Since October 2013, an integrated discharge team (IDT) has been up and running in North Kent. The team aims to reduce admissions, ensure patients’ needs are proactively managed to reduce their length of stay and to enable patients whose medical conditions are stable to leave hospital in a timely manner. This example of a local initiative forms part of our managing transfers of care resource.
The IDT is multidisciplinary and consists of:
- Operational clinical lead – this post leads the operational team, supports the planning process, improves integrated care and monitors results informing future strategy and operational activity.
- Integrated therapists and falls service – physiotherapists and occupational therapists working together
- Specialist nursing services – proactively supporting patient reviews and joint assessments with the specialist teams in Darent Valley Hospital, both on the wards and within A&E.
- Discharge coordinators (nurses) – the nursing team work within A&E assessing and treating patients, and enabling same-day discharge where possible, in addition to supporting timely discharge from the wards.
- Pharmacists – all patients who need medical admission are seen by a team of doctors on the post-take ward round. The presence of a pharmacist on this round means that pharmacist interventions can occur at the time of prescribing. This also informs the pharmacist of patients’ care plans and predicted discharge dates, facilitating prompt supply of medication at the point of discharge. This part of the service has been shown to be effective in supporting discharge and it has been agreed that the pharmacist will also work at the front-end of the A&E, five days per week, supporting admission avoidance and timely discharge.
- Acute/community geriatrician – the aim of this post is to work across acute and community settings, working in A&E with the IDT, focusing on geriatric admission avoidance by carrying out a comprehensive geriatric assessment, providing prompt intervention and tailored support and discharge the same day.
- GPs – working at the front end of the A&E, they identify those patients who can be seen by primary care and discharged safely to primary care.
- Case management – additional social care practitioners have been recruited to work in the integrated discharge team.
- Additional psychiatric liaison – a specialist mental health assessment service out of hours and at weekends, based at Darent Valley Hospital, to reduce delays in treatment for people with mental health conditions.
Achievements within the team to date:
- multi-organisational work and multi-disciplinary work are much improved with a combined sense of purpose, better communications, sharing of information and data and a greater ‘can do’ attitude
- anticipatory care plans are being developed for patients with long-term conditions, dementia and repeat presentations at A&E
- dementia management support is much improved. The IDT now works with Alzheimer’s and Dementia Support Services (ADSS), as well as other agencies, to provide integrated support for these patients, thus avoiding admission. ADSS provide support up to a month after discharge.
For further information, read Case study: Kent – Operating an integrated discharge team
The Pioneer Team