Discharge to Assess

1. Discharge to Assess Helen Krysinski

2. Issues and enablers • System agreement and buy in- understanding D2A • Current community infrastructure to support D2A- commissioned providers • Joint funding agreement • Conflicting priorities and influence to change • Pathway 1 provider- fragile • Structural stakeholder changes – ESNEFT/ECC/Alliance/IBCF reporting • Unpicking the current pathway avoiding duplication of services • Community social care team with capacity to ensure rapid flow through the proposed D2A pathways. • Organic model with expanding scope

3. Pathway 1/2 – Home to Assess model implementation - Home to assess. (requires approval and funding) Home to Assess will provide a service to pull patients from the acute hospital from ward level. Ensure same day availability of services to discharge patients to their own home. Provide with a wrap around assessment and support for 5 days. The service will then handover the continuity of care seamlessly to the appropriate provider. • Pull from hospital wards- same day discharge • Full assessment same day at home • Wrap around support provided –nurse ,therapies and care workers for 5 days in the home • Goals set for rapid rehabilitation/reablement and continued assessment against goals • Full social care assessment • Referral and signposting to ongoing services- continued reablement short term ,voluntary services and medium to long term care provision. • Maximising independence and reducing the long term care needs of the adult. • Can do ethos with patients at the centre.

4. Pathway 2/3 residential reablement and sourcing of long term needs. For patients who are unable to return home safely but require a short period of residential reablement and rehabilitation. The aim is for all patients to return to their own home or to suitable long term accommodation. • Identify 20-30 beds in current residential/care homes to accommodate transfer of patients directly from the acute hospital. • Implementing a pull model facilitated by a coordinating therapist who will work across the hospital and community setting. • Same day discharge • Full assessment and plan of care to promote independence • Wrap around support provided –therapies, social care and care workers for up to 2 weeks • Goals set for rapid rehabilitation/reablement and continued assessment against goals • Support and review by a doctor to reduce the risk of failure due to limited primary care provision • Referral and signposting to ongoing services- continued reablement ,voluntary services and medium to long term sourcing of care provision. • Maximising independence and reducing the long term care needs of the adult. • No assessments in the acute hospital

5. Patient no longer requires acute hospital intervention Pathway 0 Pathway 1 Pathway 2 Pathway 3 Safe to return home with moderate short term support ? Patients with rehab potential but unlikely to return to their original place of residence. Would improve function and reduce long term care needs Needs can be met safely at home/further rehab reablement. Pull from the acute Consider short stay whilst sourcing long term placement N0 additional ongoing care needs Y N Home Pull from the acute Focused intervention and support to return home or to source long term care up to 2 weeks in the facility Focused intervention and support in the home up to 5 days. Discharge home , restart existing care or support package. Refer to voluntary services as needed. 5 Day focused assessment and reablement/rehab. Commissioned providers : 2 weeks Reablement and rehabilitation in the home- only extended to 6 weeks in exceptional circumstances- refer to services for ongoing needs Rehabilitation /care in community bed specialist input is required . CHC assessment if appropriate Proposed residential discharge pathway Home to assess provision