Carrie Phillips, Programme leader for MA Social Work at University of Sunderland outlined how social workers play key role in hospital discharge and presented finding from her research. 

Key role of hospital social work teams

The number of hospital social work teams varies across the country, with larger teams typically found in areas with larger local authorities or higher numbers of older people. There is a trend away from hospital-based social work teams. A significant number do not an office within the hospital they support. They face more challenges in accessing wards, obtaining information from staff, building trusting relationships with staff, and speaking directly to patients to understand their conditions and needs. Information gathered over the phone often falls short in supporting a good discharge plan. 

Hospital social workers add significant value by bridging gaps in knowledge about community resources. They are skilled in negotiating with families to determine the best outcomes for patients. Social workers uniquely focus on the future of a patient's life post-hospitalisation, taking a longer-term view. 

However, the skills of social workers can be undervalued by clinical staff, leading to potential undermining. Due to bed pressures, social workers are crucial for ensuring safe discharges, and professional challenges are necessary. KPI-driven discharges are not person-centred; social workers are essential to support patient needs, preventing pressures from simply shifting to another part of the system.

Discharge to Assess (D2A) model

Sarah Leigh-Bergin and Dan McCabe from Cheshire East Council presented the evolution of the social work role to support hospital discharge and the Discharge to Assess (D2A) model. They compared pre and post covid challenges and opportunities. Using this learning they described the process of moving to a newer model and the positive outcomes this generated.

They concluded by describing how the Discharge to Assess (D2A) model strengthens the role of social workers. The benefits include ensuring that 'the person remains at the heart of all we do' and focusing on a 'home first' approach. This model not only empowers social workers to make more informed decisions but also fosters stronger relationships with clients, leading to better health and social outcomes.

Days Kept Away from Home Collaborative

Jack Fallows and Daniel Rowbotham from Northern Care Alliance (NCA) described how following the COVID-19 pandemic, the demand for care in the NCA patch became unmanageable. However, it was observed that 40% of hospital discharge care packages were cancelled within 48 hours. This clearly indicated a significant mismatch between the care packages allocated and the actual needs of the patients.

Most hospital patients expressed a strong desire to return home as quickly as possible. The aim of the collaborative was to ensure that 95% of patients over the age of 65 were discharged to their usual place of residence. This goal was driven by the understanding that patients recover better and feel more comfortable in their own homes, aligning with the 'home first' approach. 

The collaborative focused on highlighting the capabilities of patients on admission and protecting these by -
• Engaging patients and families to promote independence whilst in hospital
• Co-designing discharge planning with patients and colleagues
• Education and training ward staff on the strength based approach
• Coach staff to lead quality, strength-based conversations

During the pilot 84 patients went home sooner that they would have normally done. Now, during the full implementation the following outcomes are being achieved -

• 85% of over 65's going back to normal place of residence
• 92% of all age patients back to normal place of residence

Days Kept Away from Home Collaborative had a positive impact on 1000’s of lives.

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