We mapped the existing community healthcare services available in each borough, including the routes for referring into each service and the assessment forms used to refer. We identified:
Variance in eligibility and referral criteria across boroughs:
15 different referral and assessment forms
21 separate referral routes into community healthcare services
This made it very challenging for ward-based staff to navigate the community healthcare system and identify or access the most appropriate service(s) to support a patients’ discharge. This in turn led to a high number of inappropriate referrals and a significant proportion of clinical time being spent on administrative re-work rather than patient care and patients staying in the system longer than they should.
By working collaboratively with CCGS, acute and community providers and lay partners we agreed 2 key changes ( implementing single points of access and a single assessment form) to simplify and streamline the community healthcare landscape across NWL, making it easier for staff to access the services needed to support a patient's discharge.
We worked with CCGs and providers across NWL to introduce Single Points of Access in each borough. This meant implementing a single phone number and email address through which all community healthcare services can be accessed, reducing the number of referral routes from 21 to 8.
Working with nurses, therapists, discharge co-ordinators, SPA administrative staff, community service providers and lay partners we also co-designed a standardised needs-based assessment form. The single assessment form was adopted by all acute trusts and community providers across NWL and replaced the 15 forms previously used.
This helped reduce confusion for staff based on the wards, making it easier to identify and access the most appropriate services for patients, thereby reducing the number of inappropriate referrals and administrative re-work and time patients spent in hospital.
The initiative was well received by senior stakeholders and has been expanded to cover referrals into bedded community services and Adult Social Care, further streamlining the community care landscape. This in turn will help to reduce the Average Length of Stay of patients discharged both within borough and cross-border by ensuring staff are able to access the right services to support a patient's discharge at the point they are medically fit to leave hospital.