Patient Pathway Planning

The decision to transfer a patient from hospital to their usual place of residence requires considerable planning to coordinate the completion of activities to support ongoing care for patients. The image to the left is a representation of the steps required in an ideal process to ensure effective communication at the point of transfer, using reliable mechanisms to share information.

An innovation project, funded by Salford CCG, supported a patient pathway lead to capture the experiences of patients as they transfer between care settings after a stay in hospital. This evidence base supported development of new ideas and innovations which will ensure that patients are prepared and able to manage their health following an admission.

The project took an ethnographic approach to understanding the patient experience by observing the processes undertaken by clinicians and nursing staff and capturing patient views. Considerable focus was on non-elective patient journeys for older adults (over 65 yrs old) from admission via the Emergency Admission Unit (EAU), with follow up 4 weeks after they are transferred back home.

A research leaflet was designed to gather qualitative feedback on the patient experience of those admitted to EAU. Early findings suggested that the majority of those surveyed felt  satisfied with the care received at Salford Royal Foundation Trust, however over half of those interviewed stated they did not have a discussion about their discharge and onward care planning.

As part of the project, the pathway lead explored how GP practices are supporting patients following an admission and noted that whilst there are many approaches used to support patients identified as vulnerable, there is no standard approach.

Based on the feedback and the GP review, a number of recommendations were put forward by the patient pathway lead.

These recommendations included;

• Communication with patients regarding discharge planning, discussion and discharge summary documentation
• Patient access to advice and guidance to support discharge
• Increase the use of a patient booklet to support the discharge summary
• Collaborative working

The next phase of the project would be to explore these recommendations and develop implementable solutions. This was due to include a review of the patient-focused discharge summary document, testing options to improve discharge planning whilst in hospital for patients, and gaining further understanding of processes in place in primary care. Work was halted due to the worldwide COVID-19 pandemic (2020).