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Facilitating early discharge
Target
a) CRT staff attend all acute wards serving the CRT catchment area at least three times per week to screen all service users for potential early discharge.
b) CRT staff assess in person for early discharge for at least 50% of voluntary patients or patients detained for assessment in local acute wards.
c) CRT staff assess in person for early discharge for at least 80% of voluntary patients or patients detained for assessment in local acute wards.
d) At least 20% of the CRT's caseload are service users being supported with early discharge from hospital.
e) The CRT facilitates a patient leaving the ward within 24 hours for at least 90% of patients identified by the CRT and ward staff as ready for early discharge.
f) There is all-source agreement that the CRT offers a same-day home visit to CRT service users discharged from hospital.
Why this is important
Ensuring that people do not stay on inpatient wards any longer than necessary is another way CRTs can minimise inpatient bed use and offer a less restrictive alternative to admission as promptly as possible. Meeting patients in person and screening ward lists regularly can help to ensure the CRT is identifying as early as possible when people can leave the ward, rather than just escorting them home when they are anyway ready to leave. Service users in our consultation for the CRT fidelity measure strongly advocated the offer of a same-day home visit from the CRT to help with the transition from the ward to back home.
Below is a video of a service user discussing the importance of early discharge, and Danni Lamb, CORE Deputy Programme Manager, discussing the value of having a CRT/ward link worker in helping to identify service users who might be appropriate for early discharge.
Ways of doing this well
Presence on the ward
Brief daily visits to the ward to screen ward lists with ward staff can help identify patients to assess.
CRT staff attending ward rounds on local acute wards is one way to meet service users in person and discuss with them and the ward team whether early discharge is a possibility. This process can be streamlined if one CRT team member is assigned specific responsibility for liaising with wards and facilitating early discharge.
Early discharge assessment and planning
Edinburgh Intensive Home Treatment Team (HTT) have comprehensive early discharge assessments and a flow-chart giving a clear outline of the process:
- Edinburgh HTT Early Discharge Assessment (.doc)
- Edinburth HTT Early Discharge Process Flow Chart (.doc)
Waltham Forest HTT use the document below to ensure they are planning discharge from the point of admission:
Waltham Forest case study
NELFT Home Treatment Services are based at Sunflowers Court, Goodmayes Hospital, where all our inpatient wards are located. Following the centralisation of Acute Services, closer interaction with the ward and HTT on a regular basis was enhanced.
Gatekeeping is a fundamental role of a crisis service. In NELFT, various systems had been trialled but it was felt that when admission was recommended it was necessary to more clearly outline what the purpose of the admission was and what was expected to change once the admission occurred. At the point of admission, an Early Discharge Facilitation / Admission plan is utilised to specify what the purpose of the admission is and what is expected to change following the admission.
Once admission occurred, it was also felt that robust systems were required to ensure that gatekeeping occurred at both ends of the spectrum; at the point of admission as well as at the point where home treatment involvement was warranted, as the risk profile allows.
A structure was therefore developed where an HTT staff member attends the respective wards (borough based) daily and is part of the 09.00 Run through where plans for the day are laid out and actions are agreed to address delays in discharge.
This system works particularly well as HTT forms an integral part of the ward team and plans are followed through consistently. In order to support this further, the HTT Clinical Leads and team manager also attend the 09.00 Run through to support the process and address any complex delays / wider system interface issues.
A weekly bed management meeting between Acute and Community services Leads addresses delays in discharge from the ward and further promotes Whole System working.
Examples of good practice
In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:
- South Gwent CRHTT, NHS Wales
- Shropshire CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
- South Tyneside Initial Response Team, Northumberland, Tyne and Wear NHS Foundation Trust
- Waltham Forest HTT, North East London NHS Foundation Trust
- Barking, Dagenham, Havering HTT, North East London NHS Foundation Trust
- Redbridge HTT, North East London NHS Foundation Trust
- Eastbourne CRT, Sussex Partnership NHS Foundation Trust
- Mid Surrey (Epsom) HTT, Surrey and Borders Partnership NHS Foundation Trust
- Bath Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
Relevant reading
Morgan (2007) Are CHRTs seeing the patients they are supposed to see?
Key function B: Supporting early discharge
This function is performed by CRHT teams that are able to discharge patients from inpatient wards and take-over their care at home or in the community. The discharge is earlier than it otherwise would be because the patient is still in a psychiatric crisis but is able to be better treated at home and so is discharged into the care of the CRHT team. Some managers said this function was supported by daily/weekly review meetings, support from the inpatient staff, and sharing medical staff across the inpatient and CRHT teams; but others reported the function was hindered by an over-use of ward leave, poor understanding of the function by Consultant Psychiatrists, insufficient social services delaying some discharges, and where there was a physical distance between the inpatient and CRHT teams.' (p.5-6)
Chapter 5: CRHT teams are facilitating earlier discharges where the ward and CRHT team are integrated, but there is room to improve performance in this area
The term 'early discharge' means discharge earlier than would have happened if intensive home treatment was not available. If a patient is discharged to the CRHT team they are expected still to be in crisis and hence in need of acute care, but this care is judged to be most appropriately provided at home, enabling the discharge from hospital. The discharge is earlier than otherwise would occur - in a 'normal' discharge the crisis would have resolved and the patient could be discharged to CMHT for non-acute supervision.
[…]
CRHT teams are engaged in around half of discharges, with the likely result that the discharge is earlier than it would otherwise be […]
CRHT and Ward staff had conflicting information regarding the discharge status of around one admission in every eight […]
CRHT teams with a strong gatekeeping function were more likely to be involved in discharges […] (p.41-47)
Bridgett & Polak (2003) Social systems intervention and crisis resolution Part 2: Intervention
All admissions to in-patient care can be considered for early discharge with help from a crisis resolution team. Assessment at the time of admission should anticipate this (Box 8). A close working relationship between the team and the ward staff (Smyth, 2003), and all others involved, is important. Any of the crisis resolution and social systems considerations already mentioned might be relevant, but it is especially important to account for the failure in coping that necessitated the admission - the referral crisis. In addition to the social systems crises that preceded the referral crisis, the crisis of admission (Polak, 1967) must be taken into account: how has the admission affected the social systems to which the individual will return on discharge? It might also be relevant to take into account the influence of the in-patient care on the individual's coping behaviour, which is inevitably affected by social context. Any identified maladaptive responses should be addressed on an individual basis, and in relevant social systems meetings, by the promotion of healthy coping. (p.436)