration of social care and health, and a 'home first' mindset
  • one system, with one aim in mind: providing care in the patient's own home or community where it is safe to do so
  • positive feedback from patients

What were the learning points?

Take home medication needs to be organised in a timely manner to allow discharge to happen as soon as medically optimised.

Next steps

There are plans to provide support in discharge-to-assess beds and further therapy after discharge from hospital.

Want to know more?

Please contact:

Nicola Ellis-Roberts, D2A lead HMR Community: Nicola.Ellis-Roberts@pat.nhs.uk

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