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Discharge Integration Frontrunner Programme: Dementia, deconditioning and discharge – improving care for people with dementia across an acute hospital pathway in Salford, Bury, Rochdale and Oldham

The Discharge Integration Frontrunner Programme was initiated by NHS England as a set of six national test sites to improve hospital discharge.

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Introduction

The Discharge Integration Frontrunner Programme was initiated by NHS England as a set of six national test sites to improve hospital discharge. The test site led by the Four Localities Partnership is a collaborative partnership led by the Northern Care Alliance NHS Foundation Trust (NCA) and local Place Based Leaders across Salford, Bury, Rochdale and Oldham.

The Four Localities programme specifically focused on Dementia, Deconditioning and Discharge (the only test site to do so), and through support from NHS England has redesigned care for people with dementia alongside addressing harm from mental and physical deconditioning. Whilst initially considering hospital discharge, it was recognised that admission avoidance and in-patient care were equally as important if the programme was to improve the experiences of hospital discharge.

The plan: aims and ambition 

The programme has two goals:

  • Develop new approaches to discharging people with dementia and complex needs from hospital, building on learning from The Oasis Unit on the Rochdale Infirmary site. 
  • Preventing and manage deconditioning on hospital wards through using a strengths-based approach and changing workforce culture, actively challenging discharge plans to improve outcomes.

Beyond traditional KPIs the programme took a visual approach to understanding harmful ward moves. Evidence showed that people with dementia spend eight hours longer in the EDs than people with a stroke or cardiac issue and 14 days longer in hospital. 

Discharge options were driving people into expensive D2A beds resulting in higher than necessary admissions to long term care. Community 2hr response teams and crisis mental health were not joined up, and there is no specialist dementia Intermediate Care or D2A provision. 

People experience waiting at various points, and when admitted are moved around the hospital multiple times, increasing their confusion and distress which the workforce are not well equipped to manage. Consequently care providers would often decline to offer a placement, thereby increasing the time spent in hospital. Family and carer experience was often negative as a result with one exception, this being the Rochdale Oasis Unit.

Implementation

The model has used Plan, Do, Study, Act cycles as a means of testing out ideas and initiatives, leading to adoption. This has led to a model focused on :

  • Admission Avoidance options - preventing and responding to a crisis
  • In-patient hospital stay – improving the in-patient experience
  • Discharge options – providing intermediate care that produces positive outcomes.

The model includes:

  • Integrated Neighbourhood Teams: who have a role in: identifying people with dementia, or those without a diagnosis yet displaying symptoms of dementia; identifying people who are in the midst of a situation developing into a potential crisis; and intervening to support people in a timely manner avoids an escalation and hospital admission.
  • Support to people with dementia who live alone: 24 hour care at home which is then stepped down over two to six weeks as an alternative to a Discharge To Assess bed. Support is provided through a combination of extended reablement and care agency, supplemented with assistive technology, and intermediate care practitioners.
  • Support to people with dementia who have family support overnight: responding within one to two hours and taking people from community urgent response teams, Emergency Departments and from hospital wards. This is supported by a community nurse with access to Mental Health support over the phone; and Age UK Oldham - who provide assessments, specialist dementia day care for up to three weeks – which enables time to assess and put longer term interventions into place.
  • Supporting dementia specific care in existing intermediate care beds: throug: training and supporting staff to engage differently; ensuring people with dementia receive rehabilitation in an intermediate care environment; and dis-establishing Discharge To Assess beds in care home settings.
  • Dementia specific acute hospital beds on existing medical ward:. There are now three units at Fairfield Hospital (Bury), Salford Royal, Rochdale Infirmary (this is a previous unit now 10 years old) with a fourth to be developed at Royal Oldham. Existing medical beds have been removed to create activity areas supported by Activity co-ordinators aiming to reduce physical and cognitive deconditioning. Direct admission to the wards from A&E with no further ward moves once a person with dementia is admitted to the ward. The role of a dedicated nurse with expertise in dementia (Mental Health Nurse, or Admiral Nurse) has a positive impact, with one day follow up in a community setting for up to two weeks after discharge.
  • Underpinning approach to managing and preventing deconditioning: Supporting staff on all wards to undertake activities that support maintaining daily activities such as getting out of bed and dressed, applying a strengths-based approach and challenging discharge pathways to support as many people as possible to return to their own home. Exercise and Independence Facilitators with a Sports Science degree have been trialled to deliver strength and conditioning exercises programmes targeting people likely to be discharged to an Intermediate Care unit. This improves their function to the point where they can return to their familiar home instead.

Enablers of change

Enablers to delivery of the changes have been defined as:

  • Leadership – at every level, with Board level metrics
  • Communication and engagement – workshops, system events, Carers engagement, videos
  • People not process – a focus on people rather than ‘flow’ or processes.
  • Viewing data differently – data science to show visual impact, and Trust dashboard
  • Redefining language – a deliberate shift supporting a change in mindset.
  • Training and Education – for the local workforce through a variety of routes.

Outcomes

Acute dementia units have reduced ward moves, and overall time in hospital, on sites where these have been implemented, for people with dementia. This ranges from a reduction of LoS of 4.49 – 6.9 days depending on the hospital site.

  • Reduction in number of ward moves for people with dementia by a third
  • Increased productivity equivalent to 8.8 beds across the FGH site.
  • Increase from 31 per cent to 78 per cent Return to Usual Residence on Rochdale’s Oasis dementia unit with dedicated nursing role specialising in older peoples mental health as opposed to generic MH Liaison peripatetic role.
  • A 100 per cent reduction in people being discharged to a care home/temporary care home with the family support discharge service
  • Only 15 per cent of whom admitted to a care home in the long term compared to 41 per cent of people using a temporary care home placement .
  • At 12-45 weeks post intervention show:
    • 68 per cent reduction in re-attendance to A&E
    • 64 per cent reduction in ambulance conveyance
    • 46 per cent reduction in re-admission to hospital.

Patient outcomes

  • 100 per cent of people (77 per cent of respondents) who have been previously admitted state the acute Dementia unit was an improved experience.
  • 65 per cent of patients seen by therapists on the FGH Dementia Unit have seen improvement in their Barthel score (function and dependency). 36 per cent saw an improvement in their Rockwood (frailty) score, with 57 per cent remaining the same and 9 per cent showing decline.

Financial benefits 

  • £5,640 per person cost avoidance to NHS based on avoiding A&E attendance and hospital admission against 19 day LoS national average.
  • £5,447 per person cost avoidance to NHS when attending A&E and avoiding admission only against 19 day LoS national average.
  • Reduced re-admission rate of 46 per cent 12-47 weeks post intervention. £7,486 per re-admission avoided based on 19 day national average LoS.
  • 38 per cent of people having a discharge pathway downgraded after the Exercise and Independence team intervened releasing the equivalent of 6.6 Intermediate Care beds

Resources

Visit Discharge Integration Frontrunner Programme for more resources, both written and on video.