New UHNM-led tool helping to get patients home quicker this Christmas

Elderly and vulnerable patients across University Hospitals of North Midlands NHS Trust (UHNM) are set to benefit from faster care and quicker discharges thanks to a new in-house developed software tool. 

The High Risk of Delayed transfer of care (HRD) tool, is being used at Royal Stoke University Hospital and uses data from patient’s health and care record to help identify those at most at-risk of delayed discharge, enabling staff to better plan timely and appropriate care.

The tool, led by UHNM and developed in partnership with local NHS providers, Staffordshire and Stoke-on-Trent Integrated Care Board (ICB), the North Staffordshire GP Federation, Keele University, along with support for UHNM Charity is on a six-month trial in areas including the Emergency Department (ED), and Older Adults wards.

Dr Andrew Davy, GP Lead for Research and Development in ED at UHNM said: “Often we wait until we have fixed a patient’s problem before plans are made to get them home. This can result in delays in waiting for things like a Physiotherapy, Occupational Therapy assessment or Social Care review needed for discharge. The aim of the HRD tool is to help predict patients who might need help sooner and enable the right teams to assess and help them in a timelier way speeding up discharges either home, to a virtual ward, or to a Discharge to Access step down bed if required.

“With patient’s permission, we will access care records and look for expected risk factors for having a delayed discharge including medical conditions, exiting care provision, and if there is somebody at home to look after you. The tool then represents those risks virtually on a dashboard so that relevant teams across UHNM teams therapies, older adults and partners, including Integrated Discharge Hub, Acute Care at Home, and the GP Federation to follow up on actions.” "The hope going forward is to also continue to work closely with local authorities to better communicate when patients on a care package come into hospital to reduce wastage of carers time going out to those patients."

The tool, a first-of-its-kind in the UK, anonymises data after a patient has been discharged, and with support from Keele University, which will be analysed over the six-month period to help better determine which patients might be best suited for virtual ward review or early input as above to avoid delayed discharge.

If successful, the HRD tool has the potential to be useful in other hospital trusts.

Michelle Harris, Deputy Chief Operating Officer at UHNM said: “I’m really excited the HRD tool has gone live at UHNM, with a wider roll-out in other areas the New year. This innovative tool is all about admission avoidance which is the best way to protect the patients. What I hope to see over the next few months at UHNM is a real change of behaviour in terms of not to admit, and rather optimise, and looking at the different places we can do that.”

Dr Davy added: “I’m excited we can do something different for our patients. To be able to change what we do for our most vulnerable patients is very emotive. It would be amazing for our patients, as well as staff, if thanks to HRD, we can move the dial on those patient journeys and improve response times and flow through the system by enabling timely and safe discharge.”

Hayley Bishop, Director for Integrated Discharge at Midlands Partnership Foundation Trust (MPFT) said: “The project has seen Staffordshire and Stoke-on-Trent healthcare system partners come together to see how we can better share information to improve patient journeys through the healthcare economy.

“This tool has the potential to significantly change the way in which discharges are planned, and admissions avoided through proactive communication at point of attendance. This dynamic trial of patient tracking will facilitate earlier discharge reducing the risk of hospital acquired functional decline which will support more patients to return home rather than into alternative accommodation for ongoing care assessment.”