Supporting integrated discharge teams is a crucial part of ensuring patient safety and optimising patient flow. We spoke to hospital, social and community care teams in Derbyshire about the reality of managing complex discharges.
We spoke to Binda Gill, Nina Smith and Trudi Jones from the integrated discharge team across Royal Derby NHS Foundation Trust, Derby City Council and Derbyshire County Council. The integrated team is focused on complex discharge planning as well as proactively managing the discharge process on a day-to-day basis. They shared their experiences of how they’re managing complex discharges and the ExtraMed Patient Flow is, effectively, a platform shared between primary, secondary, social and community care in Derbyshire.
Derby Hospitals NHS Trust introduced our ExtraMed Patient Flow system in 2013 to support bed management and help address winter pressures. Adaptable and intuitive, the Patient Flow system gathers clinical and other patient data and presents a real-time view of each patient, their location and status with respect to their care pathway. The system is accessible through several interfaces – including digital whiteboards, PCs, and computers on wheels – to input and display information.
Crucially, the system can reach beyond hospital walls and integrate admission, care and discharge processes right across Derbyshire. By the end of 2018, there were more than 8,000 users in the Trust alone and included everyone from consultants and dieticians to community users such as GPs, therapists, social services personnel, carers and intermediate care teams.
How the system handles complex needs
“Discharges can be complicated because some individuals have complex needs,” notes Binda Gill. “These include young homeless people, those with addictions, or with safeguarding needs, or who were formerly in prison.”
ExtraMed uses colour coding to offer ‘at-a-glance’ status reports on each individual’s journey through the hospital from admission to discharge. This means even complex cases can be scanned easily. For example, when a patient is discharged, their status turns green. On completion, data is transferred into the hospital’s e-case notes system. If an individual presents at A&E or is readmitted, all the discharge referral information can be quickly summoned on the system without staff having to search the archive for notes.
For complex or urgent cases, such as end-of-life, the ExtraMed system takes these needs into account and allows exception reporting and management. This includes a ‘Fast Track’ option that bypasses the admin hub to expedite the hospital discharge in certain cases. The system also generates a daily Delays List of patients medically ready to leave but haven’t for whatever reason, so they can be prioritised.
In the city of Derby, duty workers respond to anything that can be done on the day, with more complex cases being allocated to social workers. In Derbyshire, social workers pick up referrals directly. ExtraMed supports this by making allocation easy. When social services pick up a referral, the PDF created in ExtraMed is simply uploaded onto a separate system used within social services.
Within ExtraMed, the team can create ‘virtual wards’ outside of the hospital that enable patients to be re-admitted after discharge. This supports staff in updating their records while patients are being treated by the community team or in a care home but are still under the care of the Trust. It increases the visibility of particularly vulnerable or complex patients.
“Things don’t get missed because everyone can see where things have and haven’t been actioned, so processes keep moving forward,” says Nina Smith.
The benefits of integration
Earlier and better visibility for all teams with live views, access to current care plans
24/7 communication channels within and without the hospital walls
Reduced or no discharge delays
Faster action improves patient experience
Automated alerts for responsive care and intervention
More timely support means admissions can be avoided
No more wasted home visits as patient movements into hospital are logged
Flow of information means everyone is in the loop at the right time
With greater visibility and integration across organisational borders, Derbyshire proves that integrated health and social care is possible, even in complex cases.