Aintree’s Discharge 2 Assess model – individualising the pathway to re-enablement

Aintree’s Discharge 2 Assess model – individualising the pathway to re-enablement featured image
What was the problem? The safe and timely discharge of patients is one of the biggest problems facing NHS hospitals. “The objective of discharge is not simply to get the person out of hospital, but also to provide seamless support, to ensure a return to their home or care home in the best possible physical, mental and emotional state.” Commission on Dignity in Care for Older People, June 2012.

What was Aintree’s solution? The Aintree@Home service was started in 2012; staffed by 6 therapists, the teams vision was to facilitate safe and timely discharge, providing Aintree’s patients with a re-enablement programme to promote independence, wellbeing and provide a high standard of care. We have achieved this by completing on going functional assessments of the patient in their own environment for an individualised period of time and where appropriate hand over, refer and/ or signpost on to relevant services.

Discharge 2 Assess (D2A) built on the success of Aintree@Home and combines early and intense multidisciplinary health assessment, commencing prior to and post discharge, and social care assessment post discharge. Previously, we would develop a package of care for a patient whilst they were still an inpatient and based on assessments which took place in the hospital setting, often leading to the over prescription of health and social need, and creating a delay in access to package of care on discharge.

By identifying and providing the appropriate social care post-discharge and in partnership with social care providers, Aintree@Home - reduces length of stay, - maximises independence and - helps prevent unnecessary readmission - reduces the need for hand-offs to community services and - informs on-going social needs with a therapeutic RE-ENABLEMENT approach. This approach shortens the pathway to independence and recovery and reduces the potential for long term or life-long dependency.

Externally, we worked with commissioners, district nurses, GPs, community therapists, local social care providers and voluntary organisations including Intermediate Care Bed services and 3rd sector agencies including Age Concern. We have demonstrated superb outcomes and the Trust Board invested to recruit additional nurses and therapists to build a team of 25.

What outcomes have we seen?

1. The ‘Aintree@Home’ model outcomes - Every month, an average of 184 patients are supported home by the model - Average of 2.3 bed days saved per patient - Without the model, 28% patients may have needed re-admission on assessment at home

2. The new ‘Discharge 2 Assess’ model outcomes (Medical social worker assessment at home) - Average of 8.6 bed days saved per patient - 86% patients accepted for D2A are taken home within 24 hours (53% within 12 hours) - 35% of packages of care were cancelled or reduced after initial support and re-enablement at home - 29% had no long term package of care requirement

Patient satisfaction has been very high and is supported by substantial evidence from patient satisfaction questionnaires.

Next steps? We would like to Increase capacity within the team to deliver the Discharge to Assess model to support a greater number of Aintree patients home using the Aintree@Home team.

Partnership working with community social and health partners has been an enormous success and we want to further develop this to deliver true re-enablement with therapy emphasis.

For further information contact: Patricia Elmore, Therapy Clinical Lead [email protected]
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