Integrated Discharge Management Service Joyce Brown Integrated Discharge Manager

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Integrated Discharge Management ServiceJoyce
BrownIntegrated Discharge Manager
Nursing Strategy Day17th August 2005
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Background

• Greater Glasgow Partnership History of
  effective joint working but
• Range of Health Social Work staff involved in
  facilitating hospital discharges.
• Investment of Delayed Discharge monies.
• Local system pressures.
• 2003, IDM proposal agreed by Glasgow City Council
  NHS Greater Glasgow

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Integrated Discharge Management Structure

• Aims
• Provide a whole systems approach to discharge
  management for all patient groups within North
  Glasgow Acute Hospitals. The integrated
  structure ensuring smooth and seamless patient
  journeys, minimising gaps and delays and
  providing clarity of roles within the single team
  framework.
• Improving and monitoring performance across the
  raft of discharge activity.
• Providing appropriate admission avoidance, early
  and supported discharge services, particularly to
  older people.

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Team
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Current Priorities

• Create a cohesive team which takes joint
  responsibility for all discharge issues.
• DPA Discharge Planning Agreement
• Joint Reporting.
• AWI Adults With Incapacity.
• C.H.O.I.C.E.
• Specialist Multidisciplinary Assessment Tool.
• Planning Remit.
• ? Delayed Discharges !

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Delayed Discharges

• Strong evidence to suggest increase in delayed
  discharges is a symptom of wider system problems.
• Scottish Executive targets to be ? by 20 year on
  year with no patients waiting in hospital for
  over a year.
• North Glasgow delayed discharges-
• April 2004 152 patients, with 56 outwith DPA
• April 2005 103 patients, with 45 outwith DPA

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North Glasgow Delayed Discharges
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Benefits

• Early identification of patients requiring
  integrated assessment / care management.
• Ensure care and rehabilitation is provided in the
  most appropriate setting.
• Provide safe and timely discharge.
• Best use of NHS and Social Work resources.

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Conclusion Recommendations

• Evidence from Audit Scotland Moving On
• Require more sophisticated systems to evaluate
  effect of integrated service.