A fully integrated ‘discharge to assess’ system for returning patients home safely from hospital has been implemented in Swindon, as part of efforts to bolster community services in response to COVID-19.

Community nursing services responded alongside colleagues from the acute, community therapy, social care, voluntary and private sectors to create the new model within just two weeks.

The work focused on identifying acute services that could be effectively moved into the community, and the partners have delivered integrated care solutions that had been discussed for some time.

The model means that patients sent home for assessment are seen within 24 hours and can step up to a discharge to assess bed in a care home if needed.

Shifting staff roles

Jo Williamson, Head of Urgent Care and Resilience at Bath and North East Somerset, Swindon and Wiltshire (BSW) Clinical Commissioning Group (CCG), says that staff and volunteers from all backgrounds have been trained to undertake duties beyond their normal scope, allowing more flexibility in care delivery.

“The heads of nursing and therapy across community and acute care, social care and hospices came together to look at the skills each team had and where they could best be used as part of the pandemic response,” she explained. “They then ensured the training was in place to give staff the skills they needed to take on new roles and that individuals were confident to do so.”

As well as moving therapists into the intensive care unit to carry out basic nursing tasks, the teams looked at acute interventions which could be safely moved into the community with the right support. In addition, many of the social care team in the hospital have been moved out into the community, working with the Live Well hub (Swindon’s central point for volunteers).

Podiatrists and domiciliary care agency teams have been trained to deliver basic wound care at home through ‘on the job’ training from community nurses.

A fantastic response from staff

Jo said: “People have been fantastic, offering their services rather than being asked and taking on extra responsibilities with professionalism. Staff have been working additional shifts or changing shifts, sometimes at the drop of a hat, and have willingly been constantly on-call. Teams have also been crossing the boundaries of what would historically be considered a ‘social’ or ‘health’ care task, working together to reduce the numbers of staff going into someone’s home. Our HR team is now looking at workforce planning alongside council and voluntary service colleagues, dealing with issues such as staff indemnity and making sure staff have all the support they need.”

The Live Well hub and community navigators help ensure home environments are ready for people to return to, for example by arranging equipment or delivering food parcels, and make sure people have arrived home safely.

Facilitating integrated care

A new system flowchart has been developed that incorporates all services and contacts, so staff from all sectors are now following the same discharge to assess process, reducing time and duplication and improving efficiency.

In addition, the community nursing service’s single point of access has been adapted to create a discharge hub that links the acute, community nursing and therapy, social care and voluntary sectors together, to facilitate the quickest, safest patient transfers possible.

“It’s been so helpful to utilise what we already had in a different way, and we’re now looking at permanent colocation as a result,” said Jo.

The number of Swindon patients discharged through the discharge hub and referred to the community nursing service or the community intermediate care therapy teams increased from an initial 22 in the week commencing 27 March 2020, to 49 in the week commencing 24 April 2020. This focus on timely and safe discharges has helped increase bed capacity within the acute hospitals.

Supporting care homes

A new care home cell has been holding virtual meetings, initially daily, to understand what support care homes need. This can include training, end of life care support, general support for residents, including those with COVID-19, and help with any outbreaks. The cell now meets twice weekly and includes representatives from the borough council, CCG, community services, hospices, Public Health Swindon and GPs among others.

A checklist was created to decide on priorities for support, and as a result two care home coordinators are now in the process of working with homes for older people on issues including PPE and staffing. Two environmental health officers have also been trained to support homes in techniques such as donning and doffing PPE, and hospices are offering bereavement and psychological support to care home staff.

“The feedback has been brilliant,” said Jo. “Nearly all 24 homes have been visited and the cell is now picking up similar work with learning disability and mental health care homes.”

Making a difference

“When we first created a surge plan, only 9 of the 24 older people’s homes were accepting referrals,” said Jo. “Now over, 75% are open to referrals.

“We had been talking for a long time about the need for more integration, and it’s taken a pandemic for us to do it; our early process data is really encouraging in terms of sustainability of the improvements we have made as a result of COVID-19. Recognition must go to all the staff – frontline, support staff, managers and exec teams. Everyone’s support has been amazing and without it we couldn’t have achieved so much in such a short time.”