Firm foundations of integrated working in Derby enabled the city to respond rapidly and effectively to the Covid-19 pandemic through extraordinary joint effort between NHS providers and adult social care
Strong collaboration enabled early implementation of the hospital discharge guidance while identifying opportunities for innovation. It led to streamlined discharge processes in the Discharge Assessment Unit and development of a new, pioneering delirium pathway
Resulting efficiencies have maintained discharge flow and capacity throughout and shifted perceptions of how support can be delivered for patients, moving the focus from hospital beds to care at home, and demonstrating the value of community services.
Stronger together
Derby City’s response to the demands of the pandemic and rapid implementation of the hospital discharge guidance was made possible only through the strength of integrated working and collaboration between health and social care partners. A core team of stakeholders identified the opportunity to further streamline, innovate and improve services. These included:
University Hospitals of Derby and Burton NHS Foundation Trust
Derby City Council – adult social care, public health and commissioning
Derbyshire Community Health Services
Derbyshire Healthcare NHS Foundation Trust
Place Alliance of GPs
Social care providers
Voluntary sector organisations.
Implementing the guidance required a new level of provider collaboration at pace to enable the system to achieve objectives quickly, while maintaining a high level of patient care. What makes Derby’s approach different is that all partners are involved in a single streamlined journey from when a patient is admitted to hospital to getting them supported to go back home.
The city-wide collaboration was overseen by a joint planning group with a PDSA (Plan, Do, Study, Act) approach to test processes and inform quality improvements. A population health management approach was adopted to understand the impact of Covid-19, demand and where capacity needed to be targeted, using intelligence to develop related programmes, such as Urgent Community Response (UCR). This has led to a cultural shift of focus to community support and provision by all.
The joint response focused on three key areas:
Transition from ward assessment to community responses:
Two wards were closed and alternative provision in the community found within 48 hours
Discharge capacity within community integrated assessment beds adapted to receive Covid positive and negative patients
Rapid expansion of out-of-hospital health and care capacity to match demand to return people home, throughout the pandemic
Creating a Discharge Assessment Unit (DAU) of health and social care staff with voluntary sector partners:
Aligned assessment by co-located specialist team of community health and social care staff
Built the trust of ward staff in our ability to discharge patients safely, effectively and within two hours
Aligned system partners, including voluntary sector and housing partners working even more flexibly, achieving a ‘pull’ from outside hospital
Establishing a social care-led delirium pathway diverting resources from acute care to enable more complex patients to return home:
Social care teams leading on developing a 24/7 pathway for patients with acute delirium or enhanced care needs.
Achieving at a time of adversity
Changes in system working were required to establish the DAU within a tight two-week timescale, changing the function of the team to assess patients within 30 minutes of arrival and agreeing discharge destination within an hour.
The collaborative approach to establishing the DAU has resulted in:
Streamlining ward referral using electronic whiteboard
Each stakeholder within the system partnership changing the way they worked
Clear roles and responsibilities for each staff group
Using trusted assessments for smooth transition from wards through to community
Creation of multi-agency oversight to have one view of all D2A referrals.
The DAU almost quadrupled the number of patients discharged without detrimentally affecting outcomes, resulting in a highly efficient discharge pathway that maintained capacity in the hospital during the pandemic, with community partners ensuring capacity and flow in ongoing Discharge to Assess (D2A) pathways. This smooth transition benefited patients by avoiding longer than necessary stays in hospital.
The pandemic brought into focus the need to radically rethink how we resource NHS and care services. This included a historically difficult decision about the need for hospital wards, or care in the community. A patient audit at London Road Community Hospital (LRCH) showed patients occupying beds as no alternative was available to meet their needs, many being physically well but awaiting assessment for care and support. Prolonged periods in hospital resulted in poorer outcomes and increased likelihood of long-term residential care. A decision was made to temporarily close two wards and shift the resources to acute and community services.
The delirium pathway was proposed to provide day and night care calls at home for up to 14 days and the additional benefits of avoiding transfer to residential care, often leading to longer term placements. The greatest value to patients would be enabling them to remain or return home and maintain independent living.
