PROJECT NINE: Work on Delayed Transfers of Care
A London Borough’s delayed transfers of care of residents in acute hospital beds was running at twice the agreed target of 12. The health and social care system was complex, but current thinking was that the delays resulted from a number of sources in the system, including a lack of resource (in terms of both money and appropriate facilities e.g. long–term placements and temporary housing) and poor discharge planning process.
Specific Objectives
The PCT commissioners listed the following objectives:
• Identify existing discharge policies/procedures within the acute trusts.
• Identify and map existing processes both explicit and implicit, for all professional groups involved in the discharge planning process on the acute wards.
• Gather together the groups of professionals (who may or may not form a formal multi-professional team) involved in discharge planning to agree a process for ensuring that appropriate plans are put in place to enable the patient to transfer as soon as they are fit to do so.
• Formalise the agreed discharge planning process by including it in the acute trust’s discharge policies, ensuring that it is in line with guidance issued by the DoH.
• Identify whether further resource is needed (particularly in the social work teams).
Outline of proposal
It was proposed that there should be an initial stage of consultation to begin to address the first two objectives and engage with the different professional groups. This focused on the acute trust and a further project had recently started to track patients through the discharge process. It was essential that these pieces of work linked up with the proposed consultancy.
The next stage involved further work with the multi–professional team to create ownership and formulate action plans for change. Further consultancy input was needed to track and review changes to policies, procedures and working practices.
Method
• Consult with all relevant hospital and community teams: Minimum of 3 wards; Hospital SW team; discharge coordinators team; bed management; minimum of 2 community SW teams; hospital OT team. (2 hours per team)
• Consult with minimum of 3 consultants and relevant managers (1.5 hours per session)
• Workshop session with the multi–professional system to include preparation and delivery.
• Report on findings of this initial stage of consultancy
