Behind every delay in the transfer of a patient from a hospital into their future place of care, there is a person, in the wrong place to best enable their recovery. SCW’s Head of Strategic and Service Innovation, Wendy Marshall, explores the challenges of discharging a patient into intermediary or longer-term care and shares her thoughts.
Whilst lost bed days due to delays in the transfer of care have reduced year on year, the actual number of patients having hospital stays longer than 21 days has increased.
In March 2020 the world was turned on its head with COVID-19. Trusts were asked to postpone non-urgent elective activity to increase capacity for the response to the pandemic. Whilst the ensuing months became a hugely challenging time for the health and social care system, the pandemic was also an enabler for significant and beneficial change.
A different approach to discharge processes and funding, through the Discharge to Assess (D2A) initiative, has delivered improvements in the discharge journey of a patient. The initiative enables patients to be discharged into “intermediary care”, with their care needs assessment being done in the place of care at a later date, rather than in hospital before discharge. Delays in patient assessment and the assignment for the responsibility for the funding of care had been cited as some of the common reasons for the delays in discharge. Ultimately leading to an extended length of stay in hospital for a patient.
Impact of delays to discharge
Being in hospital for a long period of time isn’t good for anyone, particularly an older person. Whilst patients, their families and carers often have misconceptions about the benefits of staying in hospital, the impact of an extended stay in a hospital can’t be underestimated in terms of the risk of further illness and physical or mental decline.. Agreeing that a patient is fit for discharge, as well as sorting a care package and getting paperwork completed on time, can also be difficult. Insufficient capacity for intermediate or ‘step down’ care between hospital care and social care or independent living also leads to increased waiting times and delays in accessing the much-needed care. Organising this can be both time-consuming and complex. To ensure a sustainable patient flow we must make optimum use of all resources available within the health and care system.
A better approach
Delays in the transfer of care and extended length of stays can be minimised through effective discharge planning and joint working between services to ensure safe and efficient person-centred transfers. In their 'Where Best Next Campaign', aimed at reducing long hospital stays, NHSE has outlined a five principled approach:
- Plan for discharge from the start - from the outset all parties in the patient's care including the patient and their family have a clear expectation about what’s going to happen.
- Involve patients and their families in discharge decisions – managing their expectations and dispelling misconceptions about the benefits of staying in hospital so that they don’t feel they are being prematurely discharged from hospital.
- Establish systems and processes for frail people – to avoid further functional decline and the risk that independent living is no longer an option, it is important that frail older people are discharged as soon as possible
- Embed the practice of multidisciplinary team (MDT) reviews – information to inform daily ward and board rounds is important. Patients with a seven day or longer stay should be reviewed by an MDT visit to the ward
- Encourage a 'Home First approach' - wherever possible a patient should be supported to go home for assessment to ensure their care needs are understood in familiar surroundings which can help avoid the over-prescription of care.
How can the Dynamic Discharge Solution help?
SCW’s Dynamic Discharge Solution (DDS) is an ecosystem that enables the collection of previously unstructured and uncaptured data as well as the sharing of tasks, communications, workflows and documents between all the stakeholders in the patient’s care. DDS is a patient-centred, fully integrated demand, capacity and care management solution. It enables the sharing of information between health and social care systems, patients and/or their families. It focuses on the patient's discharge journey and their user experience and not just the process of discharge.
DDS uses intelligent process management and automation tools to provide a fully integrated demand, capacity, and care management solution. It provides organisational and system-level real-time analytics and dashboards
It has been developed following more than 12 months of diverse stakeholder engagement and research to understand the real challenges and needs and is based upon understanding real patient lived experiences. The example below demonstrates just one patient’s experience of the difficulties that can be faced.
Mary’s story - A patient’s end of life Journey
Mary in May 2017 before hospitalisation
Mary, an 82-year-old mother, and grandmother lived alone and had both Vascular Dementia and inoperable colon cancer.
Mary was originally admitted into hospital as an emergency after her GP discovered she had lost over 50% of her blood volume. She was given a blood transfusion in ambulatory care but discharged later that day. Clinical staff recognised her personal challenges and so she was assigned six weeks of domiciliary care to help with her personal needs.
