1. Health and Social Care in Partnership
Doncaster Integrated
Discharge Team
Health and Social Care in Partnership

2. Strategic Lead Integrated Discharge Pathway
Debra Everton
Strategic Lead Integrated Discharge Pathway

3. In Doncaster we have changed the way we manage Hospital Discharges and in doing so reduced unnecessary delays.
Through a four year programme of transformation we have delivered significant efficiency savings across the whole health and health economy.
So how have we don’t this

4. Social Care & Health professionals working in partnership have taken integration beyond co-location and by working together as an Integrated Discharge Team we have created a whole system that works for the benefit of patients and organisations
I am going to show you how we have done this

5. Where we were - January 2011 Purple Alert 57 estimated delays
Working from 4 lists of patients
76 medical sleepers out
126 cancelled operations
Staff working in blame culture
So why did we change? We had no option

6. Issues with the discharge process
Social Care and Continuing Care Assessments completed in an acute bed
Inaccurate outcomes of assessments
Outlier for admissions to 24 hour care and CHC funding
Patients remaining in hospital too long
Delays in system
Permanent residential care as a matter of course
Duplication in assessment
Blame culture
Silo working.
Poor Communication.
Only Monday to Friday
These are the issues

7. How we changed it
Worked with CCG to develop and agree new ways of working
Utilised BCF to provide additional resource in the team including an integrated lead
Developed a Culture of Trust and removed section 2’s and section 5’s (as was)
Allowed wards to own simple discharge planning
Made IDT centre of complex discharge planning and provided proactive management of potential delays in the patient journey through IDT
Introduced a front door admission avoidance team
Developed an innovative transfer to assess model
Introduced Trusted Assessors
Worked over 7 days
Lots of differences to get over, terms and conditions flexi, home working, meetings, journeys continue outside for SC

8. Doncaster Integrated Discharge Pathway
Ward identify patient is over acute stage of their illness and is either:
Able to go home alone Discharge arrange, Home from hospital considered
Able to go home with support Discharge arranged through SPOC
Unable to go home with support at this time Referral made to IDT
Fact Find completed and MDT agreement to one of pathways below
Transfer to assess options available
Positive Step
Social Care Assessment unit
Dementia beds 22
None dementia beds 11
Complex Assessment Pathway
26 independent home beds
10 Dementia nursing beds
None dementia nursing
Intermediate care beds
Community NHS trust
Mexborough Rehabilitation Centre
Social Care staff provide discharge support to all the units,
DNs support to Mexborough and soon to cover CAP

9. Simple discharges
If the ward feel that the patient is a simple discharge they refer to rebalement through SPOC
Patient must have no ongoing care package
Assessment at home within 2 hours of discharge, Support packages put in place same day
SPOC has reduced the time that the nursing staff spend on simple discharges by the use of one call
These discharges do not come through IDT

10. Complex Discharges/Transfer to assess model
IDT staff do board rounds each day on the wards and jointly identify patients ready for discharge planning-’medically stable and fit for transfer’ and referral made to IDT, as early as possible
Fact finding assessment undertaken by a member of IDT, nurse or Social Worker who decide which pathway is most appropriate (Trusted Assessor), the recommendation is discussed and agreed by IDT
If for Complex Assessment Pathway, Patient referred to geriatrician for their authorisations as Patient remains under care of the geriatrician who provides support and weekly ward round in CAP bed
Social care staff in units are made aware of transfer of care and continue with case until discharged from unit
We have a lot of discharge pathways and soe poeel may say too many as the more beds you have the more you want. CCG have jjust completed an academically sound IMCA where they have looked at 100 cases to see if the placements in bed base services were right and some of the early outcomes are that we shodu be sending more people homea/ and wrap services around them there

11. Rapid Assessment Program Team
Admission avoidance
Front door, comprehensive assessment of need - ED, Assessment Units
Multi-professional team…therapists, social care, nurses
7-day service
Follow -up visits…equipment provision… further assessment/signposting
Follow-up telephone contact…24 hours
76% of patients turned round - discharge home/step-up bed
Education/training…appropriate referrals…RAPT App

12. PERFORMANCE INFORMATION – 13/14
ASCOF 2Ci Delayed transfers of care from hospital (attributable to adult social care) has improved from 6.7 (2012/13) to 2.3 (2013/14).
3327 Acute Beds Saved which delivered cost savings of £793,264
A 5% reduction of direct placements into permanent care
41% of people supported by an IDT assessor, returned home with support from our reablement services

13. Average length of stay within the assessment units - 28 Days
Positive outcomes for people receiving reablement service;
65.6% of people were discharge home with or without support
ASCOF 2B Number of People still at Home 91 Days has improved from 59.6% (2012/13) to 67.5% (2013/14).
The above data sets continue to be performance managed through 2013/14; it appears the trend continues to improve across the system.

14. Where We Are Now Fully integrated Discharge Team
Minimal delays in the system
7 day working across the team
Innovative transfer to assess model
DST’s not undertaken in hospital
Developed a competency based Trusted Assessor programme
2015 winners of the NHS Leadership recognition award for outstanding collaborative leadership

15. Strategic lead Integrated Discharge Pathway
Contact details
Debra Everton
Strategic lead Integrated Discharge Pathway