Stage Two: Co-designing

The second stage of this project was undertaken over eight months from early May until December 2014.

During this eight-month phase the project lead, Fiona Munro, was supported by Stuart Muirhead, a project manager within Iriss's Evidence Informed Practice Team, to run a series of monthly co-design workshops within Tayside. Three Masters of Design for Services students from Duncan of Jordanstone College of Art & Design also provided additional support helping to run the workshops during this phase of the project.

These workshops were designed to support a range of health and social care practitioners working in Tayside to work alongside older people and informal carers who had recently experienced the local discharge pathway. The Design Council's Double Diamond Methodology was used to identify issues with the current discharge pathway and to co-design interventions for local implementation.

“Just go for it and get involved you will be amazed what you learn and you will find it most enjoyable.”
—Reflections from an Older Person involved in the Working Groups

“The experience has been so valuable to actually meet people face to face and listen and process information which can then be used to develop, validate or change what has been learned.”
—Reflections from a Practitioner involved in the Working Groups

More information about the specific activities used during these workshops can be found in this audio update from Stuart:

The Scottish Co-Production Network has also published a case study of the co-production approach applied during these workshops. This provides a helpful overview of the co-design methodology used and some of the learning gained by the group as a whole.

Key problems

“As we moved into the sessions looking at the pathways I quickly focused on language and the importance to make it clear and not full of jargon or buzz words but plain and simple for everyone to understand. Professional barriers were quickly removed as we were aware that we all wanted the same outcome, an outcome that was to provide an excellent pathway of Hospital to Home for the person involved.”
—Reflections from a Practitioner involved in the Working Groups

The group worked collaboratively to identify the key problems that prevent an older person from having a positive experience during their transition from hospital to home. This process identified problems at four key stages. Click on the map icons below for more…

HTML Image Map Hospital Home Care home 4. At home or care home 4. At home or care home 3. Leaving hospital 2. In hospital 1. Getting to hospital

Hospital

The hospital (acute care) is sometimes viewed by practitioners as the starting point in the hospital pathway. Older people and informal carers, however, view it as a small part of a journey returning to home and good health.

Care home

In some circumstances, a care home is used in the pathway as a step down facility or to provide early support discharge. It is important to remember that when an older person is admitted from a care home it should be treated as their home in the same way as a house would be.

Home

The older person's home should be viewed as the starting and end point of the discharge pathway. Older people remind us: "it's where they live their lives".

1. Getting to Hospital

  • GPs aren’t notified when an older person is admitted to hospital
  • There is a lack of person-centered care

2. In Hospital

  • The pre-assessment is focused heavily on heath care and not social care
  • Older people don’t always know who needs their information or how it is passed on once disclosed
  • Communication channels could be improved
    • Anticipatory Care Plans are not shared
    • Pre-assessment care plans are not being used. They are paper based. They are used when someone goes into hospital but not passed on when they leave. "What's the point?" "A waste of time"
    • Healthcare pre-assessment is not used to its full potential. It is not shared throughout the pathway
    • Files are illegible. No one wants, or has the time to try to read them – “paper based records are a mess”
    • Notes get lost in the system
  • There is a lack of clear discharge planning
  • Balancing what is professionally best for the person whilst also trying to meet their personal needs can be challenging
  • Lack of communication between professionals and family/carers about what is happening
  • Inequality and inconsistency within pathways
  • Lack of information on roles because practitioners are not trained together

3. Leaving Hospital/Getting Home (Discharge)

  • Discharge is often too early
  • Planned discharge date and decisions around this are not always discussed with older person, family or informal cares
  • There is a lack of bed availability within care homes
  • There is a lack of consistent information across the pathway
  • There is often a lack of time to make life-changing decisions (for family and practitioners)
  • Capacity Issues (e.g. Cognition of the older person)
  • Delays in obtaining medication – Venalink
  • Explanations of medication changes don’t always happen or aren’t communicated clearly
  • There is a lack of communication between health (doctors, nurses, AHPs) and patient/family
  • Often no consideration is given to how the family will cope upon discharge

