Discharge To Assess
Aintree University Hospital
10th September 2015
Angela McAvoy: Therapies CBM
Rebecca Mitchell: Senior Physiotherapist
Claire Denton: Liverpool Senior Social Worker
Biography
Angela McAvoy
Therapies Clinical Business Manager for
Aintree University Hospital.
Picture to go here
Qualified as an Occupational Therapist form St
Loye’s School of Occupational Therapy in 1989.
Has worked in a variety of clinical settings
including Acute and Community Services,
Prosthetic and Wheelchairs Service and AED
before moving into her current role leading
the Integrated Therapy Service at Aintree
which includes Occupational Therapy,
Physiotherapy, Dietetics, Speech and Language
Therapy, Prosthetic and Wheelchairs, Patient
Appliances and North West Assistive
Technology
Biography
Rebecca Mitchell
BSc Hons Physiotherapy Manchester Metropolitan
University 2009
Physiotherapist for Aintree University Hospital
since 2013
Senior Physiotherapist within Aintree@Home
team at Aintree University Hospital
Specialist interest in falls prevention, frailty and
discharge to assess
Qualified acupuncturist and pilates teacher
Biography
Claire Denton
Employed by Liverpool City Council in the role
of Social Work Team Leader for Aintree
University Hospital.
Qualified as a Social Worker in 1999, working
in an integrated Older People’s team and GP
surgery. Following this was seconded to a PCT
to support with the implementation of the
Older People’s National Service Framework.
Claire then joined an integrated disability team
as senior practitioner, supporting service users
with a learning disability, ASD and those with
an acquired brain injury. Claire is also a
qualified Social Work practice educator.
Discharge to Assess model
Aintree’s Trust Vision
“To provide world class services for all our patients”
Aintree at Home encapsulates the “Discharge to Assess” model and facilitates early
and safe discharge through the functional and social care assessment in the service
user’s home. By identifying and providing the appropriate social care, in partnership
with social care providers, Aintree at Home reduces length of stay, maximises
independence and helps prevent unnecessary readmission.
“The objective of discharge is not simply to get the person out of hospital, but also to provide seamless
support, to ensure a return to their home or care home in the best possible physical, mental and emotional
state.” Commission on Dignity in Care for Older People, June 2012.
Overview of the service
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Aintree at home began as a pilot in December 2012 - discharge to assess approach
for therapy.
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Feb 2015 stakeholders meeting - social work assessments at home since
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A service that adopts a strong multi-disciplinary approach of Occupational
Therapists, Physiotherapists, Nurses and Generic Therapy Assistants.
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Close working relationships with hospital based social workers and community
therapy and social care services, GP’s and district nurses.
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Seven days per week 8am-6pm, working with community outreach teams to
support bedtime care calls.
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Outreach model with a strong ethos of “getting it right for every patient every
time” by moving traditional therapy and social work assessments out of the
hospital environment and into the home environment.
Drivers for Discharge to assess
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Improving Patient Care- ageing population, with increasingly complex health and
social care needs
Need to develop patient centred care – assessment in the right place at the right
time, patient family and carer involvement
Positive patient experience
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Improving patient flow- Pressures in acute and timely discharge of patients
Availability and use of community resources
Financial challenges facing NHS/Social Sector
Move of resources away from secondary care into primary care
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Process
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Stakeholder event organised by Liverpool commissioners
Opportunity to do something different
Agreement around the table – removed barriers immediately
Started process next day
Step by step approach – 1 patient at a time –learnt lessons as you go
Open forum – invited all
Weekly operational review meeting
Communication and engagement – ward mangers, patient flow,
consultants, board rounds
• Visited key wards identified – staff supported by CBM, Clinical Lead
• Test phase February to July 15 – next phase formalising project
Factors to consider and address
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Cultural change
Historic processes
Change in staff/services –opportunities/impact
Commissioners involvement
Opportunities for engagement and sharing the work
Learn from others
• Providing equitable services for all – 3 CCG’s/Local Authorities
Process for selecting inpatients
• Potential for D2A highlighted by ward therapist.
• D2A co-ordinator screens patient.
• Outcome discussed with allocated social worker.
• Co-ordinator contacts referrer and confirms plan/information details.
• Paper work completed and section two completed to social worker.
• Information given to patient re: D2A process.
• Treatment plan agreed with patient.
• Communication with the ward and patients family as required.
Discharge process for D2A patients
• TTO’s collected.
• Escorted discharge home
• Joint assessment completed at home or social worker to review at home within
48hours
• Therapy complete full assessment and provide any equipment required.
• Social worker assesses care needs and arranges POC through care agency.
• A@H bridge POC until care agency care start, independently or in collaboration with
other agency.
• Evaluation form completed and statistics gathered.
