Health and Social Care professionals working together to get patients out of hospital sooner

27 November 2018

Health and social care professionals from across the county have spent a week together to explore new ways of getting patients to leave hospital sooner so they can recover in the best possible place.

Representatives from 10 different organisations – including Shropshire and Telford & Wrekin Clinical Commissioning Groups (CCGs), Shropshire Council, Telford & Wrekin Council, The Shrewsbury and Telford Hospital NHS Trust (SaTH) and representatives from Shropshire partners in care (SPIC) – spent a week working together earlier this month to improve the way patients are discharged from hospital.

The initiative has been led by SaTH’s Transforming Care Institute, who partner the Virginia Mason Institute – the USA’s ‘Hospital of the Decade’ – and builds on a wealth of evidence that shows patients make a better recovery if they leave hospital as soon as they are well enough to do so, provided they have the right support in place.

Liam Allman-Evitts, Head of Capacity at SaTH, said: “Last month, more than 400 patients required support from our partners in order for them to be discharged from our hospitals.

“We have incredibly talented and committed people working within SaTH and the community teams, yet despite their hard work too many of our patients, especially the frail and the elderly, are spending more days in hospital than they should.

“Everyone involved in complex discharge planning strives to do their best by patients on a daily basis but sometimes, as a collective, we fall short because we are paying attention to the wrong things – the system and the processes we are used to, the way things are currently done and the time scales we have come to accept.

“By spending a week as one large team we have had a unique opportunity to work together and put patients’ time at the centre of everything and understand where time is wasted and what can be done differently.”

During the week the team identified a number of delays and inconsistencies that mean patients are staying in hospital longer than they needed. To remove these defects the team have been exploring possible new ways of working to make the process run smoother, quicker and kinder.

These include:

• Introducing a complex discharge icon to the hospitals’ touchscreen patient information boards. These are a feature of every ward and they already include icons that alert staff to patients with dietary requirements or if they are living with dementia. By using the same system, the idea is that a nurse could click on the complex discharge button to alert the specialist discharge team. This would reduce a number of delays in the current system.

• An exciting partnership proposal which could see joint working between the Occupational Therapists and Physiotherapists at SaTH and those in the community. At the moment the hospital teams are travelling far and wide to make sure a patient’s place of discharge is suitable. The improvement team would like to explore the idea of the community teams taking over these visits.

• Producing videos and leaflets to better explain a patient’s discharge plan. The videos will be available on iPads so consistent messages can be given to patients, and their families, about their chosen pathway and what it entails. The leaflets would help families understand the reasons behind their loved ones discharge plan.

• Producing booklets for each hospital ward to make staff more aware of the discharge plans available for patients with specific needs. As more of us live longer, often with challenges to our health and mobility, we and our families will need to adjust our living environment. Assisting staff and families with better information will help to alleviate some anxieties.

Tanya Miles and Sarah Dillon, Assistant Directors at Shropshire and Telford & Wrekin Councils, added: “As local authorities we are committed to working with our health colleagues to ensure people return home from hospital as soon as possible.

“Our integrated teams, work extremely hard to support people to be discharged from hospital as soon as they are well, and help people avoid hospital admissions. This year their efforts have paid off in that we exceeded the targets that had been set nationally in reducing delayed transfers of care. Whilst we are pleased with this reduction rate, we know that there this is more work to be done in this area, especially for those complex discharge cases.

“The week together provided us with a great opportunity to further explore possible solutions to help reduce the number of patients remaining in hospital and returning home, which we know they prefer to be.”

Nigel Lee, Chief Operating Officer at SaTH, said: “I am incredibly impressed with how much has achieved in such a small space of time. There is still more to be done but I am confident that the work being done this week will enable patients to be discharged sooner and make a swifter recovery.

“Helping people leave our hospitals sooner also means that we can free up hospital beds for others who need them.”