Implementing a Home First approach to discharge from hospital

LGA and ADASS have produced a short ‘top tips’ guide to safe, timely and appropriate discharge from hospital. It provides a short list of questions systems should be asking themselves to ensure they are putting individuals first by promoting a Home First and discharge to assess approach.

LGA/ADASS/CHIP banner

Download

Note to users: this PDF is not fully accessible to WCAG 2.1 AA

What good looks like

The High Impact Change Model for Managing Transfers of Care describes nine changes which support good practice during hospital discharge:

Nine changes which support good practice
  1. Early discharge planning
  2. System demand and capacity
  3. Multi-disciplinary Working
  4. Home first/discharge to assess
  5. Flexible working
  6. Trusted assessment
  7. Engagement and choice
  8. Improved discharge to care homes health in care homes
  9. Housing and related services

We have categorised good practice under five themes:

1. Outcomes for people
  • People get treatment, care and support that is co-ordinated, person centred and outcomes focused
  • No-one has to make (or has made for them) lifetime decisions in hospital
  • No-one is persuaded into short term care that is effectively long term
2. Leadership
  • Desire to make things better for local people underpins leadership and action
  • Time is given to build relationships and trust
  • There is a collective ambition and vision
  • Lines of decision making and accountability are clear and understood
  • Plans are clear, simplified and prioritised
  • Clear use of distributed leadership
3. Attitudes, behaviour, culture
  • This is actively driven by system leaders
  • There is a compelling shared narrative
  • There is a shared understanding of safe, timely discharge
  • The system systematically learns about how it works and it supports staff to be involved in continuous improvement
  • Successes are celebrated
4. Performance
  • Services, pathways and processes are simplified, standardised and streamlined
  • There is agreed shared system responsibility
  • System improvement is driven by a single agreed dataset
  • Flow and capacity is managed across the whole system
  • The nine High Impact Changes are systematically and sustainably implemented
5. Community capacity
  • System capacity is aligned to population need
  • Role of the third sector maximised to improve community resilience
  • Reliance on bed-based solutions reduced, enabling Home First models to succeed
  • Future market strategy and flexible employment opportunities co-produced
  • Pooled budgets and risk shares are underpinned by evidence

Top tips for implementing Home First

Our top tips are split into six themes, as follows:

Leadership
  • Do leaders focus on outcomes for people by promoting safe and ethical discharge, Home First, effective reablement and not using services that are ineffective?
  • Is the escalation system delegated to the right staff to enable them to focus on same-day discharge? Is the data used in escalation calls current, accurate, reliable and accepted by all?
  • Do you review issues causing delay weekly, including raising them regionally or nationally?
Pathways
  • All : Are informal and unpaid carers identified and connected to information and support?
  • Pathway 0: Are ward staff fully empowered to implement discharge? Are they connected to their councils? Do they have access to the care market and the voluntary sector?
  • Pathway 1 and 2: Are social care and community health staff aware of and able to plan early enough for people needing reablement? Is access to it same day, seven days a week? Do people get follow-up healthcare? Do discharge teams know what happens after they leave?
  • Pathway 3: Are people waiting for a bed in the community when they could be going home with enhanced support? Are people ending up on Pathway 3 because of poor early discharge planning? Have options been discussed?
Commissioning
  • Is the system reviewing data and discharges to ensure the care market is supported to take discharges seven days a week with primary and community health support?
  • Are you doing all you can to maximise capacity to support people at home? Consider payment on plan, off-frame capacity, COVID funding streams, and enabling providers to rapidly adjust care packages within agreed limits.
  • Are you considering the use of direct payments, short term reablement, care hotels, housing-based options, Shared Lives, and live-in or intensive domiciliary care?
Workforce
  • Has the council reviewed the hospital social work team to enable it to carry out Care Act assessments in the community while maintaining a presence in the acute trust to manage complex and safeguarding cases?
  • Has the acute and community trust(s) reviewed the therapy services to enable them to carry out assessments after discharge in the community?
  • Is there resilience support available to staff, and a joint approach to managing gaps in staffing?
Finance
  • Are you using COVID funding for packages to avoid unnecessary admission?
  • Have you engaged and funded the voluntary and community sector to provide home-from hospital services? Are you investing in wraparound care, 24/7 for 72+ hours to enable care at home either through expanded reablement or live-in or Shared Lives’ carer support? Are you investing in AI/smart home technology?
  • Are NHS commissioners investing in sufficient primary and community health, and have identified with their council(s) the resource implications for adult social care?
Data
  • Is the whole system sighted on the daily data return on Criteria to Reside, Pathways 1-3 and Patient Destination? Do you use that to understand why people’s discharge is delayed or not going Home First?
  • Does the data show both the internal and external reasons for delay enabling long length of stay to be addressed? Are you linking to end of life care support?
  • Is the date of discharge set at admission and driving discharge plans?

How we can help you

  • Facilitated leadership sessions using a range of tools including gap analysis tool, peer review and ‘pause and reflect’ methodologies, delivered jointly as appropriate with ECIST (Emergency Care Improvement Support Team) and Better Care Fund Team
  • Data analysis support 
  • Peer support, mentoring and critical friend challenge
  • Putting systems in touch with other systems who have tackled specific issues or have good practice to share
  • Support around health and social care system risk assessments
  • Support to develop and implement lead/joint commissioning models and support to create creative capacity now and plan for the post-COVID demand 
  • Hospital social work team redesign workshops
  • Therapy teams redesign workshops (collaboratively with ECIST)