In May, 2017 Liz Patrick, Discharge Planning Practitioner, began to implement the role of care home link in the discharge planning team.

Liz recognised the need to develop better communication and engagement with our local care homes, acknowledging that improvements could be made on both sides.

Over the last 7 months, Liz has attended CCG care home forums, transport operational meetings and visited care homes to engage the managers and nurse leads, building trust and confidence to facilitate successful joint working. Care homes will also contact Liz with regular updates on vacancies.

Liz receives daily updates about care home patients that are admitted to hospital and monitors their progress. She liaises with care homes about when a patient is expected to be discharged, (especially if planned for the weekend) and arranges reassessments if they are needed, encouraging telephone assessments with the nurse looking after the patient.

The role involves working closely with the CCG, Social Services, Macmillan nurses and the discharge planning nurses to identify appropriate placements that can meet patients’ needs.

Liz meets with care home managers to facilitate timely, accurate and transparent assessments of each patient. On most occasions we are able to make a decision at the assessment about whether the home is suitable for the patient and at what date the patient can be discharged.

Data shows that the overall time taken between ratification of CHC funding, a care home manager completing an assessment and the actual discharge has reduced significantly in comparison to 12 months prior; Oct 16/17 -4 day reduction, November 16/17 – 3 days, and December 5.2 days.

This is also evidenced with fast track end of life patients who are being discharged to placements much quicker, often on the same day of assessment.

The project has been welcomed by care home managers who feel their concerns are being acknowledged and that having one point of contact to raise queries both pre and post discharge is effective.

One manager stated that they felt more confident to accept the patients as they said that they felt reassured that the assessment was thorough and honest.

Many care homes have started to offer more flexibility as a result of increased communications and a ‘priority transport vehicle’ is being used primarily for care home and end of life patient discharges. The vehicle is coordinated by another practitioner in the discharge planning team and together, discharges are planned so that priority is given to patients being discharged to a new care home, and patients returning to a care home they are familiar with, will be offered transport later in the day.

Liz communicates with the homes to give an estimated time of discharge so that homes can prepare for the patients returning home.

The Care Home Link Role service is currently being extended into Liz becoming a trusted assessor for the care homes to further reduce delays that may occur, for example, due to managers not being able to travel to the hospital on the day of request, in times of staff sickness or if there is difficulty in making travel arrangements.

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