Addressing a whole-of-system challenge: delayed discharge

Delayed discharge reflects the consequences of someone not receiving the right care, in the right place, or at the right time.

The statistics around delayed discharge, or exit block, describe a hospital problem only if they are read from within the hospital. Step back, and something bigger comes into view. The person in that hospital bed is not stuck because the hospital failed. More often than not, they are stuck because an aged care home, the home support package, the spot in a transition care program, the community nursing support, the disability supports or the accessible housing they need is unavailable, delayed, or poorly coordinated.

Delayed discharge is not a hospital problem, an aged care problem or a housing problem in isolation. It is a care economy problem, and it needs a system-wide answer.

That was the clearest message from the Parliamentary Roundtable Catholic Health Australia convened at Parliament House in July, which brought together more than 40 participants from Commonwealth and state government, parliament, clinical practice, aged care and hospital providers, consumer groups, health economics and regulatory bodies. It was one of the most senior cross-sector gatherings on this issue to date. What emerged was not a neat consensus, but something more useful: an honest picture of where the system is failing, and what it would actually take to fix it.

Fragmentation has corroded trust

The discussion surfaced the erosion of trust that system fragmentation has produced.

You can see it between sectors. Aged care providers are not always confident they are being given an accurate picture of the person they are being asked to care for. Hospital coordinators work to place a patient who no longer needs a hospital bed, and find every door requires a key they do not hold. Transfers slow, or do not happen at all, and the patient stays where they are.

You can see it between governments too. Our funding structures reward pushing costs across a boundary. Where a patient is funded by one party when they meet one condition, and by another party when they meet a different condition, the result is a web of interdependencies that becomes hard to explain, and harder still to navigate. Without transparency, we perpetuate the very structures that erode trust.

The harder truth is that responsibility shared completely across the care economy can end up owned by no identifiable part of it. So, the answer is not to make one actor wholly responsible. That has been tried, and it has failed, because no single actor holds enough of the levers, nor should they. The answer is collective accountability: clear, agreed points of ownership for patient transitions, with each part of the system doing its part, and doing it in a way that holds true even as the system reforms around it.

Person-centred care has to be built in, not an afterthought

Doing our part means keeping a firm perspective on person-centred, values-based care. But that phrase has to mean more than a statement of intent at the front of a strategy document.

It means shifting funding measures, governance structures and the workflow arrangements that determine how care is actually delivered. If funding rewards throughput rather than outcomes, care will follow the funding. If governance makes it easier to hand a person off than to see them through, that is what will happen. Data, performance indicators and incentives all need to reflect a person-centred approach from the outset, because these are the instruments that quietly shape behaviour long after the intent has been forgotten.

This is why the roundtable’s interest in a national minimum dataset and a shared clinical language matters more than it might first appear. A shared dataset spanning My Health Record, My Aged Care and NDIS systems would allow delays to be picked up as they happen, rather than after the fact. But data alone is not enough. Without agreed definitions beneath it, including something as basic as when a patient is medically ready for discharge, we cannot have a consistent conversation about the problem, let alone measure whether we are solving it.

Ideas exist and this is only just the beginning.

Despite all the issues presented around the subject matter, there were no lack of ideas at the roundtable.

The discussions surfaced short, medium and longer-term options across prevention, coordination and capacity. Scaling in-reach and Hospital in the Home models. Discharge planning that begins at admission rather than at exit. Transition beds. Pooled funding models that recognise multidisciplinary teams working across acute and community settings.

What these ideas need is a principle to organise them, and the discussion offered a compelling one: reablement.

Reablement treats independence as something that can be actively rebuilt, rather than lost capacity to be managed or compensated for. It sounds like a technical distinction. It is not. Where much of the delayed discharge conversation frames patients as a flow problem, people waiting in beds for a destination, reablement reframes those same patients as people whose function can be restored, so that a lower-intensity destination, or none at all, becomes possible. It moves the system’s effort upstream, from managing dependence to preventing and reversing it. It recasts delayed discharge as a question of capability, not throughput.

Where to from here

If delayed discharge is a question of capability, the task then should be to build capability across the system, together. Implementation science offers a way forward. Put simply, it is the work of closing the gap between what we know works and what actually happens on the ground. This means leveraging evidence-based practice, context-specific problem-solving, and keeping a sustained focus on change that lasts.

Consensus on the problem is the easy part. The value lies in working through the areas where the sector does not yet agree, because that is where the barriers to reform actually sit.

The people currently waiting in hospital beds they no longer need are not waiting for a better idea. The ideas exist. They are waiting for the parts of a fragmented system to trust each other enough, and to be structured well enough, to act together.

Annabelle Wang is a Policy Officer at Catholic Health Australia