Case study about reducing delayed discharge from hospital

In this case study, we share what East Ayrshire Heath and Social Care Partnership (HSCP) did to reduce the total time patients spend delayed in hospital with no more need for hospital care, whilst also increasing the reliability of systems delivering safe, legal and person-centred discharge.

It describes improvement initiatives the partnership took, and aspects of leadership and organisational culture enabling this progress and continued commitment to improvement.

A HSCP is a hugely complex operation, as is the management of hospital discharge so that it ensures the right support, at the right time and in the right place for each person. A case study of this scale can only begin to scratch the surface of this complexity.

However, below we outline the initiatives thought to contribute most to getting people who no longer need hospital treatment, promptly, safely and legally home or to a homely environment. We then describe the enabling factors thought to be key, in particular the HSCP's person-centred ethos and strong leadership.

Improvement initiatives
- Early referral to hospital-based social work team (SWT) / presumption of return home
  - The SWT worked closely with ward and hospital staff, monitoring patient data daily and taking part in hospital huddles in order to identify patients needing discharge support earlier in their hospital journey, as well as to ensure that the option of going home is fully explored.
  - This allowed more time for patients and families to make life-changing decisions and for appropriate support services and/or adaptations to be identified and organised.
- Dedicated Mental Health Officer (MHO) for adults with incapacity (AWI)
  - The MHO made applications for urgent interim court orders on the grounds of risk to health, to move AWIs to care homes, and supported families applying for guardianship orders.
  - Since 2016 this reduced average lengths of stays for those delayed awaiting guardianship orders by almost 40% and contributed to reducing the associated bed days rate by over a third.
- Discharge to Assess (D2A)
  - Some patients thought likely to need long term residential care, were moved to a care home (of their choice) for a full assessment – crucial for those becoming distressed or confused in an acute hospital environment.
  - There was an estimated annual saving of over 750 bed days, along with improved accuracy of, and patient engagement in, discharge assessments.
- Intermediate care and enablement
  - Where rehabilitation potential was identified, intensive needs-driven individualised support from a multidisciplinary team was provided, lasting typically four to six weeks. The focus was on supporting the individual to achieve their own goals, and maximise their independence.
  - By 2018, an estimated 3,000 bed days per month were saved due to facilitating earlier discharge, and more were saved through preventing admissions.
- British Red Cross 'Home from Hospital' service
  - This service transports patients home from hospital and supports them with initial settling in at home. Where need is identified, short-term case work is provided to address issues such as falls risk and social isolation.
  - An estimated 2,000 bed days have been saved every year by this service, of which approximately 1,500 were associated with reducing delayed discharge.

Key enabling factors
- Leadership and person-centred ethos
  - Strong, collaborative and enabling leadership, actively and visibly working to build and continually reinforce shared values and common goals across organisations and disciplines.
  - A widespread sentiment from the interviewees was "do right by people and the money will look after itself".
  - Finance also operates in alignment with these priorities.
- Ownership of the delayed discharge target as a priority across the partnership
  - "Delayed discharge? Not on my watch".
- Flexibility of finance/budgeting to support priorities
- Whole system preventative approach
  - A steady shifting of budget towards prevention and community/home care over years.
- Integrated working values and practice
  - Transparent, open approach to commissioning and service (re)design, engaging a diverse range of voices including from statutory services, third sector, service users and wider community.
  - Commitment to building mutual understanding of values and roles, and working with shared purposes across disciplines and health, social and community sector boundaries.
  - Spreading the understanding that hospital is not always the safest place to be for people.
  - A hospital-based social work team is integral to this, particularly to facilitating the development of better collaborative working between social work and healthcare workers.
- Openness to improvement ideas from all parts of the partnership
  - Creating a climate which encourages new ideas and contribution from all.
  - Acceptance of calculated risk-taking for improvement ideas: "proceed until apprehended".
- Constructive party politics
  - Senior managers noted that in relation to health and social care, the political groupings in the council work constructively together.

We hope that other HSCPs in Scotland find this overview useful in further developing their own approaches to reducing both delayed discharge and the risks to patients from unnecessary time spent in hospital.

Read in more depth about the initiatives taken by East Ayrshire HSCP and the key findings.

Evidence and Evaluation for Improvement

Case study about reducing delayed discharge from hospital