Discharge and Transition Management in Integrated Care

Urbanski, Dominika; Reichert, Anika; Amelung, Volker Eric

doi:10.1007/978-3-030-69262-9_26

Handbook Integrated Care 2021

DOI: 10.1007/978-3-030-69262-9_26

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Discharge and Transition Management in Integrated Care

Dominika Urbanski¹,

Anika Reichert

Volker Eric Amelung

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2023

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Discharge to Assess: an evaluation of three case studies in the southeast of England to inform service improvement

Jeffery,

Monkhouse,

Bertini

et al. 2023

BMJ Open Qual

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BackgroundDischarge to Assess (D2A) emerged as a critical process during the COVID-19 pandemic facilitating patient flow within hospitals, however research on the post-discharge community services of this pathway remains limited. We conducted an evaluation to examine the impacts, capacity, processes and barriers associated with D2A and to identify best practice across three sites in the southeast of England.MethodsWe interviewed 29 commissioners, providers and staff members involved in the delivery of D2A pathways within three Health and Care Partnerships. Framework analysis of the collected data revealed three prominent themes: the commissioning of services encompassing funding, structure, culture, and expected outcomes; multidisciplinary collaboration including staff skills, team connections, and coordination; and information and knowledge exchange such as assessment methods, record management, and availability of operational insights.Results62 specific enablers and blockers to effective D2A practice emerged.DiscussionThese findings supported the development of a comprehensive service improvement toolkit.ConclusionFive recommendations are proposed: 1. Examination of pathways against the 62 enablers and blockers to identify and resolve pathway obstacles; 2. Establish a local operational policy accessible to all providers; 3. Enhance coordination and communication among service providers, patients and carers; 4. Strengthen oversight of service user flow; 5. Develop a consistent Patient Reported Outcomes Measure to facilitate feedback and service enhancements for individuals discharged from urgent care pathways.

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Discharge to Assess: an evaluation of three case studies in the southeast of England to inform service improvement

Jeffery,

Monkhouse,

Bertini

et al. 2023

BMJ Open Qual

View full text Add to dashboard Cite

show abstract

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Discharge and Transition Management in Integrated Care

Cited by 1 publication

References 20 publications

Discharge to Assess: an evaluation of three case studies in the southeast of England to inform service improvement

Discharge to Assess: an evaluation of three case studies in the southeast of England to inform service improvement

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