BaNES Council drive transformation through RIVIAM’s referral management system

Guest blog by Claire Hopkins, Delivery Director at RIVIAM Digital Care #LPSInnovation

Local Government Organisation and Integrated Care Journal recently covered the Spring 2023 successful roll out of RIVIAM’s Discharge service in Bath and North East Somerset (BaNES)

A year on, we reflect on what has enabled this new model of care to flourish.

What was the innovation?

RIVIAM’s Discharge service is a multi-sided platform.

Hospital staff make patient referrals using a single online checklist to multiple community, housing and third sector providers.

They can track the delivery status of their discharge dependent referrals using a Care Control Dashboard, making better decisions about whether medically fit patients can go home.

Many providers then co-ordinate a tailored response to patients using RIVIAM’s referral management system. In BaNES this happens at the Community Wellbeing Hub (CWH). A real time data feed from the hospital’s Electronic Patient Record to RIVIAM gives providers the latest information on a patient’s ward and expected discharge date.

It means hospital clinicians can collaborate with the third sector.

Siloes are removed; it’s easier to co-ordinate care across the system.

Work can cross boundaries.

And people are offered genuinely joined up care to meet their needs, however complex.

Insight 1 – Delivering outcomes is key to turning a pilot into business as usual

A strong CWH investment case to the council and Integrated Care Board has been approved and future funding now secured. The value-add is clear. The recent CWH business case review found it’s delivering £4.00 per £1.00 invested[1].

And between 2023 and 2024 the Discharge service has contributed to a programme of work supporting a sustained reduction in the number of patients designated as ‘non-criteria to reside’ in the hospital.

There are also other positive outcomes.

Since launch of the Discharge service, 1000 referrals to the third sector, supporting 300 patients.

Ward staff love the simplicity and efficiency; here’s a short video by a discharge facilitator.

Providers are re-organising to adapt to a collaborative working model.

Business intelligence provides insights to commissioners about service provision, duplication and capacity.

Insight 2 – Technology that delivers strategic initiatives will thrive

Delivery of the Discharge service directly supports the mission in BaNES and the local Integrated Care System to enable health and social care to operate as a single, efficient integrated team.

There’s a shared vision to create a culture of ‘home is best’, reducing a reliance on bed-based care. Decisions are guided by this.

Alignment between public service goals and technology delivery makes everything easier and underpins a more supportive environment.

When this happens:

Technology is configured to solve the problem.

Desired benefits are more easily articulated.

Stakeholders more readily buy into the vision and provide active support.

Leaders willingly commit time, with energetic engagement and advocacy.

Co-operation turns challenges into opportunities to deliver better care.

Insight 3 – Co-design and continued collaboration create sustainability

Co-design and human-centred design are central to supporting a solution’s sustainability.

Our discovery involved co-design with hospital nurses, reablement teams and discharge facilitators – always with patients in mind. We supported over 20 different provider organisations to input into the creation of the checklist referral form. Numerous iterations were created.

We were on a journey together to create an easy to use, accessible service.

Trust was built.

Everyone had a stake in configuration and the solution’s future sustainability.

And we continue to ask for feedback to add enhancements.

Insight 4 – A technology partner not a supplier

RIVIAM has remained flexible and responsive throughout delivery and now into the service’s second year.

We are a partner not just a software provider.

What does this mean in reality?

Freely sharing our expertise and experience as a trusted advisor to support optimum decision making.

Knowing what our technology can deliver and adapting it to ensure outcomes are met.

Listening and collaborating.

Delivering on time.

Managing change – during this roll out we had the doctors and nurses strikes to contend with and provider services being added and de-commissioned.

Insight 5 – Support in place

As with all software that enables transformation, there’s a need to support users as they adapt to changes at work.

In a pressurised health and social care environment, this is even more the case.

Our support desk goes the extra mile to help resolve any issues or explain functionality.

Customer success is vital.

If you’d like to hear more insights from RIVIAM or if our services can help your team, please get in touch with [email protected]

[1] This includes social and direct benefits to health and social care with an ‘optimism bias’ of 70%. For more detail about the CWH business case headlines, please contact [email protected] who will connect you with the authors

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