From the statistics we have collated on our Acute Hospital at Home – D2A  service since 2016, we have evidenced that approximately 1/3 of patients identified as needing care support for discharge were actually back to baseline function after only 2 weeks of intensive Rehabilitation.  A further 1/3 have reduced needs and either require a longer term of rehab to achieve their baseline function or go to reduced longer term support. We plan to use SMART goals and early engagement with multidisciplinary teams to identify patients who could benefit from supported discharge services. We believe we could shorten length of stay, improve bed flow and create a more sustainable patient pathway for the future. I have been looking at examples in Sheffield and Aintree who have also proven statistically that this model is efficient, effective and very well received by the patients and their carers’. However, we are a more rural area and so the model will reflect local needs.

 We have already established that this format works (AH@H stats attached) and has very positive feedback from the patients and their families but we need to try and influence a change in culture, a move from the current way of discharging patients which has caused a lot of frustration patients, relatives and staff.

Please see example from The Aintree at Home team as published by The NHS Fab Awards.

Plan:

Step 1: Patient arrives, (after initial medical assessment) key worker (nurse or therapist) needs to establish whether or not patient already has existing services & if so which ones, (where there is an existing service we need to make contact with those services and advise they should keep the patients care plan open) This should be done via comprehensive patient centred assessment by identified keyworker.

Step 2: Within first 24 hrs, for those Patient’s with no current support, we need to quickly establish if this patient is likely to need the support of D2A to enable a safe, timely discharge with completion of a referral to the D2A team in AH@H who will a use simple focused approach to plan early discharge in agreement with all parties.

Step 3: We need to establish date or time of medical fitness for discharge, ensuring all ground work has been completed, e.g. TTO’s, services informed, equipment, transport, Families informed, etc.

Step 4: Important to review plan before moving patient off ward.  If there is a problem repeat step 3.

Step 5: Patient is transferred out of hospital to normal residence or other appropriate setting with the support of D2A or other agency partner..

The steps may  all be achieved over a few hours or a few days depending on the medical status of the patient.