NHS England defines Discharge to Assess (D2A) as “a process that allows patients who are clinically stable to leave acute care, even though they may still need support after being discharged to their own home or another, permanent place of residence” (NHS England, 2016). Amidst the rising delayed discharge rates and a flurry of new schemes being developed, the Clarity Knowledge Management team conducted rapid literature review (full review available here) surrounding Discharge to Assess (D2A) to draw out key learning points as to ‘what works’ (and, ‘what doesn't’) from the perspective of patients and carers, hospitals and the wider system. Rooted in these insights, this blog highlights three success factors essential for an effective D2A scheme.
1. Effective communication between everyone involved, along the whole pathway.
Studies from Smith et al. (2019), Bhalla (2018) and Jeffery et, al. (2023) all suggest that effective D2A schemes can lead to an improved patient experience. However, the extent to which these benefits can be realized is severely limited if there is insufficient communication at all levels.
In a scheme in Kent, patients were sometimes uninformed about what was happening and why (Gadsby, Wistow & Billings, 2022). Similarly, as part of another (Smith et al, 2022), family members reported not knowing the level of assistance that should be expected or how the health and social care systems worked together which led to feelings of frustration. These findings epitomise how poor communication with patients and their families translates into negative experiences. Findings from a study in Scotland (Robertson, 2021) further support this, concluding that communication issues were the primary cause of many participants’ concerns with 40% of participants reporting feeling that they were not appropriately consulted about decisions and 35% of carers reporting feeling that they were left out of the decision-making process. Patient and carer frustration was also expressed through a supporting survey with the use of words such as "abandoned", "angry", and "disgusted".
D2A schemes have complex designs which should have effective communication patients at the heart with measures to support them throughout the pathway. However, research by Healthwatch (2022) revealed that over a third (35%) of patients were not provided with a contact number to call for further assistance after discharge. Poor communication between teams was also raised as a concern with examples cited of staff being disorganised, with support coming from people working in different teams across several locations and unable to provide enough all-around care. These studies’ findings epitomise the issues around communication, highlighting that an essential element of successfully implementing D2A models is to encourage communication among employees, patients, and various providers. This is supported by findings that communication between all parties strengthens procedures (Jeffery et al., 2022). Smith et al. (2022) concur, finding that effective two-way communication is required to create the ideal conditions for discharge. Attempts to improve the discharge of elderly patients from hospitals will be weakened unless this is addressed at a service level and through targeted patient information about what to expect during discharge assessments and after discharge.
2. Strong capacity, available in the community to both accommodate people and undertake assessments.
One of the advantages of D2A, according to Department of Health and Social Care guidance (2022), is that assessments in a patient’s home rather than in hospitals allows more time for the individual and their family or carer to inquire about support options and receive information in a way that is more effectively absorbed. However, benefits like this being fully realised are largely dependent on having strong community capacity.
A Social Care Institute for Excellence (SCIE) study found that a lack of familiarity between clinical professionals and some social care staff and services provided by the volunteer and community sector meant that some patients were left with fewer options for out of hospital support, impeding rather than enhancing flow in one scheme (SCIE, 2022). Similarly, a review of the D2A scheme in Kent found access to community nursing home beds to be a limiting factor to success (Gadsby, Wistow & Billings, 2022, p. 678). People waited two to three days for community nursing home beds, preventing patients who were medically qualified for discharge from being transferred and requiring some patients to make decisions about their long-term care requirements whilst still in hospital, which the scheme was seeking to prevent. The review also found examples where people could not be properly assessed due to community staff not always being able to give them the required support. D2A procedures that include moving patients into residential homes must take the capacity and capabilities of the community into account (Jefferey et a, 2022). To protect the continuation of D2A, system leaders must ensure that services have the resources they require, which means greater investment in social services and community services (Horton, 2022). If not, patients risk not having the support they need upon discharge. This is vital as hospitalisation has been found to exacerbate patients' emotions and increase feelings of depression and anxiety (Alzahrani, 2021). The findings of these studies highlight the need for strong cooperation across the NHS, social care, and the voluntary sector to ensure that D2A schemes are effective, and patients are provided with adequate support.
