Transformation Directorate

Community Multi-agency Discharge Event (MaDE) to support system flow

The critical behaviours required to optimise patient flow include collaboration, whole system working and a culture that supports Homefirst.

The process needs to mirror this ambition and actively involve people and/or advocates in all decisions about leaving the hospital and their level of support in the community. Alongside the work happening in all acute trusts in January 2022 to maximise the number of people leaving hospital who do not meet the Criteria to Reside (CtR). We have developed this resource to support systems to run “MADE” style events covering everyone who has left the hospital on Pathway 1 and/or Pathway 2 (Hospital discharge and community support: policy and operating model) and is receiving rehabilitation, re-ablement or supported recovery. The aims of the review are threefold:

  • To systematically review people’s current support and act for anyone whose care needs can be adjusted to meet their new level of need.
  • Where there are blockages or constraints, the review team or system coordinator should have the authority to be able to commit resources to circumvent these issues.
  • The central teams should record themes and issues that arise so that short term plans can be enacted to prevent similar issues for subsequent patients in the following weeks.

The success requires a whole system approach, with executive leadership from community trusts and directors of adult social care to ensure all responsibilities outlined in the Care Act (2014) are met. The process should be led and managed by the ‘single coordinator’ with support from a central review team.It would have the involvement of:

  • senior operational, clinical staff and professionals from all organisations
  • team leads who know the needs of all patients on the caseloads of all the teams involved, (intermediate care, re-ablement, home care etc. and leads from each bedded service (community hospitals and care homes where P2 beds are commissioned in care homes)
  • mental health clinicians
  • infection control
  • information team
  • project management and admin support
  • representation from acute trusts (for example a shortage of therapy resources may be hindering the review and discharge of patients from P1 services, and short-term support from an acute partner may help unlock P1 resources)

The approach

Community MADE’s are carried out remotely from an office base. The team reviewing the caseloads will need to know the individuals and have access to patient records. This may necessitate running the event at several sites recognising that many organisations have electronic records. Each patient on each caseload/in each bed should be reviewed by the reviewing team, and they should ask:

  • Does this person still need this level of support? Can the level of support be adjusted to meet their current need?
  • Has the individual, family member or carer and/or advocate been involved in a conversation about what they want/need to feel supported at home?
  • If they were discharged today with their current level of need what type of support do they want and would be required?
  • Do they still meet the criteria for a P2 bed, is there a clear Expected Discharge Date and discharge plan? Do they still need a P2 level of care while they continue their rehabilitation/recovery?
  • Have they reached the point in their rehabilitation/recovery where they can safely be transferred to a less intensive service, e.g. from Intermediate care providing a supported discharge service to community therapy that may provide longer-term services?
  • Could some or all their needs be met by support from family/informal carers/voluntary sector?
  • Could alternative manual handling equipment reduce the care needs?
  • Has tele-health support been considered?

The central review team will keep a list of patients, agreed actions, who is responsible for taking those actions, and follow up over subsequent days to ensure actions have been taken and resources freed up. The central review team should identify common themes that emerge from the event. Following the event, the actions and constraints should be analysed to pull out overarching themes which should be discussed with the health and social care exec. sponsors. Any areas that require a more sustained focus should be identified, discussed and actions agreed upon across system partners.

Next steps

A whole system workshop/debrief session involving senior health and social care system leaders should ideally be held on the last day of the event to formally agree on how to transform the actions, changes, and improvements from across the event into sustainable ways of working.