Alnwick Unit is a locked rehabilitation ward at Northgate Hospital; a specialist forensic service for individuals with Intellectual and Developmental Disabilities (IDD). The hospital operates over medium to low secure and locked rehabilitation wards and receives nationwide referrals. The unit’s patient population have historically been categorised as slow stream, difficult to rehabilitate patients, who have spent significant periods of time in hospital. Since November 2011, the clinical team have developed their approach to discharge planning, with the aim of reducing length of stay and improving discharge outcomes.
What We Did
Since November 2011, the clinical team on Alnwick Unit at Northgate Hospital have worked to develop a discharge pathway protocol to support the work undertaken within their Male Locked Rehabilitation environment. Northgate Hospital is a specialist forensic service for individuals with Intellectual Disability (ID). The aim of the pathway work was to reduce length of stay and improve discharge outcomes for the patient group. The pathway development involved streamlining and structuring the discrete stages to create a logical process. Consultation with patients and community partners ensured that that model encapsulated the process undertaken and was accessible to those involved. The process is focused around the patient from the initial stage to the point of discharge and this focus on discharge is now embedded as the ethos of the unit. Conversely, prior to November 2011 there had been no identified model or pathway in place to support discharges from the unit and the patient population were historically categorised as ‘slow stream’, difficult to rehabilitate patients (often intractable cases), who had spent significant periods of time in hospital.
The clinical team benefit from representation of all disciplines (nursing, psychiatry, psychology, occupational therapy, speech and language therapy and day services) to ensure a bio-psycho-social model is adopted when considering patients’ needs and risks. This has enabled them to think and work as a team rather than as professionals in isolation, pooling resources to achieve a streamlined process. The team have worked tirelessly over the past five years to refine their model. They have been able to develop positive working relationships with a range of stakeholders across the six partner local authorities and Clinical Commissioning Groups and with third sector agencies.
The team have ensured an ongoing process of service evaluation and consultation to develop and evolve the protocol to meet the needs of the client group. Moreover, the team have disseminated the protocol on a yearly basis at the International Conference for the Care and Treatment of Offenders with Intellectual and Developmental Disabilities to ensure that they are receiving peer feedback and sharing their vision with other interested parties. Moreover, the team have received visits from professionals working locally, nationally and internationally who are interested to learn more about the approach and the protocol.
The success of this ethos and approach is evident in the discharge outcomes. Since November 2011, 40 patients have been successfully discharged from Alnwick Unit; and a further six have active discharge plans at the present time. Four patients have been re-admitted to hospital; however, three have since been discharged to more suitable and stable community provision. Length of stay has reduced, rate of discharge has improved (year on year) and re-admission rates have reduced.
In 2014 the clinical team undertook a scoping exercise to ascertain community stakeholder’s views of the discharge pathway protocol. All reported that they found the protocol to be useful and helpful. Respondents identified that the protocol brought clarity of the process and roles “a useful framework as it gives clarity to the identification of what needs to be done, when and by whom”. It brought people together “enhances decision making and brings together professionals who should work towards common goals”. They valued the training “supportive training which has been…extremely invaluable” and the outreach post-discharge “continuity post-discharge…this will all maximise success of the service in reintegrating the service users into community provision safely”.
In 2014 the clinical team, and patients, began work to develop a patient friendly discharge model. This takes the form of a discharge house which serves as a visual aid to track each patient’s progression along their pathway. Importantly, patients are able to take ownership of their discharge pathways, diminishing the anxiety that once surrounded the process. Conceptually, the house model has enabled transparency and collaborative working between members of the clinical and community teams and the patient. It creates a shared language, ethos and model for discharge that is easy to understand and follow for all involved. It equips the team to plan and implement patient-centred discharge pathways with a shared vision in mind and a clear sequence of goals to achieve this; thus ensuring that there is accountability and clear division of responsibility at each stage of the process.
