A digital solution designed to assist a two-way conversation between hospital staff and patients to assist discharge. A simple online referral form helps patients put in place the support they need as they prepare to go home from hospital. The form focuses on eight areas of need, with priority given to discharge dependent services delivered by third sector partners. A dashboard view enables ward staff to keep up to date with the progress of referrals and third sector partners are able to work together to deliver a more co-ordinated approach to care.
The challenge
According to NHS England, there are "more than 12,000 patients every day in hospital despite being medically fit for discharge. Data from The King’s Fund also suggests that discharge delays in England increased throughout 2022 and that the cost of delays in 2022/2023 was at least £1.7 billion at a time when the NHS is pushing to find cost savings. For patients, being stuck in hospital when they are fit enough to leave is also upsetting.
One of the challenges to reducing delayed discharges is how to access capacity in the health and care system provided by social care, community services, housing and other voluntary organisations.
Currently patients who are referred to community services rely upon ward staff having the skills and knowledge to make referrals and understand the geographical area in which they operate. Whilst manual processes are in place for some discharge dependent services often people leave hospital without being offered a wide range of community support. In preparing for discharge, ward staff are expected to make many telephone calls to numerous organisations and feedback on progress is not always given. This can sometimes delay a person’s discharge.
For the third sector organisations, keeping up to date with the status of a patient in hospital, whether their length of stay has extended, or their situation has changed, information is very difficult to obtain. Organisations also are unaware of other services that are in place and, sometimes calling or visiting a patient on the same day or at the same time is very confusing for the patient and can duplicate effort.
The solution
The Community Wellbeing Hub (The Hub) is a partnership between Bath and North East Somerset Council, its prime provider HCRG Care group, the Royal United Hospital and 16 third sector partners. Established in March 2020, the aim of The Hub is to improve the health and wellbeing of its residents.
The Hub has been a long-standing ambition of strategic partners and third sector to create a more joined-up and co-ordinated approach to delivering care. Whilst there had been some attempts to deliver these ambitions, it was the COVID-19 pandemic that removed barriers to enable a more collaborative approach to be taken locally.
The Hub is not an entity in its own right, it brings together, through shared vision and objectives, a partnership, that joins up community services across Bath and North East Somerset. It recognises that no one organisation can improve the health of the population on its own but is a shared responsibility.
The Hub provides the infrastructure for its partners. It offers a central triage, secure referral management system called RIVIAM and governance to enable partners to work more collaborative ensuring a person-centred approach is at the centre of its work. The lead partners are the council and the HCRG.
In December 2022, funding was secured to deliver a more co-ordinated approach to community services through a digital discharge service at the Royal United Hospital.
The digital system has enabled ward teams at the Royal United Hospital to complete an Onward Admission Referral form giving them one place to refer a patient to a wide range of available community, housing and voluntary services at The Hub. This includes commissioned discharge dependent services.
Immediately reducing admin burden, the referral process is quick and seamless. RIVIAM also auto checks the patient’s details against the NHS Spine Mini service ensuring a high level of data accuracy is captured during the referral process.
Ward teams then use a care control dashboard to see in real time what’s happening regarding the care they have requested for a person. Status updates and useful information are easily accessible. Online communication reduces the need for phone calls and emails which introduce time delays to a patient’s discharge.
A view of the dashboard is also available for partners at The Hub so staff can easily see the person’s most recent ward, their expected discharge date and the different services requested.
With RIVIAM’s secure integration with the Electronic Patient Records, dashboard data is seamlessly updated providing timely visibility of this critical information. For The Hub's partners, RIVIAM makes it easy to co-ordinate care for a person with each other, reducing duplication, providing efficiencies, and improving the person’s experience.
The impact
Designed to fast-track discharge of medically fit patients through connecting hospital teams with multiple community, housing and voluntary sector services boosting capacity in NHS and improving patient care. Its impact includes:
- utilising community and voluntary sector capacity
- enabling data-driven decision-making for Ward teams
- delivering efficient multi-agency referral management and co-ordination
- providing real time integration with electronic health records for seamless system-wide insights
- offering consistency, choice and supports the wider needs of the patient and
- freeing up hospital beds through quicker discharge of medically fit patients.
How is the new project being sustained?
The project has secured a further year’s funding for 2024/25. The Hub is currently putting together a business plan for future funding beyond 2025 to the council and the Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board. Conversations have also begun with neighbouring authorities within the Integrated Care Board to see if the system can be shared across local authority areas.
Lessons learned
The project is still in its infancy, however feedback from The Hub partners and Ward staff is ongoing and the system and roll out has been adapted to respond to the operational changes need. The project will continue to be rolled out all wards in the Royal United Hospital and soon to the three community hospitals located in the district.
Contact
Sara Dixon, Locality Manager, Bath and North East Somerset Council,
Email: [email protected]