The functions of this integrated team are to:

• Prevent unnecessary hospital admissions by working across community and hospital
• Facilitate discharge from local hospitals in a timely manner
• Implement national guidance on discharge requirements
• Ensure patients are supported in the community post discharge to reduce readmissions

A coordinated approach

Ensuring a coordinated approach to care delivery at point of discharge has been a key area of focus for the service over the last year. Processes and procedures have been introduced to ensure service users are effectively tracked, assessments coordinated and that assurance systems are robust to maintain quality control. Features include:

• Integrated Tracking System – Underpinning the service is the Home First tracker. All patients referred to the Home First D2A coordination hub are captured and case-managed by the team coordinator. Dates are captured throughout the patient journey from referral to acceptance of first appointment and follow up. The patient tracker forms the central point of reference for the twice daily integrated ‘huddles’ where all patients are reviewed and progress on coordinating the acute discharges is reviewed.
• Huddle system – Twice daily ‘huddles’ are touch points during the day in the form of a multidisciplinary team meeting attended by health and social care colleagues. All actions to enable the discharge to take place are assigned to a relevant lead according to the pathway. Acute representatives provide timely updates on medically optimised patients’ status and expected date and time of discharge from the site. The Home First team accordingly coordinate the D2A home assessment with all plans and dates of assessments documented on the patient tracker. Subsequent follow ups are coordinated in the same way prior to ‘handover’ to services business as usual processes. Robust admin processes and standard operating procedures (SOPs) are in place to ensure the quality of the information captured and that actions agreed during the huddle are followed through.
• Assurance reviews – Monthly assurance meetings and regular audits have been established to ensure patients’ journey through the Home First service and onwards into the community are safe and that care is delivered in a timely manner. “Stock take” audits review key elements of the service and look retrospectively at the patients supported home as well as the effectiveness of the processes in place
• Oversight – The Home First + coordination hub has oversight of all the teams involved in service users’ care delivery and their capacity to support the anticipated discharges. This includes Community Services, Adult Social care and NHS Continuing Healthcare (CHC) teams.
• Structured Sitreps – Twice daily Sitreps are completed by the Home First Coordination hub, providing an operational snap shot of discharge activity This includes referrals to all elements of the service, total number of discharges supported on the day and those anticipated over the next 24 hours and also the next 3 days. The Sitreps are shared widely to social health and social care colleagues, including acute and community staff/services. In addition to a helpful summary of the day’s activity, the Sitreps also allow forward planning for anticipated ‘blocks’ in discharges to be resolved first thing at the next morning’s huddle.
• Capacity management – There are a range of tools utilised to quantify, measure and manage the capacity challenges across the teams involved in the discharges, as well as any influx of activity from the local acute hospitals. The team use the twice daily huddles to assess current and predict capacity, based on expected discharges and scheduled work for the day(s) ahead. This provides a real time summary of system capacity to acute teams. The team use a ‘RAG rating’ system to highlight current capacity and actions to be taken based on demand – that is, a prescribed list of actions for lead services to take based on the number of patients referred in and if this exceeds a specific number.
• Escalation report – A daily escalation report is provided to system leads. This highlights capacity issues and challenges to discharges which require senior leadership to unblock. The report also offers a high-level summary of the number of delays experienced per pathway and why, which trigger a system response.

Outcomes

• Improved discharge planning – streamlined processes
• Integrated working by health and care organisations, avoids duplication
• Place based approach to patient flow
• Reduced length of stay for patients of Sutton
• Reduced number of stranded (7+ days ) and super stranded patients (21+ days )
• Closure of wards as care moves from acute hospital to community
• Care closer to home
• Joined up response to COVID-19 pandemic.