Communication was challenging between the care provider and Mary’s family and as a result, Mary managed to evade getting any help for almost the whole of the six weeks, by telling her carers that her family was taking care of her needs and her family that the nurses were. Eventually, when it became apparent that she was refusing the nursing care the care provision was taken away.
Over the following two weeks, Mary had a number of falls at home whilst her family struggled to take care of her. Eventually, an ambulance had to be called because one of her daughters found her early one morning lying naked, cold, and confused in her own faeces. She had fallen the night before getting herself ready for bed and had been on the floor of the conservatory all night. At this time she wasn’t taken into hospital because her care need wasn’t acute. She remained at home, again with no formal care support. Finally, ten days later Mary was admitted as an emergency into hospital. She died in a nursing home over six months later having never returned home again.
Mary, January 2018, Nursing Home resident
Length of hospital stay - 75 days, despite the family being advised she needed to be transferred to a residential nursing care facility just two days after being admitted. The delay in her discharge was due to many factors – delay in her care and funding assessment and then the availability of a suitable care placement due to her care needs being complex.
Financial implications – The cost of continuing to provide Mary’s inpatient care as well as the cost of cancelled elective operations that result from lack of bed availability. Mary’s bed was not available for other needs, and staff could not be released to care for other patients.
- Loss of mobility – Mary could walk on arrival into hospital but relied on a wheelchair on discharge.
- Rapid deterioration of dementia – increased confusion due to being in a clinical lockdown.
- Distress for Mary - rotating bank nursing staff meant few familiar relationships were formed and her most personal needs were being taken care of by strangers. Due to her dementia, she was frightened and felt threatened, and became both verbally and physically aggressive to nursing staff and her family.
- Distress for her family - every day was difficult and disruptive and they become the enemy to her.
And this is not an isolated incident for people navigating our health and social care system.
In February 2021, Healthwatch England, working with the British Red Cross, published findings of 590 people’s stories leaving hospital during COVID-19. Surveys were conducted across 42 STP/ICS footprints and involved patients and both paid and unpaid carers. The findings of this report are quite compelling and give focus to the core challenges:
- Relatives experienced difficulties in contacting the hospital wards to receive updates on their relative’s health and did not feel involved in their loved one’s discharge.
- Unpaid carers felt that their caring responsibilities were not considered when they should have been.
- Patient Care:
- Nearly one in five people who did not receive a follow-up visit after discharge still reported having unmet needs.
- Nearly one in five overall reported that they did not feel prepared to leave hospital.
- Health and care staff told us that patients were often discharged without medication or not given enough. There was often little or no information given to patients and their carers about administering medication.
- Of those who were discharged at night, 64% were not asked if they needed transport support home, compared with 43% of those discharged during the day.
- 91% of people who needed transport but did not receive it, were not asked if they required help with transport in the first place.
We live in a time when we can order a pizza online and get almost immediate electronic confirmation of our order. We are then able to track it, in real-time, through the whole supply chain from being made, put in the oven and then being delivered, through an electronic app. Similarly, we can arrange an Uber through an app, pre-pay for it with one tap, and then at every minute know how far off our lift is from the moment we engage it.
Isn’t it time that we should be able to do this for one of the most important supply chains of all? One which carries the most precious commodity to all of us, whether it is for ourselves or our loved ones. That of health and care.
Working on this innovation has meant far more to me than enabling the technology and unravelling the tangled processes to create the solution. The driving force has been remembering Mary’s journey and the challenges of all of those patients featured in the Healthwatch and Red Cross publication. To strive for an outcome that delivers a better patient experience. I’ve heard the frustrations of those involved in navigating through the challenges of the discharge and care of a patient, both staff and recipients. I’m pleased to say that from all I’ve heard and seen SCW’s Dynamic Discharge Solution is a game-changer.
With inter-operability capabilities to connect with most legacy systems, the DDS has been designed to complement these existing systems and not replace them. And the beauty of the solution is in that it performs a truly system integrating role that enables the safe and efficient transfer of a patient’s care to best enable their recovery.