Countersignature Hospital Discharge Made Easy

Esign hospital discharge

hello thank you for your patience welcome to the esup webinar on the quality hospital discharge training program by Lucy presented by Lucy Pass field discharge pathways project coordinator from the london borough of camden first we have just a few simple housekeeping points this session is being recorded and the recording will be available to be on our website shortly all attendees are muted to avoid background noise during the recording at the end of the presentation there will be the opportunity to ask questions if you have a question please use the raise your hand option in the panel on the right hand side of your screen alternatively you can write your question in the question section on the panel during the Q&A sections we will unmute you to ask your question in person thank you and I'll now hand you over to Lucy Thank You Lucy so thank you Paula hello hi um thank you for introduction I am a project officer and I work on the better care program discharge pathways project for the london borough of camden and just to give you a little bit of background about my experience so I don't I don't come from a clinical or social care background so do excuse if I've incorrectly used any health terms and I'm here today to talk about why and how we develop and ran and interprofessional cross agency training program to improve the quality of hospital discharges and transfers of care in Camden so this first slide here is really a bit about the why we decided to run this training program why we thought it was a priority to set up program in this area so just to give you a little bit of background about the delayed transfers of care situation in Camden and Camden is a inner London borough and one of our big problems is a lack of available care home places in the borough and we've got two big acute hospitals which in the Royal free and the University College Hospital and in the north of the borough we offer we see some very high rates of admissions of the over 75 age group primarily because that's where the care homes we do have are located so um so in 2014 and 15 we had below comparator Barbara average delayed transfers of care rates where we had higher than average adult social care of tribute of or AIDS and actually I've just looked at the 1516 provisional figures just for before preparing this and actually saw that we now have in the borough one of the lowest rates for adult social care tribute of all delays in our comparator group and actually a very low overall all right so I can't I can't put that at the door of this initiative we hadn't got this established in during 1516 reporting time but hopefully we will see the impact in the next year's figures and we did have some other initiatives that we instigated this last year to bring those rates down but so in Camden we also have employed within situated within the council but employing employed across the whole system health and social care system we have a small whole systems team and it's our job to work with the trusts and the care providers to try to keep down the delayed transfers of care rates and to try to ensure that we have a good robust discharge pathways for patients in the borough and one thing that the whole systems team do is oversee the discharge alert process and that's like this Quality Assurance process for the hospitals and I don't know where maybe you have a similar process in your areas it's for those who don't it's just basically where health and social care professional like district nurses or social workers can report unsafe discharges or discharges which haven't followed the best practice so we received the alerts and we send them on to the hospital's responsible for the discharge for an investigation and a response which should include some organizational learning to try and prevent these issues occurring again so we were seeing issues coming up with poor quality discharges which often resulted in emergency readmissions for those patients and as I mentioned some higher than average adult social care attributable delayed transfer of care rates so my manager the whole system's coordinator really was the one who came up with the idea of having a whole systems training program and the idea was to try and improve the quality of discharges and embed the best practice into discharge planning and transfers of care and we also wanted to try to reduce the risk at transfer points along the pathways by bringing the professionals together to try and overcome these barriers so to do this to really make the training interdisciplinary and cross agency so the aims of the program were refined down and I've put them here on this slide so as you can see our to educate and reinforce to staff how to achieve high standards of discharge planning and transfers of care across the whole system to put the patient at the center of discharge in order to pride safe and positive discharge experience to approve the discharge pathways for hospital patients and really where possible to involve service users in the planning implementation and possible delivery the training so it's also it has been funded by the better care it's called the better care program fund which has actually which has been very helpful in that it has meant that we can offer the training places free to any attendees who are working in discharge in Camden really across the whole health and social care system so these were the outcomes we would hope to have seen from the training but I'll talk about these a little bit more again I'm going to talk about the evaluation at the end but we would basically hope to see in a reduction in the number of discharge alerts completed by the healthcare professionals to help demonstrate where the quality has improved the quality and safety of discharges we would want to be able to see earlier discharge planning this hopefully would lead to a reduction in emergency admissions and we would see service users return to optimal independence and activity in the community so my manager put together the bid and submitted to submitted it to the better care program and it was successful and then she was then given the go-ahead who recruit me and get started on the program and so this slide is a little bit about the how we went ahead and developed the program so I was employed to lead on the development of the training program and so from the outset the plan was to develop a collaborative whole systems program with all stakeholders involved and that was included the hospital trusts care providers voluntary sector council adult social care staff and all the service users and so to do this we started with forming a training planning steering group and that had roughly five representatives on it one from each of the stakeholders and we tried to bring in service users views on the steering group through the