Almost two years after scooping an award for the Best Integration Project at the North East, Cumbria, Yorkshire and Humber Commissioning Awards, the Integrated Discharge Team have been reflecting on their successes so far and how they have re-shaped the patient journey for those receiving care from North Tees and Hartlepool NHS Foundation Trust.
The award winning ‘Home Safe Sooner’ initiative continues with its integrated approach to discharge from hospital. The Integrated Discharge Team work across the organisation, meeting with patients to understand how they want to get home, and making sure they are involved in planning their discharge, with input from their loved ones too.
The success of this team is built upon the close collaboration with colleagues in the surrounding councils, the voluntary sector and with the local Clinical Commissioning Groups to get the right balance of health and social care for those patients that need it. It means that referrals are made simpler – by having a social worker at the hospital, they can assess the patient’s needs there and then.
This vision has since been further developed by the introduction of a Frailty Team, made up of experienced health practitioners who work with patients from the second they come through the doors of the hospital. Frailty Co-ordinators work with patients to understand any necessary adjustments they might need, making sure that support mechanisms are put in place where they live to facilitate a safe discharge and support their on-going needs
They aim to encourage independent living where it is safe, meaning that people are more likely to go back to their own home after a spell in hospital, rather than into the care setting.
As the health of the population changes and people start to live longer with more complex conditions, it’s important that health Trusts stay ahead of the curve exploring new ways to treat people, breaking away from old traditions. The NHS Long Term Plan sets out plans to move away from treating every single person in hospital, exploring innovative solutions to provide the right support to people where they live.
Steve Pett, General Manager of Specialist Services and Partnerships at North Tees and Hartlepool NHS Foundation Trust, explains: ‘We are certainly an innovative Trust and our staff are truly passionate about coming up with new ways to improve patient care. Our frontline staff are our knowledge – they’re out there every single day meeting with patients, seeing first-hand the challenges, with a unique understanding of how we might support their needs. This involves working closely with social care and the voluntary sector services to enable patients to return to the comfort of their own home with the appropriate on-going care and support.’