Reduction in community therapy waiting list
Increase in patients referred to most appropriate service
Reduction in hospital average length of stay
A local care system was experiencing increasing challenges with its Discharge to Assess (D2A) processes, which enable patients who are medically fit to be discharged and continue their assessment and care in a community or home setting. At the same time, fragmented community pathways were undermining the delivery of timely, coordinated patient-centred care, leading to:
- Discharge delays and a disrupted flow of patients across the system
- Increased costs from an over reliance on intermediate care
The hospital COO and Director of Adult Social Care commissioned TN to baseline activity, develop a blueprint for a more integrated service, and implement a new operating model.
- Baselining the current state: Triangulated complex datasets and conducted operational immersion to build a comprehensive view of activity, workforce, and processes across the system
- Aligning stakeholders: Engaged over 50 key stakeholders through two workshops to establish a shared understanding of current challenges and agree priority areas for change
- Designing the new operating model: Co-designed a new operating model, including a Transfer of Care Hub, to streamline discharge processes by reducing touchpoints, clarifying roles and responsibilities, and shifting hospital resources into the community
- Supporting implementation: Rolled out the new model, including:
- Establishing a single point of access for community therapy
- Supporting development of a Patienteer app, enabling the sharing of live site management data
- Created blended health and social care roles, to improve integration and patient flow
- Streamlined discharge processes
