The Atlas of Shared Learning

Case study

Intermediate care pathway – enhancing the Discharge to Assess model of care

Leading change

District nursing leads worked collaboratively with other key healthcare professionals and stakeholders to support the transformation of out of hospital care at the Newcastle Upon Tyne Hospital Foundation Trust (NUTH). The nurse lead identified insufficient capacity within intermediate care to meet local needs and fulfil expected standards. This unwarranted variation led the team to develop a sustainable future model for intermediate care in Newcastle, aiming to provide patient care closer to home, or at home, if appropriate. Resulting outcomes included improvements in patient experience, reduced lengths of stay in hospital and positive anecdotal evidence around the model improving personalised care. There are also a number of unmeasurable impacts of reduced stays in hospital associated with the programme such as decreased rates of infections, falls and other complications which will further add value to this programme and their patients.

Where to look

The district nursing lead at NUTH completed a review of the Discharge to Assess and intermediate care system for NUHT. The review identified unwarranted variation in that there was insufficient intermediate care capacity for the needs of the local population. This was compromising the ability to effectively support patients out of hospital, as well as avoiding admission and facilitating a timely discharge. The unwarranted variation needed to be addressed as it was resulting in patients not receiving a timely and comprehensive assessment, in a suitable environment which may be an alternative to an acute hospital. Some key operational constraints were identified, which demonstrated “what needed to change”.

What to change

The audit review data revealed that at NUTH, before an enhanced care pathway facility was introduced, 20% of beds were occupied by patients who could have been treated at home. There was an indication of insufficient capacity within community based services to support the number of patients requiring facilitated discharges and on-going therapeutic interventions needed to maintain people in their own home environments. This meant that patients weren’t able to leave the hospital setting and were at risk of developing other complications whilst they awaited discharge onwards.

How to change

The district nursing lead, together with other key healthcare professionals and stakeholders led working groups to support the transformation of out of hospital care at the Trust. The collaborative working partnership included medics, pharmacists, Allied Health Professionals (AHP), Local Authority and nursing staff across NHS and private providers. These working groups supported colleagues to implement change and to engage with the improvement methodology. To support the change, the nursing lead introduced a monthly stakeholder meeting, with all collaborators to analyse the data and discuss implications for the system and the model moving forwards. This included data such as incidents related to the enhanced care beds model.

The nursing lead, together with medical and care staff then developed a sustainable future model for intermediate care in Newcastle aligned to the Sustainability & Transformation Plan (STP), using their local review and other available evidence. This began with an initial 12 month transformation and re-design scheme to deliver a ‘proof of concept intermediate care model’ to:

  • develop an enhanced care beds pathway with a robust service specification that supports NUTH clinical, operational and governance requirements;
  • encourage and support multi-disciplinary team collaboration to tackle the triple aim outcomes of better experience, better outcomes and better use of resources;
  • test and evaluate the model of care;
  • have standardised documentation to support staff with the roll out of this pathway.

The model included the use of a ‘trusted assessor’ role, development of inter-organisation pathways and referral mechanisms and implementation of an overarching governance structure to oversee and assure the system as a whole. This new patient pathway for enhanced care beds and discharge to assess was devised and piloted at the Trust, led by the nursing leadership team.

Adding value

  • Better outcomes – During the pilot, 89% of patients were referred for step-down care, with the average length of stay reducing to 25 days, significantly below the expected 42 days. Approximately 85% of patients were discharged back to their usual place of residence which is promising. The proportion of patients remaining as an inpatient for greater than six weeks is now minimal. Thirty day admission rates remain low supporting the premise that discharges remain safe as well as timely.
  • Better experience – Only a small number of patients assessed closer to home were transferred to hospital for care (circa 4%). The referrals process was evaluated, indicating a proactive approach to patient management, suggesting a relief in pressure on the A&E department locally and a smoother discharge process – particularly noting a reduction in those requiring admission to hospital at all (down at 15% during the pilot).
  • Better use of resources – Average occupancy rates for the Trust had reduced to 88% where it had been in excess of 90% prior to the programme. Further evaluation is planned and will identify the ‘bed day savings’ from admission avoidance and or facilitated discharge from hospital as a result of this model. Early anecdotal feedback combined with the above positive outcomes suggests that the discharge to assess model has been very successful.

Challenges and lessons learnt for implementation

The main learning is around next steps for this pilot:

  • Agreement of a unified dataset to be collected from all intermediate care sites in Newcastle; to include metrics such as length of stay, admission avoidance, growth in number of hospital discharges, reduced medical boarders, reduced elective cancellations;
  • Discussions with key staff in Medicine and Community Directorates to gather views;
  • Discussions with partner organisations across the wider healthcare system;
  • Joined up working is crucial and not simply limited to stakeholder engagement.
  • Staff and patient feedback is underway to seek more information on the successes of the pilot (expected end 2018).

Find out more

For more information contact:

  • Treacey Kelly, Transformation Matron – Community Directorate, Lead for District Nursing Support to Nursing Home Team, Newcastle University Teaching Hospital NHS Foundation Trust,