The concept of ‘Discharge to Assess’ is not a new one – improving patient flow across the health economy; supporting more efficient discharges; and providing the option for more patients to recover at home are all common aims for acute and community providers.

A number of trusts and providers across the UK have implemented a system whereby community teams support their local acute hospital with OT, equipment and patient support packages to improve discharges.

But consistent, measurable success isn’t well documented. This has all changed with Medway Community Healthcare’s (MCH) Home First scheme.

Working with Medway’s partnership commissioning team (Medway CCG and Medway Council), and Medway Foundation NHS Trust (MFT); the Kent-based community provider and social enterprise has successfully implemented a scheme which is demonstrably improving delayed discharges from the hospital, and patient outcomes.

With the aim to support patients to live independently, and the aspiration to make getting patients home a priority; the scheme has now supported over 650 discharges from Medway Maritime Hospital, since April 2016.

Its success has been recognised by NHS England and ECIP. This success is now being replicated, with MCH securing the new intermediate care contract which went live on 1 October, following a joint procurement process by Medway Council and Medway CCG.

This new contract is about working together across Medway to support patients to recover at home or in the community, and to regain independence and confidence.

The focus is on reablement and rehabilitation. MCH acts as the Medway-wide lead on the project; taking referrals from the hospital; implementing post-discharge assessment visits by one of their occupational therapists; and ensuring the right equipment reaches the patient promptly.

MCH’s ‘One Call’ phone line acts as the triage point for MFT ward staff when they call in Home First discharge referrals. No longer do hospital staff need to call a number of agencies for elements of a discharge and potential care package. Now they have one central number where MCH’s team assesses the patient to ensure eligibility, and books a visit from an MCH OT within 2 hours of the patient’s return home. Within an additional 2 hours, any required equipment has also been delivered and put into place. MCH also arranges transport bookings and coordinates any community referrals on the same phone call – one phone call instead of many frees up valuable ward staff time.

The scheme has required significant communications and engagement with staff across both MCH and the hospital. MCH’s in-house creative team created a recognisable footsteps motif and brand, so that literature and signage stood out, and MCH staff have visited Board rounds, and delivered presentations across the hospital to answer queries and ensure referrals are appropriate and timely.

Mark W, whose mother received care under Home First, said: “My mum is an 86 year old lady who up to a month ago was fully able both physically and mentally, leading a full and active lifestyle. It is only since her recent illness that she has found life difficult and frustrating. Your nurses were selected to visit mum 3 times a day. Mum felt very uneasy about letting strangers wash her, let alone into her home. These ladies were, to put it mildly, very reassuring to mum and befriended her. They gained her trust and respect and she still talks about them. I cannot thank them enough for giving mum time, support, reassurance and most of all, the courage and space to allow her to find the enthusiasm to gain her self-respect and get back on her own two feet. “

About the Author:

Medway Community Healthcare is a social enterprise Community Interest Company (CIC), providing community NHS services to the people of Medway. We are formed from the services directly provided by NHS Medway and have a strong history of partnership working with local GPs, Medway NHS Foundation Trust, Medway Council and other local stakeholders. We’re a business with a £59 million turnover (in 2015-16) and over 1,300 staff providing a wide range of both planned and unscheduled care in local settings such as healthy living centres, inpatient units and people's homes. As an organisation that provides a range of high quality clinical services across Medway, we compete for services with other providers from the NHS, independent and voluntary sectors. We use our knowledge and expertise to stay up to date on local new business opportunities. Our commitment is to ‘lead the way in excellent healthcare' and our employees, who have the opportunity to become shareholders and influence business decisions, all have a significant role to play in delivering this commitment to the communities we serve.

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