voluntary sector who supported them in the community so for instance Age UK and Camden carers to active monetary sector organizations local to us and we had the older persons Commissioner as well we had ideally actually wanted to have service users themselves sat on the steering group but in the reality and practicality was it was difficult to to find people who are willing to come along and able because with quite frail and elderly people difficult for them to come to steering group meetings so to get round we're trying to try to bring in service users opinions I held some focus groups so I have two focus groups with individuals whose discharges are considered the most complex and the groups who are most likely to get delayed in hospital so that was so frail older people and people with mental health issues and it kind of riddle I'm trying to show in this in this filter diagram on the left here so that's all the different factors that influences a training program content all that information to filtering down into the the training program so the steering group met regularly to steer the program and I busied myself in between meetings on going off and developing the program some people were keen that the program was really aiming to change behaviors of the staff and so we decided to include an interactive theatre session as part of the day as a way of really sort of challenging people's biker intent already know and their behaviors and their assumptions and getting them to modify them so we were really fortunate to work with a great theater company called geese theatre company and their charity who were willing to take on a topic of hospital discharge so we formed a working group of different senior professionals to work with their artistic director to shape some suitable scenarios and know what so when I say they are an interactive theater group the attendees aren't asked to come up and roleplay the geese theater group have this it's great to what they call non didactic technique with a break in a scenario at key points and pose questions to the audience and then facilitate small group discussions and feedback what they have heard so I don't know if you've seen one of these sort of types of the other groups in operation actually they're a very effective way of getting a message across to people people can be really involved they can participate quite fully because they don't feel inhibited and actually from our evaluation we found it's something that had a really strong impact on people so one of the risks for the training program was was lack of buy-in from the stakeholders because I do I don't really do think that to make a very successful day you really need staff to attend from all the different agencies across the system and for them to come and learn together so we need to all the stakeholders really need to share their knowledge and learning resources as part of the day and I must say there was a little bit of initial reluctance from some areas because you are bringing people together from with very different perspectives about about how a discharge occurs and some you know some history about what can go wrong and some you know has working relationships which which you know not always straightforward so and so a bit of reluctance to overcome and I just overcame this by just keep keeping on talking up the day and building some credibility for it so they're actually eventually no organization really wanted to be excluded and actually what I found was that the people who were initially a bit reluctant actually once you once they overcame that you got past that with them but they weren't actually very passionate and enthusiastic and knowledgeable areas but they had just maybe were a bit frustrated about some of the ongoing problems and maybe a bit skeptical about what training could really achieve in this area but bit by bit the content came together and so eventually we were ready to run a pilot day and we ran that in April of this year with twenty attendees from a range of sectors and levels of seniority and actually was really useful to run a pilot day I found as it gave me a chance to gauge people's reaction to the content and presentation of each session and make changes to the structure of the day to reflect their feedback and actually did make several changes to the flow of the day the running order of the sessions and the session content as a result of their feedback one example was that we originally had patients and carers speaking in person at the front of the group about their discharge experiences and their their negative experiences but we realized that this was a bit unpredictable as people said the things that we weren't expecting them to say we thought it'd be better to record interviews with the patients and carers and edit this into a video and then show the video plus also you then didn't have for the problem of trying to coordinate people attending on on different dates and again as I said there some of the individuals whose have got complex discharges are people whose health might not be robust over a long period so it would be difficult for them to keep attending and do something it's quite emotionally draining as well for them so the improved training day was then promoted widely across each of Camden's trusts through key contacts through Camden Council with targeted emails and a blog and to home care and community care providers via strategic commissioners who are located within the council but have contacts out in these organizations and as as I mentioned earlier because there was no charge for their day because it had been funded by the better care program actually we've got a really really good sign up and people were really keen to come so I think that the fact it was free did help so so then we ran the program and here on the left is the final program from our most recent day which the attendee feedback suggested work best and if you can see it's quite tiny writing but in case it's too tiny for you we have the first session that covers covered best practice on discharge planning in the hospital and that was delivered by some of the senior discharged staff from alternating from both from up to pick a cute hospitals then we had a session on discharge planning options within Camden and that was delivered by again senior professionals who are running the Community Services and then after lunch we had the theatre group and they're facilitated scenarios as I mentioned earlier and then we had the video of patients and carers talking about the impact of goods and poor quality discharges on their recovery and then that was facilitated so we could sort of look at some of the issues that they were raising and why they might be thinking and feeling the things that they felt during their discharges and where communication had been poor for instance and how that led to their the perception