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