Intermediate Care and Discharge Data Analysis and Innovation North West London ICS: Imperial College Health Partners

In April 2023, North West London (NWL) had 14 per cent of beds occupied by patients whose discharges were delayed - the highest proportion in London. The system struggled with continuity of care and communication, leading to inefficiency and variability between providers.

Imperial College Health Partners (ICHP) has recently worked on two initiatives using data insights and innovation to support decision making in intermediate care and discharge. These initiatives contribute to the NWL Research and Innovation Mission to enable more days at home and reflect ICHP's commitment to using data-driven solutions and innovative technology to improve patient care. 

Intermediate care pathways specifically present an important part of healthcare services for NWL residents and can help to prevent readmission to hospital.

1. Networked Data Lab (NDL)

The NWL lab, funded by The Health Foundation, is part of a pioneering collaborative network of analysts using linked data, open analytics, and public and patient involvement to tackle health and social care challenges. The NWL NDL analysis focused on step-down care (support to remain independent post hospital stay) within the Intermediate care topic. It revealed difficulties in identifying recipients of intermediate care services due to limited and fragmented national public data, stemming from the diverse range of commissioners, providers and services involved.

However the analysis highlighted an opportunity to improve data collection through deployment of novel technology to pull together information across disparate teams, which could enhance coordination of discharge and follow-on care.

2. Optimised Patient Tracking & Intelligent Choices Application (OPTICA)

OPTICA, part of the NHS Federated Data Platform (FDP), is a secure, cloud-based application which tracks admitted patients and discharge tasks in real-time. It creates a single source of real-time information about patient discharge arrangements across different trusts and local authorities, streamlining communication and facilitating the best discharge support for patients. This reduces discharge delays, ensures continuity of care, and improves patient outcomes through enhanced visibility, understanding, and collaboration. 

The OPTICA software was rolled out in summer 2024, across Hillingdon Hospitals NHS Foundation Trust, Hillingdon Council, Chelsea and Westminster NHS FT, and the Royal Borough of Kensington and Chelsea. This was supported by ICHP with a small training, transformation, and evaluation team.

The NDL’s intermediate care topic and OPTICA roll out have highlighted key areas for improvement and the potential for more targeted, data-driven interventions in step-down care and discharge coordination:

• The NDL analysis explored access to, and journeys through, intermediate care services, revealing substantial variation in access to step-down intermediate care across medical specialities and locations within NWL, impacting readmission rates.
• OPTICA: Early reports from trust and social care teams using OPTICA show marked reductions in email volume (circa 30per cent), phone communications and streamlined meetings. This has released hours of staff time daily, and miscommunication has substantially reduced.

A full evaluation of Optica is being conducted to assess the impact on delayed discharges during winter 2024/25, with the aspiration of a full NW London implementation pending successful evaluation. 

This improved efficiency aligns with the NDL findings, emphasizing the importance of timely and accurate data in managing step-down care and patient discharge.

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