Discharge to assess bed brokerage has been a major part of our work for almost a decade, having managed one of the earliest examples of the concept. In 2009, we were commissioned in Liverpool to work on a service entitled Health and Well Being which was based on a pathway from hospital into intermediate care in nursing homes across the city. The term ‘intermediate care’ was used at the time, rather than ‘discharge to assess’ but the principle was established of giving patients more time to recover their capacity, rather than moving from hospital into a long-term care placement.
Discharge to assess
Bed brokerage with the discharge to assess model was critical to the success of Health and Well Being. A significant number of beds were block purchased in nursing homes and our company was brought in to manage these beds, recognising our experience in bed brokerage and care co-ordination. When beds are block purchased, it is critical that a high proportion of beds are occupied, otherwise funding is wasted. At times of increased demand, spot purchases are required, which inevitably cost more than block purchased beds. Skills in discharge to assess (D2A) bed management are essential, together with knowledge of the local care home sector.
We were able to apply our experience from Liverpool to other areas and services, as D2A bed management and co-ordination was increasingly recognised as an approach which can produce better outcomes for patients and reduce delays to hospital discharge. In Birmingham, we were commissioned to deliver part of a large cross-city discharge to assess service with reablement provided by occupational therapists and physiotherapists.
One of the early learning themes was that when beds were purchased in a larger range of nursing homes, therapists felt reablement was less impactful because understanding of reablement varied and they were working with many different care staff. Once D2A beds were concentrated in larger blocks across a smaller number of nursing homes, care staff increased their skills and reablement was more effectively focused. For example, it takes longer to accompany an elderly individual with mobility problems, enabling them to walk to the dining room for lunch; it is quicker to use a wheelchair to transport them. So inevitably, when reablement is the goal, the type of discharge to assess beds used is critical and the training and principles of staff supporting patients in those placements.
Another learning point and in this sector is communication with families. There is often little or no choice about D2A beds and this can cause issues: families expect to have some choice over care homes and it takes key skills to explain that a discharge to assess bed is a different type of placement and little or no choice can be offered.
Having D2A pathways is now statutory for all NHS trusts. There is wide variation in service models and home-based D2A (sometimes referred to as pathway one) is likely to become increasingly prominent, as it follows best principles of promoting independence. In home based D2A, the key brokerage skill becomes care rather than bed brokerage; working with local care services to provide the support needed, which can be challenging in many areas where there are insufficient domiciliary care resources to meet need. Again, it is the brokerage, co-ordination and communication between hospital and community providers which are key to the model work.