the overall experience for them so that was that's very that's very interesting thing to look at and then to our final session of the day was the voluntary sector community services talking about what they can provide Ave during and after hospital discharge and the the two big voluntary sector organisations that we have operating in Camden are Camden carers and the British Red Cross so we tried to mix up different delivery approaches to accommodate a range of learning styles so for instance their discharge planning option session was run as a case study problem-solving activity whereas the video and learn foot allowed for visual and verbal learning so we ran three training days over the course of three months and trained 102 people and staff attended from a wide range of organisations across across Health and Social Care so that included from the acute and the non acute hospitals the London the adult social care staff from the count so for home care providers Mungo's and Mental Health Foundation Trust actually that that all those staff came together and learn together in a interdisciplinary cross-agency way it was a really successful aspect of the day because there was a lot of cross learning between going on between people which again I'll talk a bit more about talk about an evaluation but but um eighty percent of attendees fed back that they found it useful to train with all the individuals from other organizations and in the end each day was was fully booked with a long wait list so it was it was a very successful day each of the days were so now I'm going to talk about about evaluating the training day and you know what Camden as a borough has really got from training from training staff in this area are you evaluated using the Kirkpatrick model which is shown here and try to evaluate in alignment with the different tiers here so the lowest tier it was looking at the reaction to the day so asking people what did they think of the content and the activity levels the knowledge they've got sort of thing so evaluated on that level and then we the next tier is about a transfer of learning so we asked attendees to rate their Norwich discharge for the day and after and on average over the three days there was a 40% increase in attendees rating of their knowledge and just trying to help embed the learning I really changed the workplace practices we ask the attendees to questions at the end of the day firstly about they take the learning back into their workplace and then second question that did they feel able to change their workplace practice and if not how could we support them to do this so we wanted them to really think about what they could specifically do in their roles and start certs on visualize themselves going away and doing it so then the next tier of evaluation was looking at the behavioral changes of the attendees so I conducted some interviews four to six weeks after training with a cohort of 10 attendees to look at really look at the impact of the day on their workplace practice and I would say generally in summary different professionals from different sectors learn different things so it depend on their role in discharge and also their seniority and their background knowledge but there was some common themes - - that - their behavioral changes and I've listed them here and one thing I found very interesting was that some of the learning was as expected around the improved knowledge improving the processes but actually a lot of it was about slightly unexpectedly about people's changed attitudes to discharge planning and so I thought feeling of empowerment and focused they then got for them to be able to go away as individuals and look to see what they could do to improve their general area so I have to say that was what particularly impressed me that the things people had done and gone away and done which I will I'll give you some examples shortly but yeah so the first theme was around improved understanding of the different discharged pathways and the roles different professionals having them somebody summed it up by saying now I know who to contact and how to contact them which save some time and prevents mistakes and several of the interviewees mentioned they found this one person said they had not received any training around discharged only admissions avoidance so it was helpful to them to understand the whole of the patient's pathway into and out of hospital another person said it did help them come to terms with some of the difficulties with this challenging area and I thought was quite interesting from a community-based social work found so that they actually found it quite intimidating to go into the hospital environment and assert himself as a professional because it could be quite an intimidating environment wasn't a familiar environment to him necessarily but actually it sort of by having an insight into how a hospital ran it gave him increased confidence to be able to stand up for his views to make sure that discharges were safe so some of the attendees have been able to flow and share this organization information sorry throughout their organizations via team meetings again which was something we asked people to do where possible the second theme was around improved awareness and importance of placing patients and carers at the center of discharge planning actually one interviewee commented he would may make sure his on outcomes were client focused one discharge sister said that she was making sure she was holding her family meetings at the outset of discharge planning and one social worker had said that he was because he found patients often unable to speak clearly about their discharges he was making sure he was speaking to family members care is about the discharge planning so I mean what's new this was a very important very important the point that we wanted to get across to people to make sure it was a patient-centered day and you know to really really make sure it was a priority that people were communicating well with patients and carers the next theme down.we is improved communication with all staff across different agencies at you at the start of the day we asked people to list the challenges that they found with their roles and this was miscommunication with staff from different organizations was what everybody without fail put down as their biggest challenge so actually this was a really really interesting area that has improved people's behaviors because several interviewees said they found it useful to just put faces names to faces and help them work more collaboratively several people said that they have got a better understanding of the priorities and focus of others and the constraints of the systems that they were working within so for instance at how social workers agree funding for care or how the pressure for hospitals to discharge promptly and to the interviewees