Success for partners in Blackburn with Darwen has been achieved through shared recognition of a problem, and a commitment to developing a solution, and testing, revising and taking it further. This example of a local initiative forms part of our managing transfers of care resource.
Having acknowledged that some patients were waiting up to five or six days for discharge processes to be completed, health and care partners decided to develop new ways of working, setting themselves the ambition that people could be discharged on the same day as they were deemed medically optimised.
The initial focus was on people with lower-level needs. Senior managers and frontline staff co- designed a trusted assessment document, which would capture background information and move with the person, so that everyone involved in discharge planning could update it. An integrated step-down team was established to receive the trusted assessments and coordinate discharge to reablement, sub-acute support or residential rehabilitation.
The approach was implemented in October 2016 and worked successfully over the winter months; it has now been in operation for over 12 months.
Building on this success, the next steps have been to extend this approach to patients waiting for packages of care, with a real focus on ‘home first’. Ward staff undertake a partial assessment on the ward, and the person is then discharged to their home, with a full assessment taking place on day three. Wraparound care is offered for up to five days, during which time multi-disciplinary care staff help to enable the individual as much as possible, working with the family and introducing universal services.
By starting with just one or two patients a week, they have been able to test and adjust the pathway and recruit additional staff, and the approach is now being rolled out across a broader area, in partnership with Lancashire County Council, East Lancashire Hospitals NHS Trust and Lancashire Care NHS Foundation Trust, to achieve a more consistent discharge route for people, wherever they live.
Key to success has been the relationships built between professionals, based on a shared belief that nobody should be in hospital for longer than necessary, and the time taken to co-design the trusted assessment document. Training and communication have helped to embed the approach, with co-located teams making it easier to talk through and resolve issues as they arise. Throughout the development and implementation of the approach there has been a real focus on the person at the centre.
Service Lead – Hospital, Intermediate Care and Provider Services
Blackburn with Darwen Council