Purpose
Unnecessary delay in discharging patients from hospital is a systemic problem with a rising trend. In 2016/17 there were 532,423 bed days occupied by medically fit patients in Scotland. Over 70% were aged over 75. Current evidence highlights correlation between longer hospital stays and potential harm, resulting in poorer health outcomes, an increase in long-term care needs, poor patient flow and avoidable use of acute resources.
Discharge to Assess (D2A) is a national driver and within East Lothian we looked to develop a pathway that supports discharging patients that are clinically fit and appropriate to have their Physiotherapy/Occupational Therapy assessments at home. We aimed to embed D2A as a core East Lothian service and promote a culture of 'ownership' of East Lothian patients throughout their patient journey.
Approach
The East Lothian D2A service was established in May 2015. Several strands of work have developed the service into its current format.
- East Lothian D2A referral criteria and pathway established in consultation with NHS Lothian acute sites and East Lothian Council.
- Education and awareness sessions delivered to referring staff and standardised recording and audit processes developed.
- Collaborative working with East Lothian Discharge Co-ordinators and fostering of closer working relationships with community teams was key to improving the patient pathway and experience.
- Daily screening of admissions lists from Edinburgh's acute hospitals to proactively 'pull' patients from hospital.
- Weekly in-reach by the D2A team to Orthopaedics, Stoke and Medicine of the Elderly at the Edinburgh Royal Infirmary. This supports inpatient staff to highlight appropriate patients for supported discharge by D2A and enables sharing of key patient and local information.
The D2A team support patients through comprehensive same day or next day Physiotherapy/Occupational Therapy assessment. They deliver on-going person-centred care in a patient's own environment, through the provision of equipment; minor adaptations and short term therapy support.
Outcomes
Over the 3 years the project has been running, increasingly positive outcomes have been demonstrated in our highlight reports.
- 659 patients have successfully been supported home since the project began.
- Feedback from patients and families demonstrates a high level of satisfaction in the service.
- Patients identified that increased safety on discharge, specific assessments in their own home environments and improved confidence, as key benefits that aided their recovery.
(Data: May 2015 - 1st November 2018. Costs calculated at £300 a day, averaged at 3 bed days saved per patient).
Cost and savings
It is estimated that 1,977 bed days have been saved, equating to £593,100.
(Data: May 2015 - 1st April 2018. Costs calculated at £300 a day, averaged at 3 bed days saved per patient).
Implications
The D2A service in East Lothian has been highly effective in facilitating timely and successful discharges from hospital. Throughout the development of D2A we have sought out new ways of expanding the service, to support increasing numbers of East Lothian patients home safely. This on-going innovation and development is clearly demonstrated in our increasing referral numbers.
D2A is now fully embedded within the wider East Lothian community services and is a key alternative discharge pathway. This fulfils NHS Scotland's strategic aims, of returning patient to their own homes as soon as appropriate, with minimal risk of re-admission.
Top three learning points
- Developing a culture of “ownership” of our East Lothian patients has enabled us to support patient flow and effect positive change on discharges.
- Enhancing communication links between clinicians and services across community and acute sites has been crucial in building relationships and trust.
- Developing a shared vision was a key part of our success.
Funding acknowledgements
D2A was initially set up within existing resources. Following successful winter funding bids, additional permanent funding was secured from East Lothian Health and Social Care Partnership for 2 WTE Physiotherapists and 1 WTE Occupational Therapist.
Additional notes
Project Update, January 2020: 1100 patients have now been successfully supported home by the East Lothian D2A service
Presented at Physiotherapy UK 2018.