The delirium pathway now provides crisis response including patients presenting in Emergency Department (ED)/Frail Elderly Assessment Team (FEAT), with diagnosed delirium manageable at home with benefits of:
Avoiding admission
Opportunity to settle delirium in familiar surroundings
Support for carers.
The effect on patient care
These initiatives allowed:
74 community hospital beds to remain closed while their future purpose is reviewed
Prevented the acute hospital being overwhelmed during first wave of the pandemic
Enabled new ways of working to be tested while maintaining capacity in D2A pathways.
Additionally, the focus has accelerated our planning for the Urgent Community Response by building confidence in out-of-hospital services.
Establishing the DAU and embedding a Trusted Assessment process has streamlined discharges:
Acute average length of stay reduced by two days
Reduction in delayed transfers of care
Increased patients supported by the integrated team from 10% to 55%
Activity through the discharge teams was 180% higher than same period last year
Occupational therapy-led assessments enabled discharges on the right pathway with follow up at home resulting in the right level of care and equipment to support people at home.
Daily PDSA cycles with staff identified areas for improvement. Patient feedback was captured and the comments shared in communications greatly boosted staff morale during the pandemic.
The system-wide collaboration enabled the community to respond rapidly and flexibly to supporting hospital discharges:
10% of all acute discharges supported on integrated pathways - 332 average per month
Assessment bedded care adapted at short notice to provide for 15 Covid positive beds
Capacity was stepped up for those patients deemed to be Covid negative/contact upon discharges
400 referrals to assessment beds in 2020-21 with 12 days average length of stay
85 average per month (1029 total) discharged from short term care at home with 12 days average length of stay
More patients discharged and cared for at home than previously
MSK physiotherapists, sexual health and UTC staff were redeployed to support the community response
Challenges
Recruitment to the delirium pathway proved challenging due to the pandemic, delaying implementation until March 2021. An outcomes framework is now in place to capture outcomes and to build an evidence base of patient progress and the impact of the pathway. The aim will be to present a case study to develop a scalable approach to the overall care for patients with delirium.
Involving people and partner organisations
The system-wide collaboration in Derby is built on a culture of integrated working involving staff at all levels in the acute trust, adult social care, public health, DCHS and Derbyshire Healthcare, linking with system leads in the Ageing Well programme and Joined Up Care Derbyshire. Initiatives to respond to the pandemic were therefore able to progress quickly due to the existing respect and mutual trust in the ability of organisations to deliver.
Establishing the DAU required initial support from the local Gold Board with local leadership at all levels with each organisation to change the way they worked to meet the requirements:
Estates team engaged to create the space and additional equipment required
Infection control and facilities management engaged
Co-production of with base ward staff on establishing new processes
Daily operational calls with system partners to resolve issues and make improvements
Involvement of adult social care staff as equal partners.
Patient engagement was via the ‘friends and family’ test and patients experience surveys to shape the approach and immediate feedback sought from patients and their families/carers during their discharge. They were asked to leave comments and ideas for improvement on ‘hearts’ which were then displayed in the DAU for openness and transparency, so that everyone could read and see where necessary changes were made by the team.
A social care-led delirium pathway implementation group involving key stakeholders, met weekly and included:
Consultant geriatrician from the acute trust and DAU staff engaged with clinical staff in the ED and FEAT and the primary care sector
GP representative involved with developing escalation processes
Engagement with mental health services both for their professional advice and support and to reassure them of the scope and function of the new team
Derby City Council’s workforce team working with acute trust and DCHS on developing joint training and sharing access to e-learning
Joint collaboration on recruitment, linking with the ‘Call to Arms’ vaccination campaign.
The delirium pathway is a new approach to caring for patients with clinical diagnosis of delirium. The aim is to monitor and evaluate the pilot over the short, medium and longer term to compare the outcomes with those of patients that were admitted to hospital and share the results as a potential new approach to the management of clinical delirium at home. Research evidence suggests that delirium patients fare less well and deteriorate with longer stays in hospital and this pilot will provide new evidence to show whether better outcomes can be achieved if patients are given the opportunity to be cared for at home.
Links
Establishing the DAU was used as an exemplar site case study ‘Improving Patient Discharge’ in the Government White Paper for the Health and Care Bill.
