We have done this through a two year programme of transformation where professionals from Doncaster Council, Doncaster & Bassetlaw Hospital NHS FT, Rotherham, Doncaster South Humber Hospital FT and Doncaster Clinical Commissioning Group have taken integration beyond co-location by working together as an Integrated Discharge Team creating a whole system that delivers tomorrow’s service today.
Previously, social care assessments were completed in an acute bed, resulting in delays in the system, duplications of assessment and patients remaining in bed for longer than may have been clinically appropriate. A high proportion of patients were also admitted to long term nursing care post discharge. The introduction of the Integrated Discharge Team ensures that patients with complex health needs have an initial assessment while in hospital and the team decides on appropriate next steps. In some cases, patients may be able to go home knowing they will have an guaranteed assessment there within two hours of leaving hospital so the right support is in place quickly. Other patients may be transferred to social care beds in Doncaster for further assessment and planning outside hospital.
The result of the transformational change is a patient focus on rehabilitation and reablement, with earlier assessment and intervention and personalised support packages put in place, minimising delays in transfer of care from hospital and significantly increasing the number of people still at home 91 days after discharge.
As a result, patient experience and outcomes have improved, with patient feedback overwhelmingly in support of the assessment process and being able to leave hospital sooner. The service also ensures that hospital readmissions are avoided – since introducing this service, 76% of patients within the Emergency Department or Medical Assessment Unit have had an admission avoided, following an assessment and an alternative community based package of care put in place.
The Integrated Discharge team works seven days a week and is made up of social care workers, discharge nurses and therapists from the acute trust, discharge planning nurses and mental health from the community trust and they are all lead by the strategic lead who is employed by the local authority. The strategic lead provides management support to all members of the team and sitting underneath the lead is a joint management team made up of the team leaders from each area plus the managers of the transfer to assess units. They meet on a fortnightly basis to discuss any operational issues which need feeding into each area. So whilst the team is integrated under one lead they still feel supported by their own line management structure which has allowed the team to expand and grow without a sense of loss of identity and professional boundaries.
A short film of the team, and how they work, can be seen here: