Discharge to Assess: Swale
- 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).