Transcript: Hospital to Home


An Iriss project to design a pathway to support the transition from hospital to home for older people. In this episode, Fiona Munro, the project lead gives us an overview of Hospital to Home, progress to date and the final outcomes of the project.

Podcast Episode: Hospital to Home

Category: Adult social care 

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What follows is a transcription of the audio recording. Due to differences between spoken and written English, the transcript may contain quirks of grammar and syntax.

FM - Fiona Munro
PM - Peter McLeod

Hospital to Home is a project to design a pathway to support the transition from hospital to home for older people. Fiona Munro, the project lead, gives us an overview of Hospital to Home, progress to date and the final outcomes of the project.

FM Currently I am leading a 20 month project entitled Hospital to Home which ends in March 2015. The overall aim of this project is to design a pathway to support the transition from hospital to home for older people. This project is being conducted under the theme of integration, so we hope that this will be achieved through better communication between everyone involved in the pathway, from family members and informal carers, to older people and all health and social care and community based practitioners involved. There are 3 phases of this project.

The first phase, which ran from July 2013 until March 2014, was an 8 month scoping period. This phase aimed at generating an improved understanding of the existing pathways already in Scotland, so that these could be shared amongst other practitioners working in this area. During this phase I met with over 30 practitioners working across all 3 sectors in Scotland, to gain an understanding of the pathways already in place, what was working well and what could be improved. These practitioners were invited to participate in a pathway mapping activity to visually represent the pathways in their area. This was basically a visual pathway to which they could add the key steps or milestones practitioners go through to ensure an older person is discharged from hospital in a safe and timely manner.

They could also add comments about what was working well and what could be improved, as well as details of any key problems they thought may prevent a successful discharge. When discussing the pathway using this tool, practitioners tended to focus on the problems they faced when trying to discharge an older person from acute care. This provided insight into many pathways and processes across Scotland and the challenges associated with ensuring it is a positive experience for everyone involved. Speaking to this number of people meant that we had a large number of perspectives about the problem within the pathways, and the associated causes. These opinions were often quite different from one another, even within the same locality, and made synthesising the overviews sometimes difficult and time consuming. However with guidance from a number of key practitioners and experts in the field, we were able to identify 4 clear pathways that are present in all localities.

These are when someone is discharged straight to home, or through early supported discharge, or through step down, or sometimes when they are discharged straight to a care home. Under the premise that lots of good things are happening across Scotland that no-one is talking about, I wanted to create a way for practitioners to learn about what was happening in each of the localities I have worked with, and also to learn about my findings about the challenges associated with the 4 pathways identified. To do this, I worked with our Knowledge Media Team, who created an interactive website that we showed not only the 4 identified pathways and associated problems, but also information about the problems and progress they made in each of the localities I had worked with. It also has a literature section, which highlights the key evidence to support this piece of work. This website was launched in April 2014, and has since been well received by practitioners when presented at events across Scotland.

Since completion of the website, we have now moved into the second phase of the project, this is a 6 month co-design period, during which I will be working through the Design Councils Double Diamond Framework, to support the design of an improved positive pathway for older people. This phase is supported by 3 Masters of Design for Services Students from Duncan of Jordanstone College of Art and Design at the University of Dundee, as well as Stuart Muirhead, one of my colleagues from Iriss's Evidence-Informed Practice Team. During this phase I wanted to focus on one specific locality so that I could spend several months getting to know the people working in the locality, so that we could work together to identify the key problems and design new ways of resolving them. Choosing one locality to work in for this phase of the project was challenging, as each locality I had worked with had many reasons why they would make a good candidate, however for several reasons, Tayside, and in particular, Dundee, was chosen as the most suitable locality for this phase.

As the first phase had only included practitioners, it was important for me that one of the key aims of this second phase was for older people's voices to be heard. My rationale for this was the hope that this would generate an improved understanding of how the current lack of a positive pathway for older people has affected them, and help the practitioners involved to bear this in mind in their day to day work. For this purpose, I worked closely with key leading health and social care practitioners within Dundee to identify 8 older people who had been discharged from Ninewells Hospital in the last 12 months, as well as 3 informal carers who were the primary carer for someone who has recently been discharged in Tayside. Together we also identified 15 practitioners who served to represent each of the key job roles working within the discharge pathway. As a group we meet together once a month for a half day workshop to work through the 4 phases of the Design Councils Double Diamond Framework, these phases are Discover, Define, Develop and Deliver.

