Durham: multi-disciplinary multi-agency discharge teams

Following a review by the Emergency Care Improvement Programme (ECIP) in October 2016, County Durham and Darlington Local Area Delivery Board has implemented a system-wide set of changes to improve performance. This example of a local initiative forms part of our managing transfers of care resource.

Wherever possible, people are enabled to access primary prevention through universal services, facilities or resources which promote wellbeing and help avoid the development of needs for health and/or social care services.

For those who need support, proactive case management focuses on standardisation of care planning, risk stratification and risk management, and the development of emergency or anticipatory health care plans.

MDT meetings involve GP practice teams, district nurses, case managers, social workers, therapists and mental health services for older people, with support from specialist nurses, mental health, podiatry, pharmacy, diagnostic services and the voluntary sector where necessary.

Where there is a change or deterioration in condition, specialist assessment and support is offered through rapid access clinics and ‘front of house’ frail elderly teams, which aim to prevent avoidable admissions and either maintain the patient in the community or arrange a planned admission; linking in with intermediate care, domiciliary care and reablement as necessary.

If a patient is admitted to hospital, the integrated discharge management team focuses on home first principles, and liaison services link with medical, surgical, orthopaedic and mental health staff as required.

Elements of the system-wide approach, which have seen an impact on reducing delayed discharges include:

  • investment in reablement – this has made a significant difference and is the default offer wherever possible to facilitate discharge and avoid unnecessary homecare packages
  • discharge to assessment arrangements are in place with the care sector and community health providers; with assessments undertaken outside hospital in people’s homes, extra care, or reablement beds
  • work undertaken with care homes, including matrons from care homes carrying out in-hospital assessments
  • acceptance of assessment by ‘other’ professionals. Plans are in place to develop a brokerage service to facilitate hospital discharge for people who have no one to assist them – whether privately or state funded.


Elaine Criddle
System Wide Operational Programme Manager
County Durham and Darlington Local Area Delivery Board

This case study is an example of the High Impact Change Model (Change ): Multi-disciplinary teams.