Update on Discharge 2 Assess programme
The Discharge 2 Assess Programme (D2A) is currently supporting a series of pilots aimed at getting patients home, or to an appropriate alternative, for continued care.
| P0: Fully independent. Patient returns to usual place of residence |
| P1: Patient returns to usual place of residence with interim additional support. |
| P2: Patient is transferred to a non-acute bed and receives rehab/reablement and assessments until able to safely return to place of residence. |
| P3: Complex. Patient is transferred to a new long-term bed, assessment bed, or usual residence and receives complex support for their needs. |
The inaugural pilot introduced a point of contact model for discharging patients to an alternative location for a short-term period, to receive rehabilitation and reablement before returning home (P2 facilities). These were predominantly the General Rehab Units, Short-Term Care Centre, and the Discharge Assessment Unit. The pilot introduced a streamlined referral process, which allowed for the allocation of patients to beds, based on their recommended discharge pathways and an oversight of the available capacity. It has enabled a much more efficient process for the units to receive patients from the acute setting.
Previously, each unit would have different requirements for a referral into their service and a differing handover – there also wasn’t a single oversight of the available P2 capacity, with the Integrated Hospital Discharge Team (IHDT) contacting each service to see if they had suitable beds available.
This initiative looked at a cohort of 60 complex patients from across the acute. The pilot has seen a reduction in the delay experienced in transferring patients from acute care to the designated P2 facilities, with an average decrease of 1.5 days per patient participating in the pilot – freeing up 90 days worth back into the hospital bed base.
A subsequent pilot for P1 has also adapted a streamlined point of contact model for patients following a discharge home or to a usual place of residence with new or additional needs. The overarching objective of these pilots are to reduce unmet demand, reduce no criteria to reside and optimise patient outcomes and experience.
The P1 pathway has centralised the process and coordination of people going to Hospital to Home and Home First. During the pilot, it meant one person now arranges the appropriate service for people based on recommended discharge pathway and available capacity. The aim has been to streamline processes and to provide a helicopter view of demand and capacity to reduce delays, and make best use of available capacity and support earlier planning for discharge.
The next steps will see a move towards the Transfer of Care Hub (TOC) – a key tool in coordinating discharges and admission avoidance projects in wider health and social care services. More information about this will be made available in June.
The benefits we have seen for patients, and for pathway performance, would not have been possible without the collaborative and positive engagement we have seen between teams and partners. We look forward to updating you in the next edition on the progress of the TOC and how we are supporting our patients in achieving better long-term independence and outcomes.