We are currently in the first phase, Discover. Three of our monthly meetings are allocated to this phase, during which we are aiming to identify all of the problems associated with the discharge pathway in Dundee. I used the first workshop for us all to get to know one another and a reason for being involved in the project. A key aspect of this was that everyone introduced themselves by bringing in an object which meant something positive to them and sharing the reason why with the group. This meant that everyone was talking about family stories and memories, rather than discussing their personal or professional associations with the pathway, this meant that we broke down barriers and helped everyone to work together as equals throughout the rest of our re-design journey.

During the second workshop, the group was split into 2 smaller groups. One containing only practitioners, and one containing only informal carers and older people. Each group was then asked to create a visual representation of the pathway from hospital to home, from either a personal or a professional perspective, using pieces of Lego. The outcomes of this activity were quite striking. The practitioners created a linear pathway, which started at the hospital and ended at home, with 2 small pathways, one for a care home and one for a supported discharge. They used blocks of Lego to represent key barriers to discharge and listed all the people involved in the pathway. The older people and informal carers, on the other hand, created a circular pathway, that started at home and it finished at home, and the hospital was only a very small part. They listed the main routes to hospital and the activity they were involved in taking place to get them out of hospital.

At the third workshop, we will be working together as a large group again to discuss the problems within these pathways and how they relate to each of the people involved in the pathway. During this phase, I have also been visiting care homes in Perth and Kinross to speak with people who have been discharged from Ninewells Hospital straight to a care home, this is so that their stories and personal experiences of problems, or things that went well, can also be fed into the project learning.

Our next workshop will mark the start of the Define Phase in the Double Diamond Framework. Only one workshop has been allocated to this phase, during which we will refine the problems to a list of 3 or less, that are within the scope of being addressed through re-designing this project. The fifth and sixth workshops will be part of the developed phase of the framework. During these, we will first identify which solutions could resolve these problems and then refine these to a list of solutions that are manageable and realistic for us to take forward as part of the project.

The final workshop is the only workshop within the delivered phase of the framework, during which we will co-design what solution we could take forward in Dundee.

Upon completion of these workshops, my colleague, Stuart and I, will work together to produce an implementation report that will provide guidance on how the proposed solutions could be implemented in Tayside.

We are also working closely with Tayside based medical leads in older peoples care throughout the workshop process to ensure that the final proposed solution is realistic and manageable within Tayside.

Upon completion of the implementation report, we will then move into the third and final phase of the project, which will focus on embedding changes in practice. The aim of this phase is to enable practitioners to implement an effective service model that will help to ensure older people have a positive pathway from hospital to home. During this phase, Iriss will work with the leads in Tayside to see how our proposed solutions could be implemented, evaluated and refined. We will also meet one final time with the co-design team to update them on the project process and thank them for their input.

In addition to the pathway map and locality website already produced, we will create a visual representation of the pathway from an older person's perspective generated off the back of the workshops. This will be added to the existing website so that people working in other localities can benefit from this learning.

The final outcomes of this project will therefore be a website offering professional and personal perspective from the pathway from hospital to home, and an improvement strategy to NHS Tayside to use, which will hopefully lead to the implementation of changes as part of their local integration agenda. Ultimately, we hope that these will lead to a positive pathway from hospital to home for older people in Tayside, and over time, across Scotland.

Peter McLeod, Director of Social Work at Renfrewshire Council, and newly appointed Chair of the Iriss Board, gives his thoughts on the Hospital to Home project, along with more general insights.

PM Thanks very much for giving me the opportunity to talk to you about Hospital to Home, or themes around Hospital to Home.

