Improving hospital discharge:
A minimum viable solution
A study published in Age and Ageing in 2016 found that an extended period of hospitalisation was associated with an increased risk of cognitive decline in older adults.
As you might expect, the mantra often heard on hospital wards is ‘plan for discharge on admission’. However, in December 2022, more than 13,000 beds — out of a total of around 100,000 hospital beds in England — were occupied by patients who were medically fit for discharge. Nationally, it would seem, the process is not working as well as it could.
Coordinating a timely discharge for patients with multiple needs is complex. However, a recent prototype conducted on a hospital ward in North West Wales gives us some confidence that prioritising interactions between health and social care professionals, centred around the needs of the individual, could lead to significantly better patient outcomes.
Why is hospital discharge so difficult?
Many people admitted to hospital are often receiving support from a range of services and professionals before their admission. These could include District Nurses, NHS Therapists, Local Authority Therapists, Pharmacists, Social Workers, domestic care providers, Community Psychiatric Nurses, Mental Health Social Workers, the Housing Team, and a range of third-sector organisations.
In an orthopaedic ward in Ysbyty Gwynedd, over a period of 6 weeks in 2019, 67% of the patients admitted to that ward had a social worker. Across all Betsi Cadwaladr University Health Board sites, on any given day, around 45% of patients are open to social services in one form or another. They might be receiving care at home, in a residential or nursing home or receiving Telecare service.
45% of all patients were ‘known’ to just one of the many community services.
The responsibility for coordinating a discharge often falls to the hospital. In practice, this means nurses working on the relevant ward. However, information about which services are working with patients prior to their admission is rarely available. Many services work on different IT systems and some on paper files. Routine collaboration across services and sectors is uncommon.
In this context, it’s unreasonable to expect a ward nurse to easily piece together the complex web of support services in a person’s life. Without access to the necessary information, their only option is to glean what they can from conversations with the patient and their family. It’s not uncommon for medication to be prescribed without awareness of the existing prescription, for unnecessary referrals to be made and for the patient to return home to unfamiliar faces unclear on what is likely to happen next.
Individuals and interactions over processes and tools
Coordinating a safe discharge for every patient admitted to a hospital is a complex puzzle. There is no perfect blueprint that will work in every case or locality.
However, our experience in testing ways to improve the process in North West Wales has given us some confidence that part of the answer lies in creating time and space for professionals across health and social care to share intelligence about patients on admission and to collaborate throughout their stay.
Working in a hospital in Gwynedd, members of Gwynedd Council’s Health and Wellbeing Team, supported by Agile consultancy Basis, prototyped a new approach; making the hospital and community teams equally responsible for coordinating hospital discharge, together.
We brought together a multidisciplinary team which included representatives from social services, district nursing, care providers, a pharmacist and a therapist. A barrier the team raised immediately was the lack of visibility of the support provided to patients and from which services.
Rather than trying to develop a comprehensive shared case record for each patient, or even sharing care plans and referrals, we agreed to prototype a minimum viable dataset. The team believed that if they knew which professionals were working with the patient, and had the time to talk about the patient’s needs together, they would be able to coordinate a discharge more effectively.
The team decided to meet for 10 minutes each Wednesday for five weeks. They would choose one patient admitted that day and plan for discharge. The team would quickly capture the details of which professionals were working with the patient, share what they knew about them from their own knowledge and case notes, and connect with their support network in the community to fill in any gaps.
The team’s first test
The first patient they supported was Paula (not her real name) who had been admitted for an inflamed gallbladder. During the conversation, several important details emerged:
- Paula was admitted after a fall, and her carers were concerned that she had become jaundiced.
- Her daughter wanted her home but was concerned she would need to be assessed by social services; she felt the current care package was no longer meeting her needs.
- Paula was open to an Occupational Therapist following a fall the previous year. Notes at that time said she could walk four metres and that her daughter was trained to help her in and out of bed safely.
- Paula was dependent on carers to transfer to and from different parts of the house. They also helped with transferring her from bed to chair when her daughter was unavailable. They often had to prompt Paula to eat. They felt she was coping well otherwise, and had no major concerns.
- District nurses visited every 12 weeks to replace the catheter.
With all of this knowledge about Paula’s circumstances, the hospital was able to speak with her existing support network in the community and explain the situation. She needed a course of antibiotics that would last 4–7 days and they anticipated she would be ready for discharge on the seventh day.
Because Paula was only due for a short stay in hospital, the community team decided they would retain her care package ensuring the same carers were in place on her return. Planning for the future, they arranged for her social worker to visit Paula’s home on the day she was due to be discharged. Over the course of Paula’s stay, the social worker, the care provider, hospital staff and her daughter communicated directly to get the latest on her progress. Having finished her course of antibiotics, she was ready to be discharged on schedule. Paula’s support network took the lead by collaboratively creating a discharge plan along with the hospital ward staff, pulling her out of hospital on time.
Although getting through to the ward to communicate proved difficult at times, the team felt, compared to their previous experiences, that there was a sense of control over the situation and that Paula’s needs were being considered at every stage of the process.
Progress, not a panacea, but progress all the same
The learning we’ve gained by testing this approach gives us some confidence that, if scaled, it could significantly improve patient outcomes.
Between 2015 to 2020, it took an average of 12 days for a medically fit patient, in need of a community care package, to be discharged from hospital, in North West Wales.
By enabling ward staff to collaborate and communicate regularly with the patient’s existing support network, our prototype showed that at least in some cases, the delay could be eliminated.
This solution is no panacea. But we think the principles of the approach are sound and easily testable in a variety of contexts. There is an intense focus on improving data sharing processes in health and social care. This is important for a whole host of reasons. However, in the context of hospital discharge, this need not be over complicated. Our prototype showed that sharing simple data in the form of which services are working with patients on admission and making time for conversations between the hospital, community services and the patients support wider network during their stay could make a significant difference.
In line with the principles that underpin the Agile approach, our hypothesis is that by prioritising individuals and interactions over processes and tools, professionals can adapt to even the most complex of circumstances.
Given the likely negative outcomes associated with a delayed discharge, this can only be a good thing.
Currently on secondment with Basis, Gethin Evans works for Gwynedd Council’s Adult Services Supporting Health and Wellbeing Team. Gethin led the development of the prototype in Gwynedd and Anglesey in 2022. With support from Basis, the team used an Agile approach to test new ways of working and to improve them iteratively. The project has been selected for the Bevan Exemplar Programme 2023.
If you are interested in learning more or in testing similar approaches, contact gethin.evans@basis.co.uk. We’ll share what we know and help where we can.
