Discharge to Assess: Where the rubber hits the road

There are seven key steps to generating traction and improving the discharge-to-assess pathways. These are a mix of technical development in respect of discharge-to-assess (such as the establishment of agreed patient strata) and the generic challenges of change management (such as engagement, communication, and skills building). The first 3 phases (which are the planning phases) will be broadly sequential but the delivery phases can be run in parallel, as the figure below indicates:

1. Establish a core guiding coalition: build a small group with representation from the acute, community, and social care teams who will act as the core accountable team.  This team will guide the program to ensure time and resources are well spent.
2. Understand where you are and why, in order to build the local case for change, including:
   1. Maturity model completion:  complete the self-assessment complete the self-assessment of the Akeso discharge-to-assess maturity model to show where the current system is already fit-for-purpose and where changes need to be made
   2. Internal analysis on “no right to reside” and other key metrics (such as risk adjected length of stay, and elective and cancer waitlist variation) to give additional local relevance
3. Define the overall model of discharge-to-assess which best suits your location, given the NHS England guidance, known exemplar case studies, and the results from the maturity assessment, including:
   1. Patient stratification: be clear on which patients fall under the category of relevant for discharge-to-assess and how/when they are highlighted
   2. Workforce models: with community and social care partners, develop a sustainable workforce model which meets local population health needs and is achievable with local resources
   3. High-level process: agree what the high-level discharge-to-assess process is which balances discharge efficacy with clinical risk
   4. Technology aspirations: be clear on where technology will help (with both current and potential future systems)
4. Launch the program of change: take the time to engage with a broad range of stakeholders to lay out the overall aims of the discharge-to-assess program and how it contributes to the aims of the organisation, including:
   1. Vision expected outcomes, and expected timelines: establish what success looks like from an outcome perspective (for example, number of patients remaining in the acute setting with no right to reside; 7-day re-admission rate
   2. Leadership team & resource: ensure that there is sufficient resource ring-fenced to deliver and manage the work, and that senior leaders are actively supportive
   3. Govern and track effectively: embed discharge-to-assess governance within the existing board and directorate mechanisms to ensure its visibility
   4. Communicate plans and progress
      
   5. Establish portfolio of work: the maturity matrix and case study examples will suggest a wide range of work to be done. It’s important that any portfolio and phasing is chosen which reflects the need and resources available, including:
      1. Pilot and refine: choose 1-2 specific patient groups or services on which to pilot the design where there is both a clear need and support for discharge-to-assess; learn from these pilots and moderate the initial designs as necessary and remember that “getting it right first time” doesn’t apply in this situation! Learning and adapting is part of the process. To aid this, you may want to instigate regular learning cycles (such as Plan-Do-Study-Act) and daily management meetings
      2. Embed and roll-out: broaden the scope of patients and services for whom discharge-to-assess is available, building on the learnings from the pilots (in 1 or 2 further phases)
      3. Business case development: when investment is necessary, put together a robust business case (using recognised approaches such as the HM Treasury 5-case model)N.B. when engaging in technology-driven change, it is very important to ensure that practices are “digital-ready” before they become digitised so take the time to improve ways of working before the technology is available. It is value destroying to embed poor current practice within a new system. Many organisations, therefore, go through two phases of transformation: pre-tech and post-tech availability
   6. Train, support and reward those involved in delivering this new way of working. The pilots will establish local standard methods and learnings. These should be documented and shared with groups involved in subsequent phases of roll-out. The pioneers who drive the change should be given the reward and profile that it deserves.
   7. Communication progress, learnings, and successes, including regular broad updates and particular highlights. Appreciation of the efforts of everyone involved could be included within monthly and annual recognition systems. 

Keeping people healthy and returning them to their usual home after a hospital spell is a key ambition for all those involved in health and social care. There is an even greater imperative to do so given the pressures on the system now (be they workforce, elective backlog or capacity constraints). Discharge-to-assess, enabled by technology is one of the ways in which we can work together to ease this problem. Many organisations are already making this work. We hope that these four articles can encourage more progress for the benefit of citizens and health and social care workers alike.

For a free Discharge-to-assess consultation, please contact us for an initial conversation with our consultants.