Transcript THE INTEGRATED DISCHARGE TEAM

THE INTEGRATED DISCHARGE
TEAM
Where we came from
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In August 2004 five different teams were amalgamated into one.
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The five teams were:
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Social Worker and Physiotherapist from Chichester ward
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2 Social Workers and an Occupational Therapist from A&E
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3 Nurse Discharge Co-ordinators
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1 Social Work Discharge Co-ordinator
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Fast Track Team: 1 Nurse, 1 Care Manager, 1 Social Worker, 2
Occupational therapists, 1 Occupational Therapy Assistant
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These teams were brought together in response to evidence based
research. This identified that working from the front door of
emergency care reduces a person’s length of hospital stay, reduces
the risk of the person being delayed in hospital and avoids
unnecessary admission to hospital.
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This underpinned the new Integrated Discharge Team’s remit.
Who we are
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The team is a partnership of both interdisciplinary and interorganisational professionals
Nursi
ng
Occupatio
nal
Therapy
Physi
othera
py
Socia
l
work
er
Team
manag
er
Administratio
n
Aims of the team
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To avoid unnecessary admission to hospital
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Reduce the number of delayed transfers of care within the Trust
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Reduce average length of hospital stay through early discharge
planning
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Improve patient care pathways
Who we work with and reasons for referral
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People from any geographical area
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Anybody over 18 years
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People whose activities of daily living are compromised due to:
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Infections
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Cardiac conditions
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Respiratory conditions
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Drug and alcohol issues
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Falls
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Reduced mobility
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Musculo-skeletal problems
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Neurological conditions
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Chronic pain
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Fractures
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And people who are unable to cope in the community, homeless people, people with carer
needs, mental health issues, chronic diseases, physical and learning disabilities and those
with sensory loss.
Equalities
• We celebrate diversity and believe that everyone is
entitled to be treated fairly and valued equally.
• We do not discriminate anyone on the basis of their
age, gender, marital status, disability, nationality,
ethnic origin, religion or faith, sexual orientation or
domestic circumstance.
What we do
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Rapid assessment
for people over 18
yrs who present to
A&E/MAsU
Provide multidisciplinary
intervention
and
assessment
Liaise with
relevant
primary,
community and
voluntary
health and
social care
and housing
services.
Provide multidisciplinary
intervention
and
assessment
Create
personalised
careplans to
meet people’s
assessed
needs
Provide home
assessments
and OT
equipment as
appropriate
How do we do it
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Proactive and early identification of people using inter-organizational IT systems, clear and
robust communication channels with our partners in the acute and community sectors.
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We work across A&E, medical assessment unit, Observation ward and short stay
Chichester ward with people who have short term acute medical needs.
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We proactively screen peoples’ needs in liaison with department coordinators and stream
people to appropriate care pathways.
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We work a split shift system ensuring provision of service from 08:30am to 18:00 6 days
per week and 09:00 to 13:00 on Sundays.
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We provide joint multidisciplinary assessments of peoples’ needs at the earliest
opportunity.
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We interskill within the team.
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We work very closely with the Rapid Response Service who provide assessments and
medical care in people’s own homes to avoid hospital admission and to facilitate timely
discharge.
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We constantly work to build better, person-centred care pathways within both the acute
and community sectors.
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We actively challenge discrimination and work to promote peoples’ independence within
their own homes while considering all issues of equalities .
How do we do it contd
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We all work from one office
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We challenge aversion to risk management and use all available resources to ensure
people leave hospital as soon as they no longer require acute medical care.
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One manager across team disciplines
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We proactively promote the care management model of care, seamlessly assessing
peoples’ needs and working in partnerships to provide appropriate care.
The Role IDT Plays
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Our service has been inherent to reducing the length of people’s stay in
hospital.
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We play an integral role in meeting the government’s targets on ensuring
people are assessed and transferred from A&E department within 4 hours.
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We see on average over 200 people per month. We have actively prevented
these peoples’ unnecessary admission into hospital by setting up appropriate
care and support for them in their own homes (60%) or finding transitional,
respite and rehabilitation care beds in the community.
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We have built excellent, robust relationships with our community health, social
care & housing, independent, voluntary and charitable partners.
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We actively lead on implementing the Single Assessment Process.
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We contribute to the consistent reduction in numbers of older people who are
cared for in care homes as outlined in the National Service Framework for
Older People.
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We have raised the profile of the protection of vulnerable adults and provide
training for acute medical staff in the early identification of abuse in vulnerable
adults using shared, inter-organisation policies and procedures.