It is widely known that the majority of patients recover better at home, both physically and mentally. Acknowledging this, the Trust is working hard to change the balance of care from hospital to the community and streamline the discharge of patients from hospital as soon as is appropriate.
An external review of health and social care discharge activity, commissioned by the Trust and Rotherham Council, was undertaken to get a view on current performance.
The review found a number of positives about the teams involved and their enthusiasm to work in a more integrated way. It recommended the development of an integrated health and social care discharge team with streamlined pathways, improved escalation routes and reporting. This would also provide benefits to patients and their relatives or carers by improving the process of discharge and having one key worker to coordinate services.
As part of the scoping of the project a series of conversations were held with different teams including ward staff. Further events are planned with medics and therapists. Look out for the team in reception in November when it is hoped to talk to as many patients, carers and staff as possible. If you have any views you would like to share please contact Steph Watt.
The project has identified and implemented a range of measures to improve discharge.
The Transfer of Care Team and the hospital’s Social Care Team will be co-located before winter.
The Integrated Discharge team will take charge of discharge planning for those patients with complex needs who need coordinated care and support to return home.
All potential referrals will be screened and the new processes should also reduce the number of inappropriate referrals for social care and speed up referrals where these are needed.
The changes will build on existing good practice and working relationships to produce even safer discharges for our patients.
Claire Smith, Head of Adult Commissioning at Rotherham CCG / Rotherham Metropolitan Borough Council, said: “This is fundamental to the reduction in delayed transfers of care. By making these changes we can quickly make a difference for patients, carers and colleagues. It will give us more time to work together to consider how different parts of the system including ward staff, therapists and the community can work more effectively together to reduce delays.”
Lindsey Taylor-Ward, Social Work Team Manager, said: “Being part of the same team, in the same office, will make it a lot easier for patients and the whole team.”