A collaborative response to out-of-hospital needs

In the face of the extra pressures on health and social care during the response to COVID-19, NHS and other care providers throughout South Warwickshire came together to deliver a highly effective hospital discharge and out-of-hospital health and social care service.

Much of the new service integration is made easier because South Warwickshire NHS Foundation Trust (SWFT) already provides both acute hospital and community services, but the new ways of working have required a real commitment from all local providers and commissioners.

Hospitals, primary, community and social care, nursing and residential homes, and the voluntary and third sector have created extra community capacity, retrained staff to take on additional roles and increased support for people in their homes.

Implementing national guidance ‘at pace’

Tracey Sheridan, Associate Director of Operations Out for Hospital Services, South PLACE, Out of Hospital Care Collaborative, SWFT, has a foot in both acute and community ‘camps’. She said, “My role includes managing the complex discharge service and responsibility for transfers of care. Working regularly with partners across the system to improve transfers of care has meant we were able to implement the national discharge guidance at pace.”

Tracey believes that the pandemic response has given local organisations permission to remove the challenges to working more closely with each other. She added, “We were already chomping at the bit for greater integration and we’re now going full throttle. The COVID-19 response has allowed us to do the things we wanted to do anyway.”

Introducing new ways of working

Teams have been re-prioritising work according to the national guidelines and supporting each other to allow a greater focus on COVID-19 where needed.

The NHS Continuing Healthcare (CHC) team has been freed up to work more closely with care homes, picking up some of the work of the complex discharge team. This in turn has allowed the discharge team to focus on new ways of working including the development of a new pathway for medically-fit patients to be discharged from hospital quickly. These patients are now able to go home with follow-up visits in place to stop anyone falling through the cracks. Approximately 90-95 per cent of patients are now discharged to their usual place of residence each day, with 5-10 per cent receiving support from either health or social care.

There has been an increased focus on self-care, with patients and carers trained in areas such as self-injections. This has freed up capacity for teams to focus on the more seriously unwell patients. There has also been a noticeable increase in end-of-life care; in some teams this has increased by 30 per cent. The capacity gains from focusing on self-care are helping to accommodate this new demand.

Podiatry services have also stood down non-essential services, allowing the team to take on some of the leg care treatments of community teams and freeing up specialist community nurses for the more complex cases.

Rachel Briden, Integrated Partnerships Manager, Targeted Support and Integration, Warwickshire County Council, explained: “The hospital social care team has changed its way of working to support discharges on the same day for patients needing a package of care, by strengthening its work with colleagues in the local authority reablement service.

“The reablement service is not only continuing to provide therapy programmes, it is providing the initial one to three days’ support for customers who will then transfer on to a domiciliary care provider. The hospital social care team has also worked closely with residential care providers to enable patients to move smoothly into a care home to meet their needs. Domiciliary carers can now request a clinical assessment directly from the community service, reducing the pressures on GP practices.

“We are really starting to see how all the new ways of working have improved the flow within the hospitals and the outcomes for patients; data we have from late March to mid-July shows how the new process has led to a decrease in the number of stranded patients, which should be sustainable going forwards.

“We have worked together to re-skill and re-educate our teams to create capacity in the areas where it is most needed,” added Tracey Sheridan. “The flexing of teams across the system is proving to be a real strength”.

Supporting care at home

Telehealth was already being trialled for care homes before the arrival of the coronavirus and while the full project has been put on hold by the homes involved in the pilot while the partners deliver the urgent COVID-19 response, the ability to provide remote support from health specialists and online training to care home teams to support safe discharges has been invaluable.

Rachel added: “The health, social care and third sector services such as Age UK have really come together, linking with our shielding hubs to make sure anyone in the vulnerable cohort discharged home gets the support they need. As part of our COVID-19 response, patients discharged home under Pathway 0 (no support) or 1 (with support) are offered a follow-up welfare call from Age UK to connect them into local support.”

Ensuring a consistent response

Warwickshire is served by three acute hospitals across five district/borough council areas and one county council, and teams have worked together to deliver consistency and best practice throughout.

Rachel said: “We worked on ensuring our local links and patient pathways meet the requirements of the national guidance and are clear to everyone across the system.

“Looking forward, we’re now focusing on our recovery and starting to pull together a longer-term improvement plan, understanding and building on the benefits of the changes we’ve made”.