Pathway 1 – Patient Tracking and Welfare Call Post discharge service/ Pathway 2 – Patient tracking service: East of England NHS Trust

Overview

Xyla has been supporting an East of England NHS trust with varying contracts since April 2017. We were first commissioned to support with discharging self-funding patients from hospital. A few months into this contract Xyla were asked to expand our services to include continuing healthcare patients. In June 2021, due to the changes during the COVID-19 pandemic, this contract unfortunately ceased. However, Xyla were then brought back in January 2022 to assist with tracking patient data and providing full sight of this back to the system. 

In January 2022, Xyla was commissioned to gather unbiased patient tracking data from three acute hospitals. This was for a health environmentalist which the CCG (now ICB) commissioned to carry out an analysis of the needs of the hospitals and communities in the trust. 

In December 2022, Xyla and our sibling company Pulse Nursing at Home (PNaH) was commissioned to provide a fully managed Pathway 1 Package of Care Service. This includes PNaH providing domiciliary care in the community and Xyla managing the discharge of patients from the acute and throughout their time on the pathway, to ensure the care capacity was utilised effectively.  

Since providing this service, Xyla was commissioned to deliver an additional hospital discharge service, supporting Pathway 3 patients to be discharged home with either a package of care or into a short-term care setting until the patient has been assessed and their long term care needs confirmed. 

Xyla are delighted that the services here have continually adapted to meet the needs of the system and extended since 2017 due to the success of the partnership between the trust and Xyla. We look forward to supporting the trust into our sixth year of partnership, and beyond.

Our approach

Xyla piloted 24-hour post discharge calls to all patients who went home with a package of care. This service was delivered over seven days a week, obtaining feedback from patients regarding how their discharge was handled. This data was then fed back to the health environmentalists team.

A survey with the patients was also conducted, and the results were then fed back to the CCG (now ICB). Xyla attended meetings with the ICB and social care staff to present the data gathered, and explained the information and outcomes that were found.

Xyla identified and raised escalations in a timely manner, resulting in better patient outcomes. This process had not been done before and it was then used as the foundation for a long term service which is now run by volunteers and is an NHS requirement for all systems.

Impact