South Gloucestershire residents are being helped to return home sooner following an inpatient stay at Southmead Hospital, thanks to an innovative service launched this week (19 October 2015) by the local NHS and social services.
The ‘Discharge to Assess’ service has been commissioned by NHS South Gloucestershire Clinical Commissioning Group (CCG), working in partnership with North Bristol NHS Trust, not-for-profit social enterprise Sirona care & health and South Gloucestershire Council.
The service focuses on the routine assessments carried out to establish an individual’s care and support needs following a hospital stay.
Typically these assessments are carried out in hospital but as part of the new service, community healthcare teams will provide same-day assessments for people in their own homes on the day of discharge, allowing them to return home as soon as they are no longer in need of hospital care.
Sirona care & health will continue to support patients as necessary in the days following discharge, working closely with South Gloucestershire Council to arrange social work assessments and ongoing care if this is required.
Benefits of the approach for patients include a quicker return home, the ability to rest and recover in familiar surroundings and less risk from the secondary complications that can be associated with longer hospital stays.
Assessments in more familiar surroundings also help to provide a more accurate assessment of individuals’ needs.
The service also supports measures to improve the ‘flow’ of patients through Southmead Hospital by ensuring individuals are discharged as soon as they are clinically fit to leave. Within Southmead Hospital, it will be supported by an Integrated Discharge Service which will bring together social care and health teams to focus on safe, timely and appropriate discharge arrangements for patients.
Welcoming the launch, NHS South Gloucestershire CCG deputy chair and clinical lead for urgent care Dr Ann Sephton said: “Discharge to assess is a good example of how we are working in different ways to provide a better experience for patients as well as better use of NHS resources.
“Few people want to stay in hospital once they have been declared fit for discharge and with this service we’re ensuring that people can leave hospital as soon as they’re ready to go.
“That’s good for patients, but it’s also good for the wider NHS as it frees up beds for people who do require acute hospital care.”
Cathy Daffada, Sirona’s Rehabilitation Lead, said: “Individuals, their families and carers are always really pleased about being able to be assessed in their own home rather than in hospital.
“They know they will be safely supported by services that meet their needs and will receive help to enable them to be independent at home. It’s about having the right care at the right time in the right place.”
David Allison, NBT Head of Transformation, Patient Flow and Discharge added: "Ensuring that we have staff in the hospital who work closely with patients to fully understand their needs is essential to this project.
“Our aim is to make the transfer of care from hospital to home or other destination as easy as possible for patients, their families and carers."
The service is being commissioned by NHS South Gloucestershire CCG as part of measures to improve patients’ experience of urgent care services while responding to the challenges of South Gloucestershire’s growing and ageing population.
Delivering more care for patients in the community is a specific priority for the CCG and reflects feedback from patients who say they want easier access to services, in convenient settings closer to home and with more joined-up working between providers.
As part of this work the CCG has worked with Sirona and South Gloucestershire Council to enhance and expand community health services to provide the additional capacity and flexibility needed to deliver more care in the community.
Other services being commissioned by the CCG include a primary-care based minor injury service designed to improve patients’ choice of – and access to – local urgent care services; a community frailty service providing high-quality out of hospital care for the frail and elderly; and a community falls service focused on preventing falls among the elderly.