A Practical Workshop Describing the Operational Running and Reality of

Discharge to Assess (D2A)

Cheryl Eyre Integrated Pathway Manager for Active Recovery

cheryleyre2@nhs.net

Objectives of the session

• Introduce the “Discharge 2 Assess” Model developed with Social Care colleagues

• Explaining how services and workforce have been empowered by providing an environment for innovation and the freedom to try out ideas building a no blame culture

• Lessons learned and Recommendations

Where we are…

STH Facts and Figures

• Foundation Trust on 5 sites with 1,100 beds• 2nd largest Teaching Hospital in the UK• Major Trauma Centre and Regional specialities• 1 CCG!• Integrated Hospital and Community Services• Social Care provided by Sheffield City Council• Separate Mental Health and Children's Services

Integrated Care in Sheffield

Integrated care as

experienced by our

patients

Integrated Structure• Community and Hospital Services within a combined acute and

community care group• Community services include District Nursing, Integrated Therapy

Teams and Active Recovery• Acute Hospital Services in the group include acute AHP services,

GP collaborative and Palliative Care• Professional Leads recognised and embedded into the structure• Integrated Pathway Managers across the care group to facilitate

creative joined up solutions

Active RecoveryOne service delivered by two

providers:- CICS and STIT

‘Health and Social Care working in partnership’

Active Recovery Aims• Prevent unnecessary hospital admission• Promote ‘Discharge 2 Assess’ • Facilitate early discharge from hospital• Prevent avoidable admission to long term care• Provide time-limited recovery, support and/or

rehabilitation in a persons own home

Change

‘Assess to Discharge’To

‘Discharge 2 Assess’D2A

The Big Room (Oobeya)

Big Room – starting with a patient story

Let me introduce ‘George’•82 years old

•Lives independently and wants to continue doing so•Widowed 5 years ago•Has mild dementia•Daughter lives locally•Losing weight + poor mobility

Plan-Do-Study-Act cycles of continuous improvement

The work so far • Building relationships with hospital based

colleagues • Challenge historical practice• Developing Active Recovery processes to

support rapid discharge

Building Relationships • Big Room meetings • Active Recovery therapists in- reaching in

to the wards• Shadowing • Test of Change • Developing a no blame culture

Changing Historical Practice

•Changing mind set of medics, ward staff, relatives, Patients and Carers •Reviewing expectation •Referral date = Discharge date

CASE STUDY MBIntroductionMrs B lives alone in sheltered accommodation, she is 82 years old. She has memory problems and a history of depression. Her two daughters live locally and have Power of Attorney over her finances.

Mrs B’s daughters report that they have been struggling to support Mum since her recent deterioration in her health.

Mrs B was diagnosed with carcinoma of the colon in the last month and has been losing weight and feeling unwell.

On the 16th August 2016 her daughters contacted the GP stating that they were struggling to manage her and that Mrs B had calf pain and was suffering with shortness of breath, she was immediately admitted to A&E with a suspected DVT.

From A&E Mrs B was admitted to a care of the elderly ward and diagnosed with an acute DVT, once the medical management of her DVT was completed she was referred to Active Recovery.

Case Study MHIntroduction

Mr B is a 78 year old gentleman with a significant cardiac history. He was referred to the Discharge 2 Assess pathway following a 17 day admission with atrial fibrillation.

Prior to the admission Mr B was able to independently meet own Activities of Daily Living (ADLS) but was experiencing pain from hip area and was awaiting a total hip replacement.

Benefits for the patient • Reduced length of time in hospital.• Less likely to contract hospital acquired

infections.• Less time to become institutionalised• Less likely to lose confidence re-mobility• Return to familiar surroundings• The assessment for on going support, if

required, takes place in own home

Benefits for the organisation

• Reduction in bed occupancy• Reduction in length of stay• Reduced pressure on beds• Improved flow• Saves money

Time waiting for discharge to AR

Time waiting to get home per patient

D2A starts

D2A starts

7 day reduction in length of stay

Lessons learned/Recommendations

• Service Improvement techniques/expertise• Genuine Consultation with staff• Joint design with a grounded collaborative approach• Assume ‘spread’ with caution• Patient involvement and experience at the heart of

any change

“It’s changed the way we think”

‘Discharge 2 Assess’

Any Questions

Thank youCheryl Eyre Integrated Pathway Manager for Active Recovery