Integrated Discharge Planning & Reablement with social work

Reducing delayed Discharge and Improving Independence through joint reablement and social work teams

The Swindon Integrated Discharge Planning and Reablement programme has transformed the way we care for older people - reducing delays and supporting them to live at home for as long as possible.

We have increased people receiving reablement by 163%, reduced DToC days by 69% and saved over £1.9m per year for the health and social care economy. Because of our system-wide leadership towards integrated care, in Q1 and Q 2 2017/18, Swindon was the best performing system for reducing delays in the South West, better than the national average.

The programme started with health and social care practitioners reviewing a sample of cases for patients discharged from hospital, asking: “what was the reason for delay?”, “was the best outcome for the person achieved?”.

Results showed too many patients were discharged to residential/nursing care, leading to delays. In 64% of cases, they would have achieved a better outcome had they been supported to return home (with domiciliary or residential reablement).

But staff were not working together to promote return home, and our reablement services didn’t have the capacity or capability to take the additional volume.

Our aim was to avoid residential/nursing placements when this was not in a patient’s best interests, reduce delays by promoting home first, improve the effectiveness of reablement, empower our staff, and deliver a financial benefit. We also wanted to build on best practice - bringing together therapy, care and social work staff in an integrated model.

Alongside bringing system leaders into the changes, it was crucial that the transformation was led by frontline teams. We created a design team of H&SC practitioners - including a team manager, lead social worker, lead OT, supervisor and three reablers. This was all about bringing health and social care together – not necessarily through formal or legal structures – but improving relationships, ways of working and focusing on the day to day realities of working in an integrated way – to ensure we are always focussed on doing the best thing for the people we care for.

The team created, piloted and iterated new ways of working, identifying and solving key blockers through:

• Improving discharge planning and daily meetings across H&SC.

• Co-locating domiciliary and residential reablement services to deliver a seamless ‘hospital to home’ service.

• Starting a social care internal gold call to promote daily discharges 7 days a week.

• Improving referral pathways – getting hospital staff and referral teams working together, talking about the best people to refer.

• Using a reablement dashboard to regularly check we were achieving our objectives

When we were certain that the new ways of working were having the right impact, the design team then rolled them out across the rest of the team.

The programme has exceeded its targets, results include:

• 69% reduction in DToC Days

• 163% increase in patients receiving reablement

• Annual saving of over £1.9m to the health and social care economy

  • Acute
  • Acute > Clinical Support
  • Acute > Clinical Support > Preventing delayed discharge
  • Social Care
  • Social Care > Integrating health and social care
  • Commissioning and Procurement > Fabulous Stuff
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