Integrating healthcare and social care, interoperability

Integrated working puts discharge delays to bed at the Countess of Chester Hospital

March 2007

Bed blocking occurs when patients who are medically fit to be discharged from hospital have to remain there for some reason. The issue of bed blocking regularly hits the headlines as a perennial bugbear for the NHS.

The causes are numerous. There may not be suitable facilities, such as a care home, at the patients destination; there may be outstanding healthcare assessments that still need to be carried out; or patients and their families may be unhappy about proposed arrangements. Inevitably, delays occur when Social Services staff have to provide facilities for a patient after they leave hospital and the NHS and Social Services have to manage the patients needs jointly.

The Community Care (Delayed Discharges) Act 2003 provides a basis of formalised communication between the NHS and Social Services for patients who are medically fit to be discharged from hospital but need some subsequent social service. The Act also allows hospitals to charge Social Services departments £100 for each day a bed is blocked when Social Services does not respond in time. In one way or another, blocked beds are expensive to hospitals, patients and Social Services.

Preparing post-discharge arrangements and managing the transition from hospital to the discharge destination often encompasses complex issues. Overstretched nurses usually have to follow a time-consuming and haphazard discharge procedure, which involves waiting for office hours to phone or fax details through to their colleagues in Social Services. Messages go unanswered, delays ensue from hospital/social-work shift patterns and critical details such as patients mobility problems get lost on route (or on Post-it notes).

With no manageable process in place, how can we ever hope to control it?

An electronically based solution

The Countess of Chester Hospital NHS Foundation Trust and Chester County Council Social Services (CCCSS) commissioned Medisec Software to provide a computerised system to manage discharge liaison. The system was implemented successfully in March 2004 and has since been extended to Flintshire County Council Social Services (FCCSS) for patients living in Wales but treated at the Countess of Chester.

As with any successful development across organisational and country boundaries, all involved must have the will for it to work and some tenacity.

Since 1999, the Countess of Chester had been able to manage the process of electronic delivery of clinical correspondence to, as well as the sharing of data with, primary care using a web-based system MedisecNET. On the basis of this well-established and successful facility the hospital and CCCSS wanted to examine the feasibility of supplying similar inter-organisational facilities to assist in managing the discharge-liaison process.

Development started in September 2003. The project team was formed from operational and management representatives from IT and user departments in both organisations.

There were, of course, developmental challenges:

• agreeing a specification. Ultimately, we were able to agree on version 5, but had the IM&T and user representatives not worked so well together, then the project could have faltered at this point;
• Social Services were not connected to NHSnet, so they were connected via a link with a high-security ID key fob agreed by each organisations network and security managements;
• performance of a web application over a telephone link is slow, so the application was designed specifically to provide fast local performance at hospital and Social Services offices; and
• patient privacy and confidentiality had to be assured, so we ensured that NHS and Social Services Caldicott representatives signed up to the specification and, as part of the application solution, consent to sharing their data with Social Services was sought from every patient.

Transfers were encrypted at industry-standard levels.

The process

First, the hospital patient-administration system (PAS) was enhanced to allow it to capture relevant data for discharge liaison, including referral, assessment and discharge details. A separate application (MedisecEReferrals Social Service) then interfaced with the PAS to manage the communication and data flows between the organisations.

See figure 1 below.

Figure 1. The electronic referrals system in action

By standardising the format of the discharge forms, discipline over the data-capture process has been achieved. Required templates specify for example what data is required and verify that patient consent to data sharing has been agreed.

Nurses can send electronic referrals direct from the ward or from the Discharge Liaison Office to Cheshire Social Services offices at any time of the day or night.

The application extracts the latest status for each patient from the PAS and keeps Social Services up to date on an hourly basis. Social Services staff have instant access to vital patient information such as next-of-kin, mobility, mental state and any changes that occur, such as a change of ward or patients discharge date. The fact that both the hospital and Social Services can see the latest patient updates at the same time is an important feature, as it means that both are equipped with exactly the same information when discussing cases.
Amendments detected by the Medisec application are colour coded so that significant events such as a new or withdrawn referral, assessment or discharge notification or patient death are highlighted differently from data changes like ward moves or changes of registered GP.

The system also allows for Social Services to maintain their own memo data in relation to a particular case for example, a Social Services registration number or details of which social worker is dealing with the case. All delay sitrep coding is entered dynamically. Notifying Social Services of such changes allows them to manage their own actions in a much more proactive way. Complex cases in particular can be planned for and actioned at an earlier stage than would normally be the case.

All events, changes and notifications are timed to the second within the system and any reasons for delays in discharges are accurately recorded, so any charges to Social Services can be calculated automatically with a full audit trail. There is no longer any need for disagreements at the regular Friday meetings to produce agreed sitrep reports and charges, and, as a result, this has significantly enhanced inter-agency working relationships.

Results

The number of patients and associated discharge delays registered before the electronic system was introduced were calculated manually and were, therefore, subject to some inaccuracy. It was estimated, though, that the Countess of Chester could be charging Chester Social Services for around 15 days a month for bed blocking attributable to their delays.

When the Community Care (Delayed Discharges) Act came into force in January 2004, the number of reimbursable days recorded almost halved from 15 to eight days. When the electronic referrals system was introduced three months later, this figure halved again to around four days a month. See table 1 below.

Table 1.  Bed-block days at the Countess of Chester
Change in number of reimbursable bed-block days at the Countess of Chester Hospital NHS Foundation Trust before and after: i) the launch of the Community Care (Discharge Liaison) 2003 Act; and ii) the introduction of electronic patient referrals to Chester Social Services.

The system was extended to Flintshire Social Services in September 2006. Wales does not account for chargeable delay days because the 2003 Act only covers England. Nevertheless, the amount of bed blocking attributable to Social Services again dropped dramatically from nearly nine days per month to just two-and-a-half. See table 2.

Table 2. Flintshire’s delay days
Change in number of bed-block days at the Countess of Chester Hospital NHS Foundation Trust attributable to Flintshire County Council Social Services (FCCSS) before and after the introduction of electronic patient referrals.

NB: In Wales, Social Services departments categorise delays in a different way from England and therefore these figures have not been verified by FCCSS.

Observations

The system proved, in one respect, to be too dynamic. When a patient who had been referred to Social Services died in hospital before he/she was moved, recording this on the system meant that Social Services often knew about it before the hospital could notify the next of kin. A step was added, therefore, to ensure that no action was taken by Social Services until the hospital confirmed the relatives had been notified.

Interestingly, the results revealed that the degree of delay thought to have been directly attributable to Social Services was less than previously estimated.

Successful developments rely on:

• user involvement at management and operational levels;
• good existing working relationships between relevant organisations and departments;
• a will to do; and
• an attention to detail.

Tom Rothwell, Managing Director, Medisec Software Ltd.

Acknowledgments

The author acknowledges significant contributions to the success of these installations from IM&T Department (Development and Systems Support) and the Discharge Liaison Department at the Countess of Chester Hospital NHS Foundation Trust; Cheshire County Council Social Services Access Team and Systems Support; and Flintshire County Council Social Services Adult Social Care Department and its Project Management and Systems Support Teams.