Improving social care hospital discharges


  1. Project timeline

Stockport’s Intermediate Care system identified a number of challenges in delivering its Discharge to Assess model, as their integrated partnership causes issues with the sharing and availability of quality data. 

A potential solution to transform how they work together for customers as a partnership, is an Adult Social Care Digital Patient Journey Management System. 

Stockport’s project team will conduct an investigation into this solution, which would record each part of a patient’s journey to inform the most suitable pathway for them outside of hospital care. 

Potential benefits for customers and the project partners include:

  • the ability to view capacity and demand data at an operational and strategic level
  • the ability to see where an individual is in the system, how long they have been there, and if they are ‘stuck’
  • the development of in-house tools to manage patient flow are no longer needed
  • instant access to data will allow the planning of journeys and capacity, and support decision making

This is a local, regional and national challenge, and is reflected in the latest government focus around discharge and ambulance turnaround. Stockport expects this to be a potential scalable solution.

  • instant access to data would allow the planning of journeys, capacity, and support decision making

This is a local, regional and national challenge, and is reflected in the latest government focus around discharge and ambulance turnaround. Stockport expects this to be a potential scalable solution.

Project timeline

March 2023

The project is awarded £82,000 in funding through Round 6 of the Local Digital Fund to begin a discovery phase.

April 2023

Craig from Stockport Council presenting the initial plans for their project
Craig from Stockport Council presenting the initial plans for their project

The project has recently begun its discovery phase and the project team have met with key stakeholders from the health and social care sector, including the charity sector, to outline their goals. The team has run workshops to understand the hospital discharge process, involving a group of around 15 people.

The team has also identified data leads for each part of the process and started meeting with them to better understand data availability and quality. They are trying to identify quick wins and determine which part of the process to focus on for the most significant impact in the least amount of time. The partner councils, Manchester and Oldham, have been involved in some of the workshops, and the team is exploring whether there is a common solution for process and data issues.

June 2023

Due to the school half term holiday, progress for the Stockport project team has been slower compared to previous sprints. However, they have been focussed on ensuring social care and Transfer of Care Hub colleagues can access the online form to begin capturing the necessary data from the three remaining sites. They have also been working on Information Governance (IG) aspects, including drafting the DPIA, which is currently under review by colleagues.

To build a data history for future planning, the team has developed a method to archive the captured data. They are also providing health colleagues with access to this data, ensuring compliance with IG regulations.

During the next sprint, the dashboard will be used for the time during a weekly system steering group, where senior health and care colleagues will provide valuable feedback.

July 2023

The Stockport project team have published the prototype dashboard and received feedback on capacity, length of stay, and reasons for delayed discharge. The team found the capacity and length of stay data useful, particularly when broken down by location.

Towards the end of July, the Stockport project team have primarily worked on improving the data capture form by adding new fields. The redesigned form now contains key questions about delayed discharge, such as medications, transport, social care and Continuing Healthcare (CHC). Another new development includes an ‘active bed’ flag to identify whether a bed is occupied or not, which was an issue the initial prototype faced.

In the upcoming weeks, they will ensure everyone has access to the form to capture data daily. The focus throughout Spring will be monitoring the data quality and the dashboard. This will also be shared with wider colleagues for feedback on its usefulness.

August 2023

The team have completed a number of training sessions with therapists, therapy leads and assistants, discharge coordinators and ward trackers. The sessions covered how to enter data correctly into the online form and what the data will be used for. Data is now available for the majority of beds, however there are a few data quality issues to resolve.

In addition to this, the team has also spent time ‘replumbing’ the dashboard from NHS to council infrastructure. Once the data has been fully populated and is updated regularly, trend information will be available to monitor changes over time and impact and identify improvements.

September 2023

The team have now delivered several training sessions, and most of the required data has been successfully entered. This has enabled the team to establish a baseline assessment for all available beds. Regular data updates are ongoing, with summaries presented at weekly meetings for senior colleagues’ review.

With most of the essential data now available, the project team plans to gather initial feedback from senior stakeholders on the new intelligence. They are also preparing for the analysis phase, where they will collect more detailed feedback from all team members involved, including those entering the data and customers of the data. This feedback gathering is scheduled for the next 4–6 weeks.

The project team is currently in the testing phase, assessing the data’s usefulness and making necessary adjustments to the dashboard. Team members are using this data for discussions, particularly around capacity and client status change.

In addition, the team are evaluating the prototypes through surveys and meetings, gaining valuable insights, and looking for feedback from Manchester and Oldham to join the next project phase. The scope of this next phase will be determined during the next sprint.

October 2023

The project team has successfully resolved data quality issues and made improvements to their dashboard.

The updated dashboard is now being used regularly by colleagues, informing discussions around capacity and reasons for client status not changing. They are sharing dashboard updates with key colleagues across the NHS and the local authority daily.