In 2016, the Wolverhampton Transfer of Care Project reported that avoidable discharge delays were being caused by a lack of understanding regarding intermediate care settings and difficulty in accessing these services.
They estimated that better use of an integrated service could release 318 bed days each month. They recommended an integrated model of intermediate care which would enable patients to be discharged at the point they were medically ready, and assessed either at home or in an intermediate care setting – the Discharge to Assess (D2A) model.
This would require the following:
• The capability to assess long term care needs at home or in a residential setting
• A single referral process to access the service
• A D2A hub to manage the referral process, triage patient needs, allocate patients to an appropriate pathway and manage resources. With experience of supporting other health systems to implement D2A models, Arden & GEM CSU’s service transformation team was tasked with supporting the programme.
Building consensus – The CSU facilitated a workshop in Wolverhampton with stakeholders from the local authority, CCG, local acute Trust, community services and providers of adult’s social care. Participants agreed a shared vision in which no decision about long term care needs would be made in an acute setting. They also identified the need for simple, clear pathways with clear referral criteria, a trusted single screening assessment and streamlined community services delivering multi-disciplinary wraparound care.
Programme management – Two work steams were designed to run concurrently. The first was to appropriately move people out of acute care and into a community health or social care setting. The second was to develop any services or prepare existing D2A services to be ready to work with agreed process.
Piloting and implementing the solution – In June 2017, a pilot was undertaken on four wards in Royal Wolverhampton NHS Trust to test the trusted assessment screening form and triage process. The positive feedback received, paved the way for the D2A process to be fully implemented in January 2018.
The outcomes – By 2018, programme had delivered across both work streams:
• Development of a Wolverhampton integrated D2A offer
• Completion of a trusted assessment screening tool
• Simplified clear criteria for access to each of the three D2A pathways
• A virtual referral hub bringing together Trust and local authority teams
• Completion of a full assessment, with clear goals within the care plan, upon arrival at a D2A service
• Production of metrics dashboard for ongoing monitoring and evaluation.
In the first month, more than 100 patients had been referred to the new D2A hub, with 96% of patients booked into the appropriate service within 24 hours of the referral being received. Initial delayed transfer of care (DTOC) data shows a downward trend and will this continue to be tracked, along with use (and appropriateness of use) of D2A services, and patient satisfaction.
To ensure sustainability, the CSU set up an operations group – comprising of frontline services and managers.
“The support received from Arden & GEM on the D2A programme was invaluable in achieving the required outcomes. It was a complex area of work, requiring engagement and collaborative working from the provider trust, Local Authority and CCG. The staff supporting the programme were able to quickly build effective working relationships with all partners.” Maxine Danks, Head of Individual Care at Wolverhampton CCG