Our entry Integrated management of hospital discharge pathways has been shortlisted for the prestigious Health Service Journal (HSJ) Partnership Awards.
This is a joint entry with Bath and North East Somerset Council and CCG for the hospital discharge service they commission, funded by the Better Care Fund and we deliver. It is shortlisted in the Partnership Consultancy of the Year category.
This project started as a small pilot in September 2017 and was so successful that it has been expanded to encompass all funding groups (social services funded and self-funding) and pathways, including individuals in need of Fast Track (end of life) care and a stand-alone project to safely transfer care for individuals in a care home which was closing.
We now work with up to 46 patient referrals every month, sourcing care and managing the whole discharge process and have managed, in total, more than 300 discharges to date.
This means we manage and co-ordinate the very large majority of discharges from Bath hospitals, communicating with multiple services and stakeholders in a clear, streamlined process.
Each patient and their family are allocated their own adviser coordinating every part of the process including, where requested, transport to care homes and accompanied visits and all information sourcing. This support continues through evenings and weekends as this is often the most convenient time for families and reduces delays.
Our entry highlighted a range of outcomes and strengths of the partnership:
- Improvements in the relationship between hospitals and care homes, evidenced in care homes carrying out more prompt assessments in hospital and a more responsive approach to offering places and fees (including acceptance at local authority rates)
- More than 95 per cent of service users rated the support as either ‘excellent’ or ‘good’
- Audits of care three months after placement show very low hospital readmission rates
- Reductions in delays to hospital discharge