The Royal Devon and Exeter NHS Foundation Trust aimed to embed into their community hospitals the intermediate care (IC) and temporary support needed to help people recover and rehabilitate safely following a stay in hospital.
The aim was to reduce the number of people medically safe to leave from being delayed to do so. They also wanted there to be fewer people who were admitted directly to a care home to optimise independence and reduce need for long-term commissioned care.
Our innovative intermediate care project has enabled us to rethink our inpatient services in 3 community hospitals. We have provided more intensive rehabilitation, by a collaborative team approach, which has led to improved outcome measures.
Patients have shown both an increase in their functional independence and an increase in the numbers of patients being discharged to their own homes. There is real strength and quality in our workforce. We can achieve so much when the multidisciplinary team simply all come together for the benefit of the patients.
professional lead for occupational therapy (community)
Royal Devon and Exeter NHS Foundation Trust
What was done and why
This allied health professional (AHP) led project was delivered with the community hospital teams. It focused on redesigning the approach to bed based IC. Initially, instigated by the publication of our guidance for IC, a review and benchmarking exercise was undertaken.
This led to the place-based system that looks to optimise the health and wellbeing of the population. It promotes independence by supporting people to live the life they want to lead after a stay in hospital. The project relates to the development of 3 community hospitals within Eastern Devon Services based in Tiverton, Sidmouth and Exmouth.
The new model of care focused on 5 main deliverables:
- equipment in community hospitals
- development of a new workforce model
- training and development of staff
- developing a new daily routine
Following a successful Integrated Better Care fund bid, a new bed based model was developed, designed, and delivered which focused on embedding the key principles of IC in community hospitals. The model was designed using our guidance along with AHP advice on improving flow, patient experience feedback, and productivity statistics.
The vision of the project, objectives and main deliverables were communicated to IC teams. An AHP project lead with regular ward presence was put in place and a collaborative leadership approach was used. Project groups and dashboards were created to help teams to deliver objectives; create action plans and manage risks and issues.
Patients were asked what activities they would be interested in doing on the ward to maintain their independence. They were also spoken to about their experience and how the service can be improved.
Outcomes and impact
Compliance to our guidance increased by 50% and patient feedback reported that 90% recommended the service and that they were treated with dignity and respect. They also knew what was happening at each stage of their care.
Individual and group activities on wards increased and the number of individuals discharged to their own home also rose from 55% to 69%.
Patients were proactively provided with information to support them in making informed decisions about their next steps. Each patient was also set SMART goals to assist them in their rehabilitation.
The project also led to a 28% increase in admissions to community hospitals and a reduction in length of stay from 20 to 14 days. There was also a reduction in wait time to transfer to unit from 5 to 2 days.
What was learnt
Strong AHP and nursing leadership is required to nurture this collaborative approach to ensure all staff groups feel valued. When developing skills across the workforce using terminology like shared skills is more helpful than using generic skills.
A rolling training programme for all staff, that included evening sessions for night staff, was the most productive way to deliver training. However, finding time to take people off the ward was at times challenging.
Taking away weekly multidisciplinary team meetings and introducing daily board rounds was daunting at first but has led to closer team working and better outcomes for patients.
An inclusive approach helps staff lead the change themselves by overcoming perceived barriers to do things differently. It also helps them find their own solutions together, holding each other to account in order to deliver action and change.
If the project was to be carried out again, it would be helpful to introduce clinical outcome measures sooner to ensure more evidence was available to demonstrate impact before and after delivery.