Improving Hospital Discharge Into
the Care Sector

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Technology is enabling the radical transformation of patient flow across multiple health and care organisations in Lincolnshire. Working to support admission avoidance through pro-actively managing care to avoid unnecessary hospital stays, it also supports a planned and timely discharge from in-patient services into the community.

Teams now have a complete picture of information in real-time of caseloads, capacity, planned availabililty and capability for community services for discharges. Previously, organisational wide capacity was obtained by contacting individual teams and services. However, constantly fluctuating information quickly became outdated and the process time consuming and open to error.

The idea for using technology was first explored informally as part of a need to better manage patients during winter pressures in 2013/14. The system has been organically developed with Cambio PFM, who ran a series of workshops with key staff to review processes, those they aspired to and then configured a new system that would help them save time and streamline processes. Its roll-out was led by clinicians and non-clinicians at LCHS and was overseen and scrutinised by a multi-organisational urgent care board. At first, this solely supported admission avoidance, with the IT supporting a 'contact centre' – a single point of access for health professionals seeking alternative community based services.
The teams quickly saw how they could further exploit the technology, extending the solution into discharge planning. Discharge information previously held in a spreadsheet at the county's acute hospital trust was accessible to only a small number of individuals and shared with other organisations verbally – a time consuming and unrealiable approach. The team worked on a clear design that extended the patient flow solution further to create a managed view of the planned discharges easily accessible to all involved. The iterative and active design process is ongoing, with teams encouraged to feedback ideas for improvement as they encounter new situations.
Many benefits of this system are seen by the clinical workforce managing caseloads. They are no longer reliant on spreadsheets, face-to-face or verbal contact, and can ensure consistency as they all see the same real-time data.

This improved communication means teams can spend more time on clinical activity and work more effectively with colleagues in other organisations. Patients unaware of this behind the scenes work are benefiting from the smoother more seamless transition of care between services and providers.
Staff members are saving an estimated 20 minutes of calls per patient.