Visualising and understanding post discharge management of older people in general practice

Problem

Discharge from hospital is a critical part of the patient journey, particularly for older patients with multi-morbidity and polypharmacy. Clear communication via discharge summaries is essential to a safer discharge experience. While national standards for discharge summary creation in secondary care exist, there are no agreed standards or interventions for primary care management after discharge. Furthermore, despite the speed of discharge summary processing in primary care, omissions and errors are occurring. To address this issue, there is a need to first understand and visualise the current processes in place for the post discharge management of older people in general practice. The present study aims to understand and visualise practices’ systems for post-discharge management of older patients and therefore what types of intervention will work well.

Approach

Purposeful sampling was used to select ten practices based on size, geography (rural/urban) ethnic diversity, and socioeconomic status. Systems information was gathered from fieldwork at the practices, including informal discussions with administrative and clinical staff during the initial site visit. Function Resonance Analysis Method (FRAM), a technique used successfully for complex systems in primary care, was used to illustrate practices’ systems and points of variability.

Findings

We present novel process map summaries of our ethnography (FRAM diagrams) which allow unique insight into GP systems. We found evidence of innovative use of administrative and clinical staff in managing discharge summaries. There is a focus on the actions section of discharge letters and a strong focus on safety. A range of different staff members are involved in the post discharge care process, with new PCN roles, especially pharmacists in primary care, playing an increasingly active role. Some core functions are common across all practices but in other functions there is a high degree of variability. With the dissolution of DES funding for the post-discharge space, there is currently no standard (proactive) appointment offered to older patients following discharge and more reactive care is being offered.

Consequences

There is currently a large degree of variability in the general practice care offered to patients following discharge. While there is no one-size-fits-all approach, it is useful to understand commonalities and variances in care because it has the potential to enhance access for patients following discharge, especially for frail and vulnerable patients.