Digital Discharge: Bridging The Health & Social Care Gaps Between Treatment & Recovery

There can be no denying that the UK’s National Health Service (NHS) faces a myriad of challenges right here and now. Nowhere is this more evident than in patient discharge practices.

However, a new perspective on ‘holistic care’ and government-backed initiatives aiming to bridge the gap between healthcare and social care settings are streamlining processes, fostering better collaboration, and ultimately, helping patients recover more quickly. But how?

The idea that patient discharge is ‘the final step’ in healthcare treatment has changed. Why? Well, the success of modern medicine means that we are living longer; but often with ongoing health conditions – which means an increase in patient care needs in home- and social care settings.

NHS leaders suggest that patients treated at home or in a community setting recover more quickly and have better outcomes; which reduces pressure (and costs) on healthcare services – as fewer in-patients means more beds become available. But, like many public healthcare issues, actioning such initiatives means bridging a growing gap between funding, staffing, and patient needs.

Patient Transfer

Close Cooperation

It’s clear modern healthcare providers need to work more closely with social care organisations for several key reasons: to ensure a more streamlined set of discharge processes; alleviate hospital capacity; and to help people live healthier, happier, independent lives.

But doing all of this, given the inherent challenges, means taking a different perspective.

A More Holistic Approach 

Until recently, there’d also been very little change in patient discharge processes. People who were admitted to hospital received treatment, and then, when they were well enough, were sent home or back to their community setting.

However, looking at national NHS statistics around these issues, many patients aren’t actually being discharged on the day that they’re ready to leave hospital. For example, nearly 14% (13.6%) of patients are discharged a day or more after they’re officially ready to leave – with nearly a quarter (23.9%) waiting an extra 2-3 days.

14% of patients are discharged a day or more after they’re officially ready to leave.

The reasons for this wave of ‘delayed discharges’ are twofold – caused either by a lack of awareness of where suitable ongoing care is available, or a lack of information about a patient’s care needs. These issues have not gone unnoticed by the recent independent government review of the NHS by Lord Darzi, which makes frequent reference to the need for improved discharge processes.

In short:

• Whereas the NHS is funded by taxpayers and free at the point of need, social care is means-tested and only provided to those with the greatest need and least ability to pay.
• With each passing year, the gap grows between those in need and those receiving publicly funded care. This places an increasingly large burden on families and on the NHS.
• The impact on the NHS has been more people staying in hospital for longer than their medical needs require them to be there. This means older people have been stuck in acute hospital wards rather than in facilities better suited to their needs.

Additional analysis from the report found that there were more than a million admissions or re-admissions to hospital per year for conditions not normally requiring hospital treatment. In addition, 2,000 people aged over 65 are admitted to hospital for a condition that could have been treated in the community or prevented altogether.

So given this growing trend, which is placing increased pressure on NHS Trusts around the country, a more holistic approach to the patient care journey is now being taken. More attention is being placed on the entire patient pathway – from first admission, through hospital treatment, and into recovery in a social care setting.

However, joining up these services requires all providers involved – the NHS, care homes, age-related charities, and even housing associations – to focus on integrated care pathways for patients, with care given in the right place at the right time.

Successful Transfers Through Digital Interoperability

As well as bridging the gap between hospital and community care; the NHS is also committed to two other key priorities: moving from a sickness to a prevention-focused model, and transitioning from analogue to digital services. These three things are by no means mutually exclusive when it comes to patient discharge, and most healthcare organisations now acknowledge that these challenges concern people, process, and technology.

Until recently, discharge solutions were provided as part of a core Electronic Patient Record (EPR) system, and didn’t always capture the necessary information relating to a patient leaving hospital. Similarly, hospital IT systems didn’t communicate with the systems used in a community or home setting – and didn’t map to the processes they followed in helping the patients recover.

Ultimately, discharge is all about the fluid and successful handover of patient care between settings. If you don’t have the digital tools to communicate across those boundaries effectively, then you can’t effectively discharge patients.

Ultimately, discharge is all about the fluid and successful handover of patient care between settings.

Right now, while many organisations pass on patient information digitally, all they’re doing is submitting a single siloed piece of information to another care provider. They’re not contributing to an ongoing care record. And that needs to change: for everyone’s sake.

One of the things that’s key to improving all of these issues is for providers and others to integrate interoperable solutions. If all of these elements are aligned, the digital tools perform. But fundamentally, strong stakeholder engagement is needed. No software system can work if people aren’t collaborating and using it in the right way.

Accessible For All

Centralised communication is what’s critical here. Working with organisations that understand the relationship between health and social care is crucial too. Of course, involving patients and those close to them in decisions about their care is also important and is now identified as a key pillar of a successful discharge strategy. However, understanding that recovery is an ongoing process that requires expertise and coordination from several different services means appreciating the bigger picture, which in turn brings the broader need for holistic healthcare into sharper focus.

There can be no doubt that all NHS hospitals are addressing their discharge processes as a key priority, but a lot of them are still struggling to overcome issues. While discharge might seem like a recent endeavour – here in the UK at least – over in the Netherlands the Enovation team has been working with healthcare providers on it for the last 15 years. Designing solutions to fit processes is a key part of our work – rather than the other way around.

Sharing vital patient discharge information should be a seamless process, but that doesn’t mean every service should adopt the same system; instead they should ensure the right information can be accessed by the right providers at the right time. That is what’s most important – and will continue to be; right across the NHS and beyond.

Enovation works with businesses across the health and social care sectors. As a software, integration, and connected device specialist for the industry, being able to unite information across different systems in order to improve patient outcomes is where we excel.

Webinar

On Thursday, 16th January 2025 (11:00 GMT) we will talk to some of the people involved in helping streamline the patient pathway between providers and across care settings during a live webinar. We will discuss the 3 main considerations for any organisation embarking on its digital transfer journey:

• People
• Process
• Technology