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

Discharge to Assess is an innovative approach which sees health and social care professionals work together to help people return home or to care homes sooner from hospital.

In South Warwickshire, the Covid-19 response has galvanised collaborative working across the system to support Discharge to Assess, re-admission avoidance and new models of out of hospital care.

This has been achieved through partnership between South Warwickshire NHS Foundation Trust (SWFT), Warwickshire County Council (WCC), nursing and residential homes and primary care.

New ways of working have included:

• Integrated system leadership, with support from Public Health
• More people enabled to go straight home from hospital with integrated support
• ‘System approach’ to use of step-down beds
• Close working with out of hospital services
• Greater use of technology – virtual meetings between staff and remote support for high risk shielded patients

The main positive impacts have been improved patient care and better use of resources.

What does your project aim to achieve?

The unique circumstances of Covid-19 have accelerated collaborative culture embracing new ways of working for benefit of patients and community. Our aim is to see whether demonstrating the environmental and social benefits of the changes can help sustain this.

We will measure and communicate the impact of changes to hospital discharge using ‘sustainable value’, to analyse health outcomes of patients 65+ discharged to residential/nursing homes together with environmental, social and financial impacts.

By capturing the true range of benefits achieved through Covid-19 adaptations and communicating these creatively with involvement of key stakeholders, we aim to nurture ongoing pride and commitment to service improvement, benefiting the NHS, patients and wider community.

Anchoring positive service changes will sustain improved outcomes for patients being discharged to care homes, reducing inequality for the most vulnerable elderly patients.

We will take learning into recovery planning, as well as spread to other services and other organisations.

How will the project be delivered?

The Centre for Sustainable Healthcare (CSH) will work closely with NHS partners to measure impact on work patterns, travel and resource use, alongside clinical and social outcomes. CSH leads work to mainstream sustainability in healthcare and has extensive expertise in analysing environmental and social impacts of service change at national and international level.

Key people from SWFT including the Associate Director of Operations, Out of Hospital Collaborative and the Sustainability Manager, will work alongside the Integrated Partnership Manager at WCC, primary care and residential/nursing homes to provide data and insight.

The Emergency Care Improvement Support Team (ECIST) at NHS England & NHS Improvement will provide support to communicate the benefits to staff and patients, and share learning from the project widely in the NHS.

Evaluation will include the impact of our integrated team and delivery approach to care homes on length of stay in hospital and readmission rates.

How is your project going to share learning?

1)    The Emergency Care Improvement Support Team at NHS England/Improvement will create and implement a local and national communication plan (infographics, press release, staff info, social media) in order to share the project’s learning widely not only with staff, patients and communities in South Warwickshire but also with Q members and across the healthcare system.

2)    Within Warwickshire we will share our learning across health and social care through the 3 Place Delivery Groups (South Warwickshire, Warwickshire North and Rugby), the Care Expert Advisory Group and with providers through Provider Forums.

We will produce a written report and a template to enable other services to undertake a similar analysis. We will take learning about how to embed service changes using a Sustainable Value model into recovery planning, as well as spread to other services and other organisations.