One year on - positive impact of innovative hospital discharge programme revealed

A programme that supports people in Oxfordshire to leave hospital more quickly to continue their recovery at home, has shown significant benefits for residents since its roll out last year.

Discharge to Assess is a system partnership programme, involving staff from Oxfordshire County Council, Oxford University Hospitals NHS Foundation Trust, Oxford Health NHS Foundation Trust and Age UK Oxfordshire, working together to identify the best way of supporting a patient to leave hospital safely and quickly.

The latest figures demonstrate it has enabled 23 per cent more people to leave hospital compared to last year. In October, this amounted to 657 people going home from hospital through Discharge to Assess.

Councillor Tim Bearder, Oxfordshire County Council's Cabinet Member for Adult Social Care, said: "Nobody wants to stay in hospital for longer than necessary. Indeed, for some of our older residents, remaining in hospital for longer than necessary can have a huge negative impact on their ability to regain their independence.

"By working closely with health partners and organisations such as Age UK Oxfordshire, we've developed a service that supports people to leave hospital more quickly, enabling them to continue their recovery in familiar surroundings.

"It's an important part of our Oxfordshire Way vision, to support people to live well and independently within their own communities.

"In the first year, statistics show Discharge to Assess is having a positive effect for our residents while freeing up hospital beds for those who need them most."

The programme is based on national guidance and came into effect in November last year. It brings together experts in health and social care in Transfer of Care Hub meetings, which take place three times a day.

The team considers a plan for a patient to leave hospital, as well as any homecare support they might require, before they are well enough to go home, speeding up the discharge process.

By working with the person and their family, plans are then put in place to support them to leave hospital and return home as quickly as possible.

Tamsin Cater, Head of the Transfer of Care Hub at Oxford University Hospitals NHS Foundation Trust, said: "This system is good news for all patients being admitted into hospital, and we're really pleased with its progress.

"The outcomes for people recovering in their own home are far better than staying in hospital unnecessarily, and we've been working hard with our health and social care partners to make this happen wherever it is safe and appropriate to do so."

Under the Discharge to Assess programme, people are offered short-term, immediate care on the day they get home through a council arranged care provider. This can range from a short care visit to short term overnight (live in) support.

This has significantly improved hospital flow, shortening the average length of stay in an acute hospital setting from eight days to five days. It has also reduced the need for as many short stay hub beds used by the system, as personalised support is now being arranged for people within their own homes.

For people returning home through Discharge to Assess, 73 per cent of people have gone on to reach full independence following a period of reablement.

Karen Fuller, Oxfordshire County Council's Director of Adult Social Care, said: "While it's great to see the impact of Discharge to Assess on hospital flow, the real success is being seen in people's homes.

"By supporting people back into a familiar environment, with all their home comforts, we can take a far more informed approach to the goals that someone wants to achieve. This enables more people than ever before to regain the levels of independence they had before going into hospital.

"It's incredibly rewarding to see the difference the programme is making to people's lives."

Discharge to Assess forms part of the recently published Healthwatch Oxfordshire report, 'People's experiences of leaving hospital in Oxfordshire', which praises the effective way that health and care professionals are working together to help more people to return home with the support they need.

The report identifies that many people had a positive experience of leaving hospital, and that the majority of people felt safe and happy to be home.

The document also includes some recommendations, including improvements around the continuity and quality of care experienced by patients, clearer communications for patients and carers, and better support and identification of unpaid carers.

The report goes on to recommend the continued close working relationship between health and social care partners to further improve the hospital discharge process.

Dan Leveson, Oxfordshire Place Director at Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board, said: "It's relatively early days for Discharge to Assess but we're already seeing its benefits, helping people leave hospital more quickly, offering them an even better chance to regain their independence

"We recognise that improvements still need to be made to ensure everyone has a positive experience of being discharged from hospital.

"We thank Healthwatch Oxfordshire for the valuable insights we have gained from their report and look forward to continuing to work with health and social care partners to build on our early success."

An executive summary of the Healthwatch Oxfordshire report, including responses from health and social care partners, can be found on the Healthwatch Oxfordshire website.

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