4. At Home (or Care Home)

  • Older people can feel a lot of challenging emotions once discharged – fear/anxiety/social isolation
  • Older people can rely on others who fail to deliver (care at home services sometimes fail to turn up)
  • Older people can encounter unexpected issues once alone at home
  • Family expectations don’t always match reality
  • There is often a gap between the care you get and the care you actually need once in the community
  • Social isolation can occur because of no overnight care
  • Suitable care packages can't be put in place without the right information
  • There is a lack of appropriate settings between hospital and care home or appropriate housing
  • Equipment is not always in place in time for discharge
  • Lack of funding can cause frustration
  • Communication between agencies is not always clear
  • Medication – sometimes people are left to self-medicate and they are not able to – proper instructions are needed to avoid confusion
  • Time restrictions
  • Rules and regulations are stifling person-centered practice
  • Older people don’t always know who they can turn to if their care at home is poor

Key learning

“Our outcomes quickly became apparent that it was a pathway for the person or people involved and we all wanted to get it right.”
—Reflections from a Practitioner involved in the Working Groups

One of the key learning outcomes from this phase of the project was the varying perspectives of the pathway from hospital to home.

The pracitioners' view

Practitioners, as a group, illustrated the pathway as starting in the hospital and ending when the older person is discharged and returns home or to a homely setting.

The non-pracitioners' view

Non-practitioners in the group, on the other hand, illustrated that they see the pathway starting and finishing at home, with the hospital playing only a small part of their journey.

Shifting the perspective of practitioners to match that of the people within their care will ultimately help to lead to a more person-centred pathway that focuses on the person’s desired outcomes.

pracitioner view versus non-pracitioner view

Pracitioners' view
Non-pracitioners' view

Identified solutions

“I believe it is important that problems with communication are addressed. I would like to see at least one of this group's recommendations going forward and to hear that it is actually working in practice.”
—Reflections from an Older Person involved in the Working Groups

In response to the key problems at each of these stages, the group proposed a three-pronged approach as follows…

1. An admission coordinator

There were concerns about the quality of the information gathered at the point of an unplanned admission to hospital and how this is then shared through the pathway within hospital and into the community.

The introduction of an admission coordinator may resolve some of these issues. This coordinator would be responsible for gathering and recording all necessary information at the point of the older person’s unplanned admission to hospital and ensuring that this information is passed on appropriately throughout the hospital staff. In addition, they would also take responsibility for notifying the key services already involved in the older person’s care in the community (GP, Social Services and third sector organisations) and involving them in the discharge planning process.

This process could be informed by the success of the planned admission planning already in place. In response to the problems identified, this approach would help to ensure that the older person:

  • Has their needs considered from the start of their pathway
  • Is kept at the centre of all discussions
  • Has their information only passed on to those who need it
  • Isn’t asked for the same information repeatedly
  • Has a person they know they can turn to for further information and reassurance

In addition this would also help to ensure:

  • Existing forms are utilised more effectively and appropriately
  • Better communication between the hospital and community based staff from the point of admission, rather than discharge
  • This in turn would prepare the community based teams for discharge at an earlier stage and help to prevent unnecessary delayed discharges
  • All practitioners share the same good communication strategies

2. A named practitioner following the older person

Information is not always shared with the older person, their family or informal carers and they don’t always know what to expect, what is happening next or when their discharge is likely to be.

The number of practitioners involved in an older person’s hospital stay and discharge only compounds these issues.

The group proposed, therefore, that one practitioner take responsibility for all information shared with and about the older person. This person could also have the role of the admission and/or discharge coordinator, mentioned above.

In response to the problems identified previously, this approach would help to ensure that the older person:

  • Always knows who to ask questions if they have any concerns or uncertainties
  • Has their needs identified and addressed throughout their hospital stay and discharge
  • Always has the information about their care with them - “nothing about me without me”

In addition this would also help to ensure:

  • One practitioner has responsibility for the older person’s information and for ensuring it is shared appropriately within the hospital and community
  • An effective communication link between the community and hospital based care

3. ‘Discharge’ at home

One of the recurring issues arising through this project was how older people feel when they are discharged and how this can contribute to them not experiencing a positive pathway from hospital to home.

