Barnsley Hospital NHS Foundation Trust, working collaboratively with community partners, took the decision to implement a Discharge to Assess (D2A) model following the release of the Hospital Discharge Service Guidance in March 2020. To progress the change with immediate effect, services made overnight changes and took on additional roles in order to support the discharge to assess pathway as described in the guidance. These changes included:

• Temporary redeployment of therapists to work within the community to complete patient assessments within their own homes rather than in a hospital environment
• Social services completed assessments within patients own homes rather than a hospital environment
• Barnsley Healthy Lives supported the service with a follow up call 24 hours after discharge
• Changes to the roles for completion of fast tracks for end of life (EOL) patients
• Implementation of a discharge hub to work 7 days 8am to 8pm, to identify medically safe for discharge (MSFD) patients and to allocate patients to appropriate discharge pathways
• Change of placement structure – change from permanent beds to assessment beds.

Structure and pathways

The D2A implementation followed a project structure to ensure appropriate governance and escalation reporting routes were maintained throughout.

For the implementation to be successful, the pathways were split into the following discharge pathways:

• Pathway 0 – Non-complex discharge
• Pathway 1a – Reablement, Social Services, Volunteer, Warmer Homes
• Pathway 1b – Acute and Community Therapy
• Pathway 1c – End of Life care (EOL) and Fast-Track
• Pathway 1d – Medicines Management and Nursing
• Pathway 2 – Intermediate Care
• Pathway 3 – 24-hour care placement (permanent or temporary) (NB: The Hospital discharge and community support: policy and operating model notes that Pathway 3 is for those who ‘are likely to require 24-hour bedded care on an ongoing basis following an assessment of their long-term care needs).

Each pathway was given a workstream lead to be the key individual to implement and report back progress to project task and finish groups. A monthly steering group was set up to provide direction and guidance, which then reported progress to a system wide project group. It was clear after three months that the changes to discharge pathways had had a major beneficial impact on patient outcomes and experience. Therefore, it was agreed at an executive level that a permanent model would be developed. The permanent model supported the sustainability of the changes in working practices the service had made to implement D2A pathways. The development of these pathways included:

• Permanent implementation of a discharge hub to work 7 days a week 8am to 8pm, to identify medically safe for discharge (MSFD) patients and to allocate these patients to appropriate discharge pathways.
• Pathway 0 – Single point of access nurses to continue patient follow up calls 24 hours after discharge, replacing Barnsley Healthy Lives in order to sustain the service. This service now has assurance with a registered nurse completing phone calls with decision making responsibilities.
• Pathway 1a – Social worker services to complete all assessments within the patient’s own home rather than in a hospital environment
• Pathway 1b permanent changes:
  • Redeployment of occupational therapists to work within the community to complete patient assessments within patient’s own home rather than in a hospital environment.
  • Incorporated changes to Reablement Services to support joint assessments with therapy staff.
  • A social worker allocated for Pathway 1b patients
• Pathway 1c – Specialist EOL nurses to complete the fast track paperwork rather than a medic to support EOL pathways.
• Pathway 3 – Allocated social worker to place all patients in short-term assessment beds.