In May 2015 a service evaluation was undertaken and generally respondents found the house easy to understand and liked the way it looked. They reported it was an “important tool that has refreshed and improved (discharge) for the patients, their families and overall everyone” (Qualified Nurse) and “it is clear and concise…a visual, transferable tool that gives each patient an immediate report/status on their progress” (External Professional). Patients reported that “you know what’s happening, what level you’re on”, “looks good with the bricks and colours…Information leaflet tells you about the house… I like the last bit, the roof… as long as I’m doing the foundations the other bricks will be laid and the house won’t fall over”.
The work undertaken by the clinical team is exceptionally important. In 2011 a BBC Panorama investigation exposed the terrible physical and psychological abuse suffered by people with ID at Winterbourne View Hospital. There has been subsequent focus on the number of inpatients with ID detained in hospital settings and the quality of care offered to this client group. This focus on reducing hospital admissions is particularly important as patients with ID are more likely to be detained in hospital; spend longer in hospital; and experience more adversity within this setting than other client groups. The important work of the discharge pathway project team has been recognised at a regional and national level. More recently the CQC recognised the pathway protocol as an area of Best Practice. They noted that “staff on Alnwick Ward had developed a discharge planning model to effectively engage patients on their discharge pathway… the development of a community transitions team… worked with patients on the wards prior to discharge and continued to support patients in community placements after discharge. This had positively impacted on community placements being successful”.
Wider Active Support
The clinical team have positive working relationships with health and social care colleagues from the six local authority areas to which they routinely discharge patients. Moreover, they work alongside IMHA’s, solicitors and commissioners from within these regions on a daily basis and collaborative
relationships are at the heart of the work they undertake. Of equal importance are the relationships that the Alnwick Unit team have with the community providers. The care providers are from residential provision and independent supported living. All relationships are positive and have enabled the team to work in conjunction with a wide pool of services to successfully implement discharge plans for a wide range of patients with IDD.
Adapting the approach to discharge has involved consultation with patients, family members and community partners during all stages. The team has developed a patient friendly discharge model. This takes the form of a discharge house that serves as a visual aid to track each patient’s progression along their pathway. Conceptually, it has enabled transparency and collaborative working between members of the clinical and community teams and the patient. It creates a shared language, ethos and model for discharge that is easy to understand and follow for all involved. It equips the team to plan and implement patient-centred discharge pathways with a shared vision in mind and a clear sequence of goals to achieve this; thus ensuring that there is accountability and clear division of responsibility at each stage of the process. Consequently, the discharge process is clearer, more efficient and inclusive. Importantly, patients are able to take ownership of their discharge pathways, diminishing the anxiety that once surrounded the process.
Looking Back/Challenges Faced
On reflection there are some clear areas for improvement within the project. One of the real difficulties the clinical team face in moving patients towards discharge relates to gaining agreement for funding; this can seriously delay a transition plan from occurring. For example only recently we have had a three month wait for funding to be agreed for a placement. Therefore we have proactively worked with the local authority and health commissioners to identify what improvements were needed to documentation and now routinely include a Section 117 Aftercare plan within the service specifications with the aim of shortening the funding process. The overall discharge process relies heavily on staff support to facilitate each element of the pathway. During the initial three and half years the commitment to staffing has come from existing resources who have many competing demands. The development of a Community Transition Team within the Trust which links to the discharge model to facilitate discharge planning, transition and follow-up support. This has enabled an expansion of the model across the hospital site and has allowed an increase in staff numbers to support the work.
An area still requiring improvement is monitoring and implementation of research and service development. Without a dedicated resource for this purpose we have potentially not captured all of the rich and vitally important information that we could have.
To ensure that the approach continues, should those involved move on we have developed a discharge planning protocol a patient friendly discharge model document and committed time to disseminating the model to colleagues within this part of the service and wider teams. The work of the team has been presented in various formats at relevant National and international conferences. Moreover the model and ethos are embedded into the working practices of Alnwick Unit and the function of the ward has changed to meet the demands of the developing process. It is important to note that there is no one individual on whom this approach is reliant; it is whole MDT approach and ethos and therefore sustainability is more likely.
