The system in North Staffordshire faced a number of issues, including risk-averse practice and fragmented services in the community. This example of a local initiative forms part of our managing transfers of care resource.
Hospital pressures were increasing, but assessments were still happening in hospital and there were too many people stranded in hospital when medically fit for discharge, with gaps in seven-day services and areas of duplication and inefficiency contributing to delays.
This meant that too many patients were losing independence, going into beds and not to their own home.
System-wide health and social care demand and capacity planning was undertaken and a ‘Track and triage’ discharge to assess (D2A) system has now been implemented. Replacing the assessment functions on the acute site, it tracks patients from entry to end of D2A, with a ‘pull’ function once the patient is judged medically fit for discharge. Clinical triage ensures that patients move to the right service based on health and social care needs with moves to beds as exceptions. Home first is now viewed as the first option at all times. Track and triage has been set up to be a seven day function which will cover the whole footprint for University Hospitals of North Midlands, working with discharge facilitators and patient flow staff to ensure that patients move to the right place first time.
Contact
Lisa Duncan
Integrated Service Manager – Track and Triage
Staffordshire and Stoke on Trent Partnership Trust
[email protected]
This case study is an example of the High Impact Change Model (Change 4): Home first.