Reducing delayed transfers of care (DTOC) for older adults with frailty: a systems-thinking approach to health and social care processes.

Research Team

• Professor Yvonne Birks (PI)
• Dr Mark Wilberforce
• Dr Abby Dunn
• Dr Louise Newbould

Background 

A continued challenge to the success of inpatient care remains the prolonged length of stay caused by delays in the discharge process. For older adults, delayed transfer of care (DTOC) have been shown to result in declining mobility and a reduced ability to undertake tasks of daily living, with some requiring additional care than
otherwise would have been necessary.

Studies of the management of frailty and its relationship with prolonged hospital stays has prompted established recommendations to facilitate prompt discharge. Yet DTOC remains problematic. A recent review concluded that delayed discharge problems are commonly system-specific, requiring system-specific responses. Evidence needs to be supplemented with detailed local understanding of the unique system faults giving rise to DTOCs, and how these may vary depending on the model of discharge being used. Additionally, published studies mainly focus on the health system, with social care being included as an external agency rather than as a central part of the system. Health elements are usually accounted for in comprehensive detail, ‘social care’ is commonly restricted to assessment staff and the immediate interface with hospital discharge teams.

The purpose of the research

The study aims to understand how complex health and social care processes contribute to DTOCs for older people, when comparing traditional models of discharge to the new discharge to assess model. The findings will be used to inform interventions to aid the reduction of DTOC at participating trusts.

What we will do

1) We will conduct a scoping review, which will be used to chart projects that have employed systems thinking methodologies to explore the complexities and health and social care processes relating to DTOC. It will also inform the methods used for this project and will identify factors that can be modified to reduce DTOC and explore the feasibility of systems changes.  

2) We will then explore causes for delays in discharge at two trusts. One trust will be using the new discharge to assess model and the other sustaining a traditional model of discharge. Within each site we will: 

2.1 Conduct interviews with managers involved in the discharge process within both the NHS a social care sector. These will aim to develop an initial understanding of competing world views and areas of conflict within each trust.

2.2 Conduct a broad range of interviews with a range of health and social care staff, and practitioners within each trust. These will aim to explore the goals of the different stakeholders, and perceptions of the competing pressures they face, and how they interpret the challenges of DTOC.

2.3 Using the findings from the interviews, we will build a rich picture of DTOC at each site; identifying key activities that participants are engaged in and how these might conflict with each other and other parts of the system. The findings will be presented as a conceptual model (s).

2.4 We will then conduct workshops with approximately 15 stakeholders at each site. The findings will be presented and discussed, with the hope of identifying potential areas for improvement. 

3) We will then share the findings with the Improvement Academy so that they are able to identify and implement relevant interventions for each participating site. 

Additional information