Evaluation (Peer or Academic)
Since November 2011, 40 patients have been successfully discharged from Alnwick Unit. 4 patients have been re-admitted to hospital; however, 3 have since been discharged to a more suitable and stable community provision. The mean length of stay in hospital for this cohort is 6 years 9 months;
ranging from 2 months to 22 years, 6 months. The rate of discharge has improved years 2007-2011 12 discharges years 2011-2015 37 discharge. Over the same timescales readmission rates fell 2007-2011 7 readmissions 2011-2015 3 readmissions. The mean length of stay on the unit has also reduced, from 3 years 3 months to 1 year and 2 months for the review period.
In summary discharge rates trebled readmission rates fell from 58% to 12% while length of stay also reduced. Rates of patient restraint (PMVA) and the use of as and when required medication (PRN) have fallen.
In May 2015 a service evaluation was undertaken and generally respondents found the house easy to understand and liked the way it looked. They reported it was an “important tool that has refreshed and improved (discharge) for the patients, their families and overall everyone” (Qualified Nurse) and “it is clear and concise…a visual, transferable tool that gives each patient an immediate report/status on their progress” (External Professional). Patients reported that “you know what’s happening, what level you’re on”, “looks good with the bricks and colours…Information leaflet tells you about the house… I like the last bit, the roof… as long as I’m doing the foundations the other bricks will be laid and the house won’t fall over”.increased exposure to and familiarity with the Alnwick discharge planning protocol; improved understanding of the discharge pathway; increased collaboration between service users and their staff teams around discharge planning; and has made discharge planning a less stressful process for all involved. Overall, the Discharge House has empowered service users to become involved in their discharge planning. This service evaluation complements a wider ongoing research project evaluating Alnwick discharge outcomes for the four years pre and post implementation of the discharge pathway.
Within the review period:
Discharge rates trebled
Readmission rates fell from 58% to 12%
Length of stay also reduced.
Rates of patient restraint (PMVA) reduced
The use of as and when required medication (PRN) fell.
The clinical team on Alnwick Ward are committed to sharing their practice with other colleagues and professionals:-
They have met with colleagues working in the acute wards of the hospital to share the approach and consider the implementation of the pathway at the earliest possible stage for patients.
The house model is also being rolled out across the two other rehabilitation wards within the hospital (older adult services and female services) as a model of best practice.
The approach to discharge has been presented at the International Conference for the Care and Treatment of Offenders with an Intellectual or Developmental Disability in 2013, 2014, 2015 and 2016.
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The work of the Alnwick clinical team has received recognition at a regional level:-
The team have been visited internally by members of the Trust senior management team who have subsequently shared the approach with wider services.
The team being shortlisted as finalists in two categories for the Northumberland Tyne and Wear NHS Foundation Trust Excellence Awards: Clinical Team of the Year (where they placed second); and Research and Innovation.
NHS Innovations North 2016 Bright Ideas awards (shortlisted)
Alnwick’s clinical team have also been recognised more widely:-
The Nursing Times awards 2015 in the Learning Disability category (shortlisted)
Positive Practice in Mental health awards 2015 specialist service category (highly commended)
Care Coordination Association awards 2016 innovation in support of service development category (winner)
North East Leadership Academy Award Leading for Service Improvement and Innovation 2017 (winner)
They have been visited by a Principal Adviser from Winterbourne View Joint Improvement Programme, Local Government Association who was keen to share the discharge house model as an example of good practice within an upcoming publication.
Mentioned as an area of good practice by the CQC in their report following the inspection of all NTW services in June 2016 in which the Trust achieved an Outstanding rating
They have also been visited from colleagues outside of the trust, working in other NHS and private provision to share the approach and discuss the protocol and pathway for discharge.
Visits have also been facilitated from NHS England, the North EAST Commissioning Service (NECS) and a representative of the Winterbourne Joint Improvement Programme who is keen to share the house model in any publication on this topic as an example of good practice.