Outcome measures
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Capacity Vs Demand- statistics kept and evaluated monthly for length of stay,
prevention of re-admissions, changes in care packages, number of patients
accepted, number of patients deferred and the reasons for this.
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Patient satisfaction forms- completed for each patient and evaluated on a
quarterly basis by the clinical audit department.
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Blaylock assessments- standardised assessment.
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Referrals generated post discharge/ sign posting -recorded to examine if there has
been an increase or reduction in the need for community organisations.
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Discharge problems identified/ resolved e.g. medication, equipment.
Discharge To Assess challenges
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Delay in TTO’s and difficulties with medication- nursing role developing supports to
resolve issues, developed a local medication administration guideline, established good
links with pharmacy and community GP’s.
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Delay in transport- applied for funding for additional vehicles including wheelchair
accessible vehicles to escort patients home in, currently have one available work car
and two vans to deliver essential equipment.
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Initial lack of understanding of the discharge to assess process- established working
policies and ++ promotion to members of the MDT.
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Lack of communication from the ward re: discharge- kept record of difficulties,
provided regular feedback and training.
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Lack of initial crisis support in community- lack of step up beds/ access to community
resources e/g lifelines, key safes etc, capacity of emergency teams to support bed calls,
D2A only available to one of our three CCG’s.
Challenges in Social Care
• Understanding roles of different professionals
• Timely and appropriate assessments -risk assessment, not over whelming
the patient
• Establishing pathway for D2A alongside process for response to
Assessment and Discharge Notifications from the trust (not causing
further delay, requesting care in a timely manner)
• Agreeing criteria for suitable patients (Clarity between A@H and D2A)
• Issues of Mental Capacity, consent and Safeguarding issues (terminology,
risk-particularly for patients lacking in capacity who may refuse to return
to hospital)
Results
Discharge to Assess Feb-July 2015
NUMBER OF PATIENTS
40
NUMBER OF VISITS for D2A including
bridging POC gaps
368
NUMBER OF BED DAYS SAVED
327
POC changes following one initial visit
POC reduced = 13 patients
POC increased= 1 patient
8 bed days saved on
average per patient
(total of 21 calls reduced)
Summary: Our analysis clearly demonstrates that valuable bed days could be saved if
patients were being assessed for packages of care earlier and in their own home.
Previously, we developed a package of care based on assessments which took place in the
hospital, only to find the reality in the patient’s home required different or additional
elements, which would further delay the patient’s discharge. It reduces patient
dependence on long term POC by incorporating a re-enabIement approach.
Case study one
• 58 year old female. PMH: COPD, depression. SH:
lived alone in house
• Joint SW/ PT Ax at home- on arrival home house had
been burgled
• Completed Ax and equipment to facilitate stay at
daughters property
• Gave information and support
• Patient and daughter happy with support, no POC
needs identified.
“ You were excellent, 10 out of 10.
Thank you so much for all your help”
Case study two
• 91 year old female. PMH: Registered blind, OA. SH:
lived alone, no family support.
• Joint SW/ OT ax at home
• Previous POC- patient identified as having increased
needs as an inpatient (4calls)
• Equipment provided to increase safety
• A@Home provided POC 2 calls/day
• 7 visits completed, 7 bed days saved
• LT POC- 2calls/day
Patient feedback
Are there any comments on areas we could improve?
“None, It was very good care”
“I was treated well…… with respect and staff were very attentive”
“Excellent, 10 out of 10. Thank you so much for all your help”
Plan for future
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Increased D2A patients per week- continue to grow as the pilot expands.
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Better access to step up beds.
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Continue to improve networking with community teams/ collaborative working.
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Increased awareness of D2A throughout trust.
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Increased family/ patient education at front door/ ward re: assessment at homesome reluctant for discharge from hospital.
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Increased SW support from our other two CCG’s.
Service Evaluation
Since the service was piloted in December 2012 there has been continuous
evaluation to ensure we learn through good and bad experiences. We have
shared our learning through training and awareness sessions, formal
presentations, articles in trade publications and visits to other hospitals to share
our model. Aintree at Home has also been presented to undergraduates at the
University of Liverpool and at national conferences.
Aintree has demonstrated with the growth of the Aintree at Home service that more
patients can be supported home from the acute setting sooner with an early
supported discharge approach. The model could be easily replicated within other
Trusts, potentially easier than Aintree, who are challenged by managing discharge and
on going support for our patients from 3 different boroughs, with 3 different social
services, equipment providers and community services.
We firmly believe that we have a high quality service that will continue to grow
and adapt to meet the future needs of the NHS.
Thank you
Any questions?
For further information please contact:
Angela McAvoy
Aintree University Hospitals
Therapy Outpatient Department
Lower Lane
Liverpool
L9 7AL
ANGELA.MCAVOY@aintree.nhs.uk