I spoke to had subsequently invited staff from other agencies that they had met at the day to come and speak at team meetings about the services they provide actually I was in a meeting recently and housing colleagues at a council mentioned they had started outreach work with the hospital discharge team to try to identify people who are at risk of readmission due to their housing conditions and they said no that was on the basis that they got a had an awareness of you know that these discharge teams existed in the hospitals which they hadn't really really realized before and then had started to think along those lines this was some examples of going back to sort of giving people a sense that they songs of empowerment that they can start to look at their areas and see what they could do to try and improve quality hospital discharges so the next point down is talking about is about better awareness and ability to anticipate identify earlier potential discharge issues and plan accordingly so a good example of this was an attendee who worked for Mungo's who said did change the way that the Camden Mungo's and and assessed clients because they were had a better awareness of the types of issues that may prevent people from moving moving on successfully into a Munger's have some step-down bed so prevent people moving out from their step-down beds so they can people they were now looking to I try and identify those issues earlier so things like a sink lighting concerns or social care needs and take action accordingly where they did identify those those challenges next point down it's talking is talking about more knowledge of the assessment process and discharge notification process so this wasn't sort of just about knowing what information was relevant to put into the referral forms and the notification forms so that was saving people time because previously information might have been missing that was being included and somebody said that there they understood them expectations around the timeframes - for these for these forms that they could actually prevent delays but they could they could start these processes in a timely way we provided quite a lot resources for attendees so information about the different community services that were were speaking at the meeting and referral forms and some best practice guidance and I think this was useful again for attendees to take away from the day to have to refer to nationally some people mentioned that they had shared them in their organizations when they got back in the training day the last point is about better understanding of the voluntary sector services on discharge so one interviewee was now referring service users to the British Red Cross for helping getting them to and from appointments and actually the British Red Cross had new referrals which on the back of the training day so that was very useful again for everyone to know more about what support was out there and how it works exactly to be able to support particularly with clients and patients who don't necessarily trigger the threshold for proper social care so for social care support but maybe still do have care needs and they could be supported by by the pancha sector instead so on to my last slide here which is me some of the conclusions that I've drawn from from running these developing the program and running these days and some of the recommendations I would give to people who were maybe thinking of doing something like this in their in their own area as well so so I would say one recommendation really is to to get total commitment from senior professionals working in each sector across the health and social care because actually that was just really for us it was really key to shaping and delivering a really successful interprofessional across agency day which really did for us it underpinned sort of cheating the aims of the program so I do I do feel that the aims that we set out at the beginning were were met through the program or stated aims and having spoken to these interviewees who evidence seeing improvements to their workplace practice really that that does evidence improvement or discharged pathways for hospital patients it was it was really good to be able to involve service users in planning of the content and implementation and delivery of the of the training day because again just to keep it patient-centered keep it focused on on their experiences because again you know I think that could get lost sight of and actually people's experiences are actually quite different from more you know organizations are setting out to achieve so I'm easy to lose that I think so we did have some outcomes that I showed you right at the beginning and I would say really I can't evidence at this point that we have achieved our expected outcomes because it's very hard to to categorically say that sort of improvements to performance outcomes were just down to this training because I have so many other health system factors which impact on the delayed transfers of care performance data and the emergency readmissions performance metrics I suppose it is really hopefully this initiative will be one part of the range of initiatives that will will we will see an impact in the end on on reducing the bed blocking the no transfers of care and we during the training day actually we encouraged me attendees to use our discharge and process and report all quality discharges and unsafe discharges so we think we probably will actually increase the number of discharges discharge American issue me because they are non mandatory in Camden so we think that probably is under reporting of problems at a moment but I think again by encouraging people to report what's going wrong and then the hospitals to have to feedback on iterative improvement process that again we hopefully will reap the benefits of with with better quality discharges and the reduced emergent emissions in the future so there's my little little picture the funny goggles on is really looking towards the future and what we were going to do next so so so Camden as an organization does feel that the benefits of this program do justify becoming an ongoing program and we currently have six further dates scheduled starting in a couple of weeks with the potential to train further 170 people from across the health health and social care and it's we're going to run a collaborative training day with University College Hospital and it will be a similar interprofessional across agency whole systems approach but we will be able to to bring in some of the expertise and resources from the hospital so so that and the presentation and Hospital training program so thank you all for listening and I think answer as well okay Thank You Lucy that was great yeah absolutely said we've got a time to have some questions if anybody's got any questions you can either use the raise your