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Addressing health and care’s highest priority – D2A and patient flow

The challenges associated with patient flow and safely getting people home from hospital continue to cause a choking point in the system. As a result, the health and care sector is focussed on identifying opportunities to reduce the amount of time spent in hospital for people that no longer require acute care.

The need for strategic planning around the discharge to assess (D2A) process is not a new requirement. Even prior to the impacts of Covid, the National Audit Office reported that delayed transfers of care rose by 31 percent between 2013 and 2015 and in 2015 accounted for 1.15 million bed days.

Getting people safely back home after treatment in the safest and quickest way possible – and helping them stay there – benefits not only the individual but also the system at large.

Getting discharge to assess right

From a system perspective, the D2A process requires effective operational-level integration and rapid joint decision making across organisational silos.  It needs to consider the ever-changing picture of demand and capacity across multiple pathways and organisations. When D2A works well, good decisions are made in a timely fashion, ultimately delivering significantly better outcomes for patients and reduced costs for the sector.

What is D2A?

Where people who are clinically fit for discharge and do not require an acute hospital bed but still need care services are provided with short-term, funded support to be discharged to their own home or another community setting. Assessment for longer-term care and support needs is then undertaken in the most appropriate setting and at the right time for the person. Commonly used terms for this are: ‘discharge to assess’, ‘home first’, ‘safely home’, ‘step down’.

Although the national D2A guidance was released and rapidly embedded at the start of the pandemic, the pace of this implementation has left many systems with the need and opportunity for significant improvement now. 

Moving beyond D2A to intermediate care

The aspiration in many systems is to move beyond D2A to consider a wider model of ‘intermediate care’ as the key next step. Intermediate care services are provided to patients, usually older people, after leaving hospital or when they are at risk of being sent to hospital.

Successful models of intermediate care require the delivery of health and care services that are wrapped around the person rather than siloed within individual health and care organisations. In that sense, they can be considered a microcosm of what integrated care systems (ICSs) are trying to achieve.

The aspirations of the sector for a better future state are clear and include:

A move away from the narrow focus on D2A to the wider framing of intermediate care.

Addressing the cultural challenges to system flow as well as process and system.

Enabling all the organisations involved in intermediate care – including those providing social care and community support – to see a shared view of demand and capacity.

Enabling the emergence of a ‘community pull’ model to get people home more quickly, rather than a ‘hospital push’ model, which often leads to delays.

However, the necessary first step in many systems is to get D2A right. That will then provide the foundations to move beyond D2A to intermediate care.

Taking the first step

The delivery of this vision will take time. And whilst it can seem daunting for system leaders, it is critical that we start the journey towards it. In response to this situation, Channel 3 engaged with the sector to clearly understand the immediate operational challenges that need to be fixed and to help define the potential next steps.

Through these discussions we have identified that most systems are not able to use information to support flow. This is caused by an inability to:

Channel 3 has subsequently engaged with several technology vendors to identify the best digital solutions to address this challenge. This has led to our new collaboration with Hospital 2 Home and a joint proposition which we believe will help many local systems take a significant next step in addressing the operational challenges associated with D2A.

The H2H digital solution, which has been co-produced with the sector and is backed by NHSD and the LGA, provides a single platform to capture, update, track and report on a person’s journey through D2A. When combined with Channel 3’s people-first approach to digital implementation, which ensures the solution is configured to meet the needs of local systems and become embedded in new ways of working, H2H delivers the anticipated benefits in a sustainable way.

To date, the H2H solution has delivered a 10:1 return on investment within 12 months of implementation.

If you would like to understand more about this solution and the local systems that are already benefiting from using it, please contact us now or read more here.

About the authors

Ralph Cook

Ralph Cook has over 20 years of consulting experience within the public sector, more recently specialising in designing and delivering complex transformation programmes across health and social care. In recent years Ralph has helped the sector pioneer thinking in the areas of demand management, sustainable change in complex systems, behavioural science and intermediate care.

Stuart Lindsay

Stuart has over 20 years of experience within frontline services and consultancy within health and social care. He specialises in delivering whole system transformational change through independence-focused demand management by embedding strength-based practice, enablers to independence such as technology-enabled care and system performance improvement.

If you would like to understand more about this solution and the local systems that are already benefiting from using it, please contact us now.

Call 0203 866 4838 or email info@channel3consulting.co.uk

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