United-Kingdom

Region:

Kent

Target group:

Patients which would be triaged from hospital as needing category 2 health rehabilitation and which would then have transferred to community hospitals

65+ patients at Medway Maritime Hospital are currently assessed by the “Integrated Discharge Team” following the “own home is best” principle. The aim of the service is to reduce the number of patients transferring from acute hospitals to community hospitals or into care homes. The Team currently conduct triages and safety screens in the Hospital and, if clinically appropriate, patients are then discharged for a full care needs assessment in their own homes within four hours of the initial triage. Once home, patients receive the enablement and rehabilitative care as stipulated by the home assessment. In March 2016, “Discharge to Assess: Swale” will expand its service offer to patients who are discharged back home. The interventions will be delivered by the “Active Recovery Team” which will be made up of health and social care assessment practitioners like occupational therapists, physiotherapists, nurses, a Community Mental Health Practitioner Nurse, a Kent County Council Case Manager and Occupational Therapist. They will provide (more health & social care integrated) complex and high level support where required (including night care).

Region:

Kent, UK

Target group:

75+ with long-term care needs

Sandgate Road Surgery has developed an “Over 75 Service” which aims to establish clear multidisciplinary care pathways. The service identifies frail, older people and provides them with care that is person-centred and integrated in order to improve their health and wellbeing and maintain independence.

The initiative introduces a single assessment tool – the Dalhousie Frailty Screening Tool. A range of services can be offered such as befriending or regular telephone contact for those who are socially isolated, access to health training and care navigation as well as more complex care management involving multiple agencies. Anticipatory care planning is carried out for those nearing end of life. Carers’ needs are also assessed and supported. Through the Over 75 Service, care is individualised and preventative with a focus on patient safety.  Information sharing is enabled by monthly multidisciplinary meetings for those patients considered most at risk of unplanned admissions.