Digital Discharge to Assess

• Helping people remain independent, safe, and well after leaving hospital can be challenging for all the services and organisations involved.
• It is vital to have effective discharge to assess arrangements across local health and care systems. 
• Councils have collaborated and developed a more comprehensive approach to address this common challenge in health and social care.
• The Hospital to Home solution enables all parts of a local system to work together to help smooth discharge from hospital.

The challenge of tracking patients from hospital to home is a national issue and which has been significantly exacerbated by the pandemic. The current Discharge to Assess (D2A) process relies on gathering information from separate services and organisations across acute and social care settings. Much of this information is managed and stored in disparate information systems across different organisations, resulting in a siloed approach with little transparency and a variety of service delivery challenges.

The aims of the SCDIA Digital Discharge to Assess project were to:

• develop a cloud-based case management system that did not depend on a single IT partner or supplier
• allow users (with appropriate permissions) to capture, update, track, and report on data about a person’s journey through the Discharge to Assess process
• create a ‘single version of the truth’, with a raft of associated patient benefits and service efficiencies.

Five councils – Southend-on-Sea Borough Council, Herefordshire County Council, Birmingham City Council, Sutton London Borough Council and North Lincolnshire Council – worked collaboratively and at pace with the technical partner Maldaba to co-design and develop the ‘Hospital to Home’ solution since July 2020.

It facilitates more efficient communication, collaboration and data sharing between the different organisations involved in the process. Importantly it supports more effective handoffs between the various touch points, including providers, domiciliary care partners et al.

This system offers users more accurate and timely information to better manage a person’s transition of care from hospital to home or care setting.

Hospital to Home supports the Discharge to Assess process from the point at which a patient is identified on the ward as requiring support on discharge, to the point that the patient receives an assessment of their longer term needs within the community setting.

The system provides users with a real-time, single version of the truth regarding all the people being discharged from hospital via the Discharge to Assess process into care services.

Hospital to Home was deployed for partner testing in February 2021 and now offers councils case management and tracking functionality, allowing users from multiple organisations to create, update and track Discharge to Assess cases through an open, human driven workflow. The workflow design and development approach ensured the system can be adapted to the varying local processes within each region.

The programme of work was at all times steered by the councils involved as to their needs and challenges, requirements were continually captured in a ‘living requirements document’. Via monthly meetings development was discussed and prioritised by the group. This approach alongside realistic and tight project management has led to the following functionality and key Discharge to Assess process elements being delivered within the end-to-end digital system:

• Criteria to reside
• File attachments
• Multi factor authentication
• Pathway management
• Re-admissions and duplications
• User/case manager/staff management
• Reporting and analytics Dashboards and alerts
• Data interrogation
• Audit functionality Discharge record deletion functionality
• No fixed abode
• Password management

• Hospital to Home solution delivered with associated information governance documentation, this documentation is available for reuse by other authorities
• Penetration and accessibility testing complete
• DPIA signed off and shared with all partners
• Contracts and information sharing agreements in place with councils now using/in the process of Hospital to Home deployment
• Cyber security documentation completed and shared with all partners - including NCSC Cyber Security Principles (again available for reuse)
• User training sessions and collateral
• Commercial discovery report completed, outlining the benefits, and expected savings a council should expect by moving to a digital Discharge to Assess approach
• Accessible commercial model developed in partnership and subsequently signed off by the five co-funding councils (local authority specific business case now available on request)
• Additionally, funded interoperability work with North Lincolnshire Council and Sutton:
  • Initial investigation is complete, and the outcomes/requirements documented
  • Work progressing to integrate with acute partners in North Lincolnshire and conversations progressing with other partners.

• single version of the truth
• improved safeguarding
• information governance compliance
• clear communication
• timely discharge
• improved capacity in system
• improved resource planning
• financial savings and benefits
• released acute bed nights
• comprehensive audit and reporting
• improved speed of discharge
• improved patient experience
• cyber security
• mobile working options
• improved patient and family communication
• integration options.

Financial benefits to society per area are estimated to include savings of £50,000 across transport, domiciliary care, care homes and community settings.

• Interoperability (the ability of different computer systems to exchange and make use of information) is important but not critical to take up and work is ongoing.
• The information governance documents were a key deliverable alongside the IT solution.
• Information security concerns tackled at the outset led to increased trust in the system.
• The ongoing challenges of the Discharge to Assess process, volume of patients and ongoing Discharge to Assess challenges related to the pandemic, made the opportunity of co-funding/match-funding a digital approach to Discharge to Assess a very welcome one.
• Hospital to Home is in the process of deployment with several councils outside the original group and as such learning will continue and the approach will be further refined, particularly considering staff training.

The development roadmap has been prioritised with partners and currently includes – in order of priority for collaborators:

• interoperability
• failed discharges reason
• trend analysis
• strict/loose search setting
• additional workflows
• ability to merge discharges
• neighbouring local authorities
• ordinary residence
• deletion authorisation workflow
• bulk data uploads/downloads
• GPS integration
• improved glossary
• development of further staff training resources.

Digital discharge to assess - simply, safely and securely

Hospital to Home videos featuring North Lincolnshire and Sutton councils:

• Watch this concise (two-minute) video to quickly understand the 'why, what and how' of Hospital to Home
• For those of you who know about Discharge to Assess, this eight-minute video explains the key features of the Hospital to Home solution and how it is changing the Discharge to Assess process at North Lincolnshire and Sutton Councils for the better
• For a more in depth understanding of Discharge to Assess, there is a 16-minute video to explain everything about the current challenges councils face and how Hospital to Home came about.

For more information, contact [email protected]

For support from the LGA, contact [email protected]