Being discharged from hospital can often be as traumatic for an older person as when entering the hospital at the start of their journey through acute care. They often don’t know how they will cope at home, who will support them and what to expect generally about their changed capabilities. A hospital stay will often reduce an older person’s confidence, mobility and independence as well as increasing their frailty. All of this constitutes a number of unwanted emotions such as fear, anxiety and stress. These are furthered by a lack of communication about when they are likely to return home.

Lack of appropriate assessment of an older person’s home prior to discharge and delays in necessary housing adaptations only create additional problems once the older person returns home. This increases the likelihood that they will be readmitted.

Considering these concerns, recommendation was made that older people be discharged from the hospital service once they are in their home and they are happy to be so, rather than at the point when they leave acute care.

In response to the problems identified, this approach would help to ensure that the older person:

  • Receives support once at home that is appropriate to their individual needs
  • Remains in control of when they are discharged
  • Has time to adapt to and understand that their circumstances and/or capabilities may have changed
  • Has overnight support within the community through communication links to acute care
  • Has control over decisions about their care – these are made with them in a setting in which they are comfortable (i.e. their own home)
  • Is able to better manage the unexpected concerns that may arise
  • Doesn’t feel socially isolated following discharge
  • Is always involved in discussions and in control of what happens to them

In addition this would also help to ensure:

  • An overlap between hospital and community based practitioners
  • Integrated working
  • Person-centred care

The people

This eight-month co-design phase of the project was greatly supported by a number of practitioners, older people and informal carers in Tayside. We have also been fortunate enough to gain support and insight from local University of Dundee Masters of Design for Services Graduates.

With special thanks for their time and input, and with their permission, some of those involved are listed below:

NHS Tayside

  • Caroline McQuillian: Associate Nurse Director NHS Tayside, Nursing & Midwifery Directorate
  • Cesar Rodriguez: Clinical Lead Older People in Acute Care Collaborative, NHS Tayside

National Project Advisory Group

  • Bernie Campbell: Scottish Care
  • David Strathearn: CCPS Associate / Voluntary Sector Advisor
  • Diane McCulloch: Head of Community Care, Social Work Department, at Dundee City Council
  • Miles Witham: Clinical Reader in Ageing and Health at NHS Tayside/University of Dundee School of Medicine
  • Roy Soiza: Consultant Geriatrician & Honorary Clinical Senior Lecture at NHS Grampian

Tayside Project Working Group

  • Andrea Blyth: Occupational Therapist, Community Rehabilitation Team, Dundee
  • Amanda Clements: Nurse Coordinator Intermediate Care, Assessment Clinic for the Elderly Manager, Perth and Kinross CHP
  • Arlene Ogilvie: Social Worker, Community Mental Health Team Older People, Dundee
  • Catherine Davidson: Angus Discharge Co-ordinator within Social Work Department, Dundee
  • Christina Cooper: Project Coordinator, Reshaping Care for Older People Change Fund, Dundee Voluntary Action
  • Donna Laird: Team Leader District Nursing, Dundee
  • Elizabeth Fairgrieve: Service User, Tayside
  • Iain Paton: Project Officer, Special Needs Unit, Housing Investment Unit
  • Ian Leitch: Informal Carer, Tayside
  • Jean Cook: Service User, Tayside
  • Karen Gall: Team Leader, Dundee Discharge Team
  • Karen Lesslie: Acting Team Manager, Enablement & Support/CMHT, Dundee
  • Kristy Whitton: Nurse Practitioner, Medicine for the Elderly Team, South Angus
  • Margaret Hume: Informal Carer, Tayside
  • Michael Carson: Locality Pharmacist, Dundee CHP
  • Olivia Robertson: Head of Nursing, Medicine for the Elderly, NHS Tayside
  • Stan Eggie: Service User, Tayside
  • Tanya Gold: Social Worker, Social Work Department, Ninewells Hospital
  • Tracey Passway: Clinical Governance and Risk Management Team Leader, NHS Tayside
  • Willis Brown: Service User, Tayside

University of Dundee Masters of Design for Services Graduates

  • Aishwarya Iyengar: Service Design Graduate, University of Dundee
  • Lorri Smyth: Service Design Graduate, University of Dundee
  • Yiqiu Wang: Service Design Graduate, University of Dundee