3. A focus on delivering high quality care.
Clarity’s literature review found that a focus on delivering quality care is essential to effective D2A schemes. Similarly prioritising the delivery of high-quality care throughout the entire discharge process is vital. A focus on delivering high quality care helps put in place the measures around the success factors necessary for an effective D2A scheme such as communication at all levels and a strong community capacity, previously explored.
Patient welfare and wellbeing should remain the priority throughout the pathway. There is consensus within the literature that patients should never be released at night and should always be kept informed about the next steps in their care (Healthwatch, 2022). Everyone leaving the hospital must have a comprehensive welfare check to ascertain the level of help they might require, including non-clinical aspects such as their physical, practical, social, psychological, and financial requirements. Given the pressure on systems to manage growing waiting lists and the needs of an ageing population, incorporating schemes such as D2A within the model of care will be increasingly necessary. The same Healthwatch survey found numerous instances of patients experiencing disorderly transitions from the hospital to their homes, some of whom were left waiting at home by themselves for assessments and services that failed to materialise. They had fewer "pop-in" visits than promised and had to take the initiative to arrange assistance when needed. Unfortunately, 82% of respondents did not receive a follow-up visit and assessment at home and almost one in five of these reported an unmet care need. (Healthwatch research, 2022). The task of managing aftercare at home shifted more substantially to the patient or carer than most expected. The lack of focus on quality care may contribute to figures showing that, according to a Health Monitor report, one in five (19%) patients felt unprepared to leave the hospital while some thought their departure was hurried. The studies summarised here demonstrate that a focus on delivering high quality care is essential to ensure that patients are supported throughout the pathway and have their care needs met.
Clarity has a breadth of experience in Performance Improvement services to make positive changes for the future. If you would like to learn how we can support your health improvement goals, please get in contact with Karen Smith, Quality & Performance lead at Clarity. You can also find out more about our quality and performance improvement services by reading some of our case studies.
References
Alzahrani, N. (2021) ‘The effect of hospitalization on patients’ emotional and psychological well-being among adult patients: An integrative review’, Applied nursing research: ANR, 61, p. 151488. Available at: https://doi.org/10.1016/j.apnr.2021.151488.
Bhalla V (2018) ‘Success of a “discharge to assess” model for medically optimised patients - having commissioned beds at a nearby care home’, Age and Ageing, 47(suppl_2), pp. ii25–ii39. Available at: https://doi.org/10.1093/ageing/afy028.54.
Gadsby, E.W., Wistow, G. and Billings, J. (2022) ‘A critical systems evaluation of the introduction of a “discharge to assess” service in Kent’, Critical Social Policy, 42(4), pp. 671–694. Available at: https://doi.org/10.1177/02610183211065028.
Healthwatch (2022) Our position on safe hospital discharge. Available at: https://www.healthwatch.co.uk/news/2023-11-20/our-position-safe-hospital-discharge.
Horton, T. (no date) Discharge To Assess: The case for continued funding and support, National Health Executive. Available at: https://www.nationalhealthexecutive.com/articles/health-foundation-discharge-assess-funding.
Jeffery, S. et al. (2022) ‘Does a discharge to assess introduced in England meet the quadruple aim of service improvement?’, Journal of Integrated Care, 31(1), pp. 16–25. Available at: https://doi.org/10.1108/JICA-02-2022-0018.
NHS England (2016) ‘Quick Guide: Discharge to Assess’. Accessed 1st September 2023.
Robertson, B. (2021) Rapid Response -Evidence synthesis: Discharge to Assess. Accessed 1st September 2023.
Smith, H. et al. (2022) ‘Reducing delayed transfer of care in older people: A qualitative study of barriers and facilitators to shorter hospital stays’, Health Expectations, 25(6), pp.2628–2644. Available at: https://doi.org/10.1111/hex.13588.
Social Care Institute for Excellence (SCIE) (2022) Hospital discharge and preventing unnecessary hospital admissions (COVID-19), Social Care Institute for Excellence (SCIE). Available at: https://www.scie.org.uk/care-providers/coronavirus-covid-19/commissioning/hospital-discharge-admissions.
