Igniting a spark: Improving the Discharge to Assess (D2A) model

Delayed hospital discharge continues to be a significant problem. D2A is increasingly becoming the predominant route out of hospital, thus freeing up beds in the acute services. But what happens to people when they are discharged into care home D2A beds? These routes can also get ‘clogged up’ by people who might otherwise go home.

In Gloucestershire, a partnership between local integrated care board (ICB) and local authority commissioners, a care home operator and a private therapy provider has been successful in facilitating timely discharge from hospital but, equally importantly, it has maximised the patients’ potential for independence, making it more likely that they go home.

Discharge from hospital

Reducing the number of people delayed in hospital is a long-standing priority for health and care. Currently, one in seven occupied hospital beds (13,585) is taken up by someone who is ready for discharge. It is a complex problem to solve but the most common reason why people are delayed is that they are waiting for community support. Age UK periodically produces statistics that show the number of hospital bed days lost to people who are waiting for social care runs into millions.

It is certainly not good for older people. Patients with a long stay in hospital (three weeks or more) are often in a poorer state of health, experiencing reduced mobility and a loss of confidence, known as ‘deconditioning’, when they do go home. Thus, they need more support or even have to move into residential care.

An effective model?

One solution has been D2A, where the multi-disciplinary assessment takes place after the person has been discharged. According to D2A guidance, this is a key service change intended to contribute to system sustainability and improve patient flow, process and outcomes.

It is deployed ‘where people who are clinically optimised and do not require an acute hospital bed, but may still require care services, are provided with short-term, funded support to be discharged to their own home or another community setting. Assessment for longer-term care and support needs is then undertaken in the most appropriate setting and at the right time for the person’.

There is a surprising lack of evidence on the efficacy of the D2A model. In 2022, NHS England and NHS Improvement (NHSEI) reported a 28% reduction in patients staying over 21 days in hospital, stating that the D2A model was effective at reducing stays and supporting timely discharge. Case studies on D2A have reported a three-day shorter length of stay in hospital. But what about the impact of this system on the person? Research on the post-discharge community element of this pathway is even more limited.

A study in Kent found that D2A came to be understood primarily as a tool for reducing discharge delays rather than one for facilitating discharge and providing individualised support outside hospital. People were going home but expected improvements were not materialising because they waited too long for assessment and care.

D2A works in terms of getting people out of hospital quicker but they do not always end up where they should be. You might be tempted to conclude that D2A has become just another discharge pathway. It is good for getting patients out of hospital but the ‘system’ is not too bothered about what happens to people after that.

Furthermore, there are challenges navigating the system. Even when it is effective in getting people out of hospital and into D2A care home beds, the pathway can still get blocked. Live information on capacity and flow is often not visible to managers. Communication between all professionals, the patient and the family is critical.

The Gloucestershire initiative

Commissioners in Gloucestershire recognised that the healthcare system is complex. Multiple services and areas require effective co-ordination and access to prevent acute hospital admissions and to facilitate timely discharge. As part of a wider ‘Working as One Programme’, commissioners resolved to improve the availability, flow and outcomes of rehabilitative care in the community. The programme intended to build capacity to allow prompt discharge from hospital (or step-up from community) into care in the most suitable location.

Commissioners turned their attention to the D2A pathway, reasoning that it is more comfortable and less stressful for patients to assess their ongoing needs in a non-acute setting. However, they found that the bed-based model was not producing the outcomes they were seeking. There were too many D2A beds scattered between care homes on a spot-purchase basis. People were getting stuck, and communication was difficult.

The solution was to establish an innovative partnership between a care operator, the Orders of St John Care Trust (OSJCT) and a therapy provider, Therapies on Thames (ToT). The partnership aimed to have fewer beds but greater productivity and to give better oversight of the pathway.

The initiative has been running for six months and the number of D2A beds has reduced by over 50%, from 240 to around 90. The consolidation of the D2A beds in fewer locations has provided commissioners with oversight of what is going on and improved communication with all the partners who attend multi-disciplinary meetings. As a result of the initiative, people have been getting home faster, thus freeing up the D2A care bed for the next person medically fit for discharge from hospital, with fewer hospital bed days lost.

Rebecca Long, Registered Manager at Jubilee Lodge (OSJCT), said of the partnership, ‘We have seen some real improvements in ways of working when it comes to our D2A pathway, thanks to collaborative and constructive working between partners. We are now in the positive situation of being able to support with short notice discharges due to a structured approach being in place with clear communication between ourselves and the local authority brokerage team.’

The key to the improved patient flow is the provision of rehabilitation in the D2A beds. Therapists work intensively with patients to help them to regain their independence, maximise their functioning and adapt to their changed situation. The service will assess the patient’s mobility, commission any equipment required, communicate with the family and ensure the person is on the right pathway – either home with a package of care or to a permanent care home placement.

A key improvement is speed. The therapists work seven days a week. The rehabilitation starts within 24 hours from admission into the care home, including Saturdays and Sundays. This contrasts with one example before the initiative started of a patient waiting three weeks for an occupational therapy assessment in a spot-purchased care home D2A bed. In addition, working in fewer locations is more efficient. There is less travel time and therapists can upskill the care teams in the homes. The deployment of therapy assistants has further increased service capacity.

The joint focus on therapy key performance indicators has resulted in faster recovery for the individual and a shorter length of stay. Faster throughput frees up the pathway for the next person discharged from hospital. ToT applies a business approach, generating financial efficiency, often deploying fewer therapy hours than those commissioned to get patients safely home.

Key statistics and impact

According to NHS Gloucestershire ICB, the innovative partnership has reduced patients’ length of stay, reduced readmissions, increased home-based care and gained bed capacity:

The average hospital stay has reduced by 3.4 days since the implementation of D2A.
Readmission rates dropped by 12%, highlighting improved post-discharge support.
70% of patients on D2A pathways were supported at home.
The initiative has freed up the equivalent of 35 hospital beds per day, easing system pressures.

In addition, the partnership’s success has prompted the following key recommendations:

Start small and make the initiative sustainable, closely monitoring data and ensuring clear objectives to address specific system problems.
Consolidate D2A beds in fewer locations.
Proactively commission rehabilitation.
Provide therapy seven days a week with immediate start.
Ensure the regular flow of information between partners with daily active management of D2A beds.

Case Study

Mr Brown was discharged to a D2A bed at Windsor Street Care Home following an eight-week stay in the acute hospital. He had a history of recurrent falls and hospital admissions due to Parkinson’s. He was keen to return home. Prior to his hospital admission, he had been independent at home with his wife, his main carer, supporting him in domestic tasks.

Initial assessment

Mr Brown was relying on a hoist for transfers and was unable to stand or walk. He was very anxious and had a high level of fear of falling. He was cognitively alert and keen to progress.

Rehabilitation

The therapy input began within 24 hours of admission, with goal setting involving Mr Brown, his family and staff at Windsor Street Care Home. The occupational therapist formulated a personalised rehabilitation programme, delivered by multi-disciplinary team members.

Result

After a four-week period of rehabilitation, Mr Brown achieved:

Independence in transfers (bed, chair and toilet).
Independence in mobility with a frame.
A return to home with support for personal care and domestic activities – three times’ daily care and a weekly visit by the therapist to maintain functional abilities.
Avoidance of long-term support and consequent cost savings.

How could a collaborative partnership like this help in your area? Leave a comment on this feature or join the conversation to share your thoughts.

Raj Senniappan is a Consultant Occupational Therapist and Founder of Therapies on Thames. Email: [email protected] X @TherapiesThames

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