My name is Peter McLeod, I am the Director of Social Work in Renfrewshire. I wanted just to give a personal view on how what I think is really important. Having looked at, what I think is fantastic work, by Iriss, on the Hospital to Home project, I am really attracted to guiding professionals through different stages. I am also really thoughtful about some of the recent comments made, I think by older people themselves, that it's not just about hospital to intermediate care or to another form of care, but it's also home to hospital to home, or perhaps as homely a setting as possible.

The experience that we have had in Renfrewshire is that we've reduced bed days lost, as per the delayed discharge target, from around 1700, 2 years ago, to 50 last month, I am talking now in July 2014. That is fantastic, and it's a real accolade for the team in terms of that achievement, but it's the accolade for the team working with older people to achieve the best possible outcomes for these people, and that's, I think, has to remain the focal point for the work that we do together.

A key issue that I have, and I wanted really to underline it in terms of my contribution to the Hospital to Home project, is that we must always remain focused on individuals and their outcomes. That sounds like a bit of a sound bite, but if we concentrate on beds and days lost of beds, we actually forget the person and we forget that really, for that individual, it's the ability to move on, usually at some of the most critical points in their lives, and to deal with them as equals who require the best possible care, and that's what we have a duty to provide. So when we drive for the target, the target is actually secondary to the outcome and the journey with the individual and their family. I think the part of that means that we have to equip and resource our capacity in hospitals in social care, to be, first of all in hospital, I believe those resources should be based within hospitals or relate as closely to hospitals as possible in the social care sense, because I think that social care also has to have the capacity sometimes to say, 'I am not sure that that is the right thing to do, let's consider the whole picture.' Where there is a real pressure on the system to release the bed, release the resource, and I understand absolutely that there is a right for the individual waiting, to come into that, as equal a right as the person leaving it, to the best possible alternative for them. That has to be equalised. Social care is also about recognising the holistic picture that leads to the outcome.

Part of my reflection, and I hope it's a helpful one for those that may listen to this, is that the journey we have had, and I would reflect on some of the work I have done nationally in this regard, would have led me into rooms with people around the late discharge issues a couple of years ago or more, where unfortunately the narrative was more about what wasn't working and where it wasn't working, and sometimes that became a little bit about apportioning blame. What I now recognise, and I took a team including some of the senior leadership from my own area, into a room with the health and social care professionals in Paisley recently, I couldn't tell who the social care people were, as opposed to the healthcare people, because the teams spoke the same language about outcomes, a common objective, and a real focus on the right kind of targets for the individuals concerned. I think that's what we should try and achieve, is actually moving across barriers, as we truly integrate health and care, towards outcome focused work that is very much about team, rather than individual or agency responsibility, it's about joint responsibility for best outcomes.

I think probably the final thing I would want to say in reflection is about if our services are really to be fit for purpose and we really do care about outcomes, then we must provide people with the fullest set of alternatives to allow them to choose properly with their families what is best for them, and I am conscious that in terms of capacity issues for individuals that's sometimes really difficult, which means we will have to work harder with them and their families to identify the best alternatives.

But for me, to finish off, those alternatives should be, home first and that we should recognise that the assessment in a hospital environment is usually not the best place to assess people when they are at the biggest critical moment of their lives. Secondly, that when we have assessed them correctly in the correct place, that should sometimes often be intermediate care, step down, step up type facilities, where rehabilitation and support is available for people to get to the best place that they can be with their families then to enable them to make the best choices. Some of these choices aren't just about care home settings, we've developed extra care housing, I would develop more of it tomorrow, because I think it's a fantastic alternative for people when they require that little bit of extra support. And of course, Care at Home, Reablement and Self Directed Support should also be part of these choices. I am also a firm believer in tele healthcare, as an enabler and as a safety mechanism, but also something I think we need to go much further with in terms of social interaction, social networks, and also interaction with services that don't mean that people always have to come into your home, but that you can contact them when you need to.

So these are some of my reflections on what I think is a pretty successful journey. A focus on outcomes, a focus on people, and perhaps finally, remembering that as some of us professionally and personally have been on this journey with older relatives, the thing that you have to remember at the core is ... what would you think if it was your loved one and putting that down as the test to what's good enough in terms of what you do as a professional.


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