Background Many patients will unnecessarily wait too long for discharge from hospital resulting in a poor experience of the health/social care system, which may cause a reduction in their overall health outcomes (Emergency Care Improvement Programme, 2015). A pilot is being conducted to reduce numbers and waiting times of patients ready for discharge from hospital and facilitate their move back to their care home speedily, effectively and safely. A Trusted Assessor’s (TA) role has been assigned and its role is to act as a central communications link, facilitator and trouble-shooter.
Aim The pilot aims to provide:
Smoother transition between care providers thus improving the discharge of patients
Potential reduction in bed days within an acute care setting following the timely discharge of patients involved with the pilot
Evidence of how the TA model could work within care homes on a long term basis.
Methods Care home staff initiates referral to the TA about proposed hospital discharges. TA visits the hospital to assess patients admitted from a care home ensuring that all current end of life plans and clinical information are considered as discharge planning commences. TA liaises and confirms the patient’s current condition can be managed by the care home and any equipment/medication is ordered prior to discharge. The TA is responsible for completing documentation for data review and audit trail.
Feedback Care home staff report communications have improved with the hospital because of intervention of the TA which keeps all parties in the discharge/admission loop. The hospital is monitoring potential reductions in bed days. Positive outcomes of pilot have helped build a new level of trust and co-operation between all parties.
Conclusion The impact of the pilot has been enhanced trust and working relationships for all stakeholders. Further explanation of the role is anticipated with recruitment of TA to cover more homes.
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