hand option and then I'll be able to unmute you or you can type in a question and then I can read it out to Lucy or we've got one question Lucy it's from a lady called Emma Owen and Emma's question is does the trust have an escalation in choice policy in place around discharge and was this part of the training package so it was it was something we didn't really bring that into the training program because this is probably more sort of face to face level or maybe a more simple level about there ten steps of getting the discharge planning right good discharge planning practice so sort less about of going into what might happen how we resolved more complex problem so there was quite a lot discussion that went on in the room about what people might do in certain sort of complex scenarios and senior professionals in the room were able to answer queries as they came up okay I've got another question from Michelle would would Michelle's question is Oh Emma said thank you your answer Michelle's question is how our discharge alerts made and where do they get sent community health providers like maybe [Music] work as I said that they can fill in its form that asks about or has room for people to report what went wrong with the discharge and what the impact was and so they will healthcare fill it in and will send it to whole systems team at the local authority which is asks and then we then keep a record of these and we'll send them on to discharge teams at the hospitals for for a response and for investigation and some and some learning outcomes for the hospital so and then it's a process that will then get fed back to the whole system's team who will then feed it back to the person who reported the incident in the first place have to be able to pick up some trends and issues around poor quality and we we tie back to their four key issue areas in their Ombudsman it was out recently he so tried to look for things to bring up hospitals okay thank you um got another question Michelle said the thank you sounds helpful we've got another question from a Hynes question is what do patients / service users say about what would improve / make their experience of discharge better the Mental Health Service uses I spoke to focus groups see they had they had some mixed experiences at discharge so where they had positive experiences around how their discharge was was sort of talked about from the very first moment but that staggered that was quite that was quite a useful point to pick up in there in the training also about how they had experienced sort of lack of multi-agency working and sort of the importance of multi-agency working again that's something we picked up through the ester group scenarios and actually that's where the theory was quite it was quite good at being able to pick up something sort of softer side of things so they had also my mental health services have talked about sort of trying to sort his dignity and because when it had an episode of poor mental health he found his dignity was very very low low point and actually how you treated in the hospital was quite important as we're looking take your dignity restored to you rather than they're removed so again these were sort of through having a scenario about sort of discharging somebody with mental health issues that was we were able to pick up sort some of those those sorts of attitudes and trade some of that in the theatre it's quite a very it's very powerful I think people take away from the Train Day isn't seeing seeing these things acted out in front of them yeah the the frail and elderly people I spoke to the main the main thing for for that group was more about like good communication so for them to understand how how they were going to be discharged and how you know they they had worries about how they would cope back in the community and and how that was you taking care of I guess maybe it had been a loss of confidence prior to the discharge and that's manifested itself in people being quite anxious about it's when they would go which day they would go and and so they didn't like while gentlemen particularly didn't his discharge was brought forward he hadn't haven't been prepared for the fact that it might become be earlier than he'd expected so anxious about it was on a particular day so it was not that was a bit and that's quite a that's something that we could get across in the videos with people talking about what they their negative perceptions sort of start to realize really that you know people might say one thing for instance that I find something but actually they just are saying they want to hear then you know they um now they're a bit yes they were a bit anxious and just to make sure that you know people prepared maybe for changes to the plan okay that's great earth thank you yet yeah that's lovely thank you lecie the next question we've got is from Oh a high inter thank you very much next question is from married Heslin question is how can we implement this training in our own organization / network and what resources / support are available from NHS improvement banks how Qui Houck we implementing yet sure how cui implement this training in our own organizations / network and what resources / support available from NHS improvement to be able to to fund a post my name is a part-time post cost associated with it and fund some of the training costs I'm not sure what else is out there I think you probably could do it add on somebody else's role the enthusiasm to take on that edge to work and actually all the senior health care professionals and social care professionals who did collaborate make the day and deliver the day actually it obviously they were doing it all for free just as part of their on top of their day job so there was no cost or cost implication there so yeah I mean it wasn't massively expensive what I would say as well you just and following on from that Lucy sorry flopping on from that question as a one from Heidi barber what was the costing of this project [Music] probably to do those three training days okay that's lovely thank you Lucy just checking it does look like we've got any more questions at the moment please feel free if you do think of anything after the webinar finishes you can always send an email to our mailbox which is esup info at NHS elect org you K and we'll certainly pass those on to Lucy for you is there anything you'd like to say Lucy before we before we finish up this session as lovely thank you so like say just give us an email if you do think of anything after we finish and just say thank you to Lucy if we're taking the time out to provide us with this presentation we really do appreciate it and just a reminder also that the recording of the webinar will be available on the ECF website shortly to view so just to say good bye from all of us and thank you very much for dialing in today thank you goodbye