A team based at Wrightington, Wigan and Leigh NHS Foundation Trust is demonstrating how shared expertise, better communication and new ways of working can make a very real difference to patients - while also alleviating pressure on hospital resources.

The Integrated Discharge Team (IDT) is working hard to reduce the number of patients who have completed medical treatment and are ready to be discharged – as evidence shows that people recover more completely and quickly in a home environment.

Traditionally some people have had long stays in hospital, even though they were medically fit to leave. This was because health and social care teams all worked separately using different systems which caused delays to patients going home or into care in the community.

The IDT are tackling this problem head-on by bringing health and social care workers and services together under one roof, so they are able to work closely together in an integrated way for the first time. This includes bringing together discharge coordinators, health care professionals, social workers and social care officers, community matrons, district nurses, re-enablement services, and third sector organisations, including homeless charity “The Brick”.

This has led to a much more coordinated approach which means in many cases people can now go home when they are medically fit to do so, with the right care package in place to suit any ongoing health and social care needs.

Vital to this approach is the ability to share information, which the IDT has done through the introduction of an electronic discharge tracker. Information is entered into the tracker from all the services – giving the team a more rounded view of a patient’s situation. The tracker also allows discharge plans to be drawn up in tandem with medical plans, again helping remove unnecessary delays.

A more integrated approached and improved IT has also allowed changes and improvements to patient care. For example, a complex case panel has been introduced, which includes input from a multi-disciplinary team. This allows health professionals to talk through the best care options available to patients with very complex needs and log this via the electronic discharge tracker. This is then discussed with patients and their carers before any decisions around future care are taken.

As Chris Broadbent, Directorate Manger of Integrated Health Services, explained, “Discharge planning is a speciality and we need to always ask, ‘what’s stopping this person from going home?’”.

Chris takes pride in what he sees as IDT’s motto ‘Home First’, which focuses on discharging patients, whenever possible and appropriate, to their own homes. This can avoid problems associated with long term hospital stays such as increased dependency.

The results speak for themselves. In 2016-2017 the hub helped 81 more people than the previous year to be discharged directly home from hospital, rather than into residential care, as well as, reducing lengths of hospital stay.

The IDT team have also been to other Hospital Trusts in Greater Manchester, including Manchester University NHS Foundation Trust, North Manchester General Hospital, Salford Royal NHS Foundation Trust and Tameside and Glossop NHS Foundation Trust, to share their knowledge and experience with other teams.

The IDT hub is still evolving and hopes to bring even more services on board in the future, such as therapeutic services. Technology is set to play its part too in improving efficiency with the IDT hub aspiring to become paperless and introduce electronic whiteboards, which will allow further integration with IT systems.

Another innovation under consideration is the use of tele-therapy, which allows triage of patients to take place via the internet in a home environment; preventing patients coming to hospital when they don’t need to so they can receive the care they need in the comfort of their own home.

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