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Meet the team

Also:

  • Anne Mann, Service Manager
  • Tammy Gotts, Matron
  • Claire Lee, Discharge Planning Lead
  • Nicola George-Powell, Senior OT, SDS Service Lead
  • Maggie Wood, Service Manager
  • Sara Moore, Pharmacy
  • Tina Vento, Nurse - Discharge Lounge

What is the positive change that has emerged through new collaborations or partnerships during Covid-19 that your project is going to embed?

During Covid-19 there was a focus on hospital discharge to create in-hospital capacity for sick patients. This created greater need for capacity in the community to care for patients at home as well as improved processes to ensure plans supporting patients to leave hospital are in place at the earliest opportunity.

Teams involved in discharge across hospital, community and social-care worked together, sharing information across the system in the form of a virtual MDT which tracked patients in the hospital to discuss what they were waiting for in order to be safely discharged and put plans in place collaboratively, forming a joined up pathway out of hospital to home.

Therapy teams previously based on acute wards joined the supported discharge service to support patients to safely leave hospital sooner and be cared for at home by expanding the virtual community bed base and carry out assessments in a home setting.

What does your project aim to achieve?

We aim to develop a visible discharge caseload that can be used across hospital, community and social care teams to enable plans to be made at the earliest opportunity and the most appropriate support to be in place for our patients.

Linking with community MDTs to review people who would benefit from proactive preventative multi agency approach to support discharge and prevent future admission.

Closer working relationships with primary care, community services and the acute base will enable the use of a population health management approach to identify health inequalities in the local population and use this data to inform further service developments.

Monitoring how we perform as an integrated system by tracking the patients being discharged on each pathway and the number of bed days saved through early discharge and admission avoidance, will inform system level discussions around funding additional service changes across acute, community and social care.

How will the project be delivered?

The project will apply Quality improvement methodology, working with a Multidisciplinary team across acute, community and social care to plan and test ideas and the use of a project management approach to manage risks and issues. Measurement for improvement will be used to monitor progress and impact.

How is your project going to share learning?

  • Case study report
  • Sharing of data
  • Impact on capacity and demand
  • Sharing of new model approach
  • Sharing of successful cross boundary solutions to funding further developments

How you can contribute

  • Ideas and advice for solutions to support information sharing across systems
  • Ideas and support in communication and spread
  • Refining measures and plans

Plan timeline

1 Mar 2021 project group convened
1 Apr 2021 Measures agreed and Data collection beings
1 Apr 2021 Review existing process and identification of specific areas for improvement
3 May 2021 First test of change piloted
1 Jul 2021 Impact and further development assessed
8 Jul 2021 Test of change piloted
1 Sep 2021 Impact and further development assessed
8 Sep 2021 Test of change piloted
1 Nov 2021 Impact assessed
1 Dec 2021 Draft Project write up
24 Feb 2022 Final report

Comments

  1. Integrated and joint working 'across' services for a pathway is essential - for the best patient outcomes. As well as the 'pathway' and process (the what) will you also consider the 'how' - the team working and what is needed in different relationships and ways of working too? I'd be interested in sharing ideas on this as thats the basis of a bid I've put on here re integrated working with primary and community services

  2. This is such a crucial area, wishing you success and would be very happy to bring social care voice if required.

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