The Scottish Government

Tackling delayed discharge: a research review

Gill Hubbard, Guro Huby, Sally Wyke, Markus Themessl-Huber
Scottish School of Primary Care

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Main Findings

Introduction

This research review was commissioned to inform a review of current policy on delayed discharge in Scotland. The main aims were to review delayed discharge Joint Action Plans and any other information to identify initiatives to tackle delayed discharges in Scotland, and set the information on action on delayed discharges in Scotland in the context of current policy and existing evidence on the nature and extent of the problem and on 'good practice' in tackling delayed discharge.

Policy Developments

Since 1999, a number of policy developments in Scotland have been introduced to tackle delayed discharges. These include the establishment of a learning network to disseminate 'good practice,' and annual funding streams to support the development of initiatives to tackle the problem.

Other policies which have an impact on delayed discharge include the introduction of free personal care, Guardianship orders, and national care standards, single shared assessment and choice of accommodation guidance. The impact of specific policy developments on delayed discharge needs to be considered when monitoring delayed discharge.

Decision-making criteria

In 2000, the Scottish Executive issued a definition of delayed discharge from NHS care. However, publication of a definition does not guarantee that clinicians and other professionals use the same criteria to decide who is 'ready for discharge.' Inconsistencies in decision-making are likely to have an impact on the numbers of people recorded as a delayed discharge. There is currently a lack of information about the use of social and medical criteria for judging when a patient is ready for discharge.

Risk Factors

A combination of individual, medical and organisational factors interact to put people at risk of delayed discharge. The literature review found that older people, those with multiple pathology, and those with some specific clinical conditions (such as neurological deficit and stroke) are most at risk. A small number of studies suggest that patients waiting for a place in their first choice of care home to become available, and patients who did not have a companion to escort them home were also likely to be delayed.

The literature review also highlighted that some medical conditions appear more likely to lead to a delayed discharge for all age groups and that this is often because there is a lack of alternative care facilities available for these particular people. In other words, it is not the clinical condition per se which causes the delay, but how organisations are managing services to care for people with these clinical conditions.

Problems within both health and social care organisations have been attributed with causing delayed discharges. Organisational factors associated with delay include: (i) lack of home support, (ii) unavailability of convalescent or rehabilitation facilities, (iii) waits for community care needs assessments or home care packages.

Schemes

The literature review suggests that a range of initiatives within a whole systems approach may be most effective overall in tackling the problem of delayed discharges.

'Hospital at Home' schemes, or 'Early Supported Discharge' schemes have contributed towards tackling the problem of delayed discharges for some people. Studies show increases in patient satisfaction, reductions in hospital lengths of stay, increases in the number of patients still at home 6 months after discharge, greater community reintegration, improvements in health-related quality of life, and reductions in costs per patient. On the other hand, these studies show that some of these schemes have led to lower carer satisfaction, no improvement on health outcomes or functional status, and increases in overall length of care. The studies reported in this research review thus show mixed results.

Studies show that discharge planning can reduce the length of hospital stay, increase patient satisfaction, and reduce the number of patients experiencing a delay. However, how discharge planning impacts on, for example, readmission rates, patient recovery time, health care costs, and which professionals need to be involved in multidisciplinary teams, is largely unknown.

The literature search found limited evidence about the impact of equipment/home adaptations; step up/step down beds in care homes; joint case management, cross-charging, care home places and interim care home beds.

There are gaps in the evidence base about the role of different health professionals in tackling delayed discharges. For instance, little is known about GPs' utilisation of community-based services and the impact that this has on hospital admissions and delayed discharges, and this would be particularly useful given that small changes in GP decision making has a disproportionate impact on the acute sector.

There are also gaps in the evidence about patients' and carers' views of delayed discharge, especially relating to people in minority ethnic groups.

Joint Action Plans

Partnerships reported that the main causes of delayed discharge were insufficient care home places, lack of community-based care, and the slowness of assessment for community-based care. In other words, problems within social services were perceived as the main cause of delayed discharges.

Care homes placement, hospital at home, rapid response and early supported discharge, rehabilitation, out of hours, assessment, equipment and adaptation, and the introduction of managers were the most common initiatives being introduced by Scottish Partnerships to tackle delayed discharge. However, a difficulty with comparing initiatives was that Partnerships gave different names to similar services. For example, rapid response, early supported discharge and some types of home care services and rehabilitation may have a different name but operate in a similar way and with the same purpose. It would be useful therefore if Partnerships provided a brief description of the initiatives in future Joint Action Plans.

There were a number of information gaps arising from the Joint Action Plans, which made it difficult to gain a comprehensive understanding of how Partnerships were tackling the problem in the long term. For instance, it was not clear which groups of people were identified as most at risk; whether causes of, and solutions for delayed discharges matched; whether schemes being introduced were evidence-based; what information systems were in place to monitor delayed discharges, and what data was being collected.

Whole systems approach

The research review indicated that a whole systems approach that follows four key inter-connected stages may contribute towards tackling delayed discharges:

This kind of approach can be supported if there is collaboration between local Partnerships on the one hand, and national strategic bodies on the other. Capacity building in terms of skills in whole system data collection, data handling and analysis is also likely to be required. Finally, organisational capacity to use a whole system approach systematically in service development and planning is also likely to be essential.

Methods

This research review draws on UK and international literature; information produced by ISD; 2003/04 Joint Action Plans provided by local Scottish Partnerships; and eight snapshot interviews with health and social care professionals to identify key areas that need to be addressed for delayed discharges to be tackled long term. These four sources of information were analysed both separately and in conjunction with each other to find evidence on the nature and extent of delay, evidence on 'good practice' in tackling delayed discharges, and to find out how Partnerships were tackling the problem.