Prior to the move into the discharge hub, work had already taken place to replace the ward discharge Officers with a more administrative role, new staff were recruited at band 4 on each ward within the Trust. A decision was also made that each directorate would have a supervisor Band 5 post to over-see the work of the discharge officers. This example of a local initiative forms part of our managing transfers of care resource.
The Integrated Discharge Team has been part of the Luton and Dunstable Hospital for a number of years, however the structure of the team was changed approximately five years ago and has continued to develop into the team it is today.
Previously the team was based within several areas of the hospital which was not conducive to timely discharge or working cohesively. It was agreed by the hospital executives that the team should be based together which was facilitated in 2017. Prior to the move there was little interaction between the different teams, although there was a mix of disciplines within the individual offices and these became quite siloed with little or no communication outside of their own office space.
In addition to office based staff, the Trust had a number of discharge officers based on the Medical Wards, Medicine for the Elderly and Surgery wards. Prior to the current structure, discharge planners were nursing staff whose remit was to facilitate patient discharge. However their role was impeded by having to resort back to the core business of nursing whenever there were shortages on the ward. This was a natural response however did impact on their role as discharge planners and delayed patient discharge.
Prior to the move into the discharge hub, work had already taken place to replace the ward discharge Officers with a more administrative role, new staff were recruited at band 4 on each ward within the Trust. A decision was also made that each directorate would have a supervisor Band 5 post to over-see the work of the discharge officers.
The objectives for the move in relation to office based staff were that all staff would be based together in one open plan office, the hub; this then provided instant access to all disciplines.
Over a number of months the individual teams moved into the Estates Building at the Luton and Dunstable Hospital which is now known as the ‘Discharge Hub’ There were a number of practical challenges such as minimizing the noise levels and respecting individual space, learning about each other’s disciplines and understanding who was responsible for the different needs of patients being referred. Preventing duplication, joint processes and robust pathways were explored, and any negative concerns were outweighed by the positive impacts. It became immediately clear that by being based together allowed for more effective information sharing and soft intelligence to inform decision making and reduce the time to resolve issues.
The Integrated Discharge Team has regular multi-disciplinary sessions to track and look at complex patients and their length of stay. The front door, Accident and Emergency, and the back door, Discharge Planning, work closely together. The integrated discharge team has escalation processes in place, supported by the Trust Executives Senior Managers and those from partner organizations. Issues are regularly discussed in the A&E Delivery Board.
A discharge App has been developed by a company ‘PHEW’ to support the work that the IDT undertakes on a daily basis. The discharge team helped with the design and continue to input into the development. The app tracks patient’s length of stay, identifies organizational responsibilities and provides live information directly to managers. This is done for every patient in the Trust and does not focus on medically optimized patients. The App is a tool to support safe and timely discharge, but it also helps to reduce patient’s length of stay. It prevents duplication and releases staff to actively discharge patients. Patient tracking is now embedded into the discharge officer’s daily routine and provides the discharge managers with the information required to problem solve and address complex issues that cannot be addressed by ward staff. The process for tracking patients is constantly reviewed and up-dated by the discharge team. There have been a number of changes made to pathways and processes for both the Trust and the community providers, and this continues to be an on-going piece of work.
Delayed transfers of care (DTOCs) have reduced and The Trust has maintained DTOCs below national benchmarks (CQC report). The work achieved relating to discharge has supported the flow of patients out of the Emergency Department.
There are a number of discharge pathways created by the local authorities and clnical commissioning groups whose patients are admitted into the Trust. These pathways have been created to provide whole system working to reduce length of stay and provide better outcomes for patients leaving the L&D.
The coming together of like-minded people, working together across organizational boundaries, enabled the development of a culture change. This was made possible by the commitment of senior management within the local authority’s primary health and the Trust.
Key elements of success
Having a culture where there is a coming together of organizations and like-minded people. This enables whole system working - working across organizational boundaries and positive culture changes. Whole system working engages those working inside and outside the Trust.
The Chief Executive and Deputy Chief Executive have been proactively involved with the development of the App.
There has been the enablement of fresh thinking and the autonomy to make decisions. The team recognizes the need for development and reviews and amends the process for tracking all patients to reduce Length of stay.
Head of Discharge Planning