Improving the Discharge Pathway / Process

Examples of Practice

The financial cost of delayed discharges in P&K to NHS Tayside is estimated to be over £1.5 million.  Aside from the financial implications of delayed discharges, evidence suggests there are many other risks associated with being in hospital longer than is necessary, a delay in the opportunity to restore a persons independence and potentially the loss of independence and mobility.

Delayed discharges can potentially also cause further problems within the wider community through delayed urgent admissions, cancelled operations and overall problems with emergency and elective access to beds.  Consequently any delays in discharge are bad for patients, their families, the NHS and the Council.  Minimising delayed transfers of care is therefore fundamental to ensuring capacity and flow through the system as well as ensuring a person-centred, outcome focussed approach to health and social care.

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Perth Royal Infirmary Liaison Service

Examples of Practice

Improved access to dementia liaison services in Perth Royal Infirmary to improve the knowledge and skills of nursing, AHP and social work staff which will improve the management and care  of patients with dementia / delirium in a general hospital environment and within the community.

Proactively identify patients with a cognitive impairment who would benefit from early supported discharge.

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Information for All

Examples of Practice

  • How to try and promote awareness and a greater understanding of the 3rd and independent sector to health and council staff.
  • Promoting the services that third sector and independent sector can and do already provide for older people and how they can prevent avoidable admissions and delayed discharges.  Also how to access the organisations and services their, referral systems, costs etc

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Homecare Reablement

Examples of Practice

  • The reablement approach in homecare offers support and encouragement to individuals to empower them to help themselves and so increase their independence. It supports individuals ‘to do’ rather than ‘doing to’ or ‘doing for’.
  • Goal setting and review of outcomes achieved are central to the reablement ethos. This means that we work with individuals and their carers to establish what tasks they want to gain confidence in doing or relearn particular skills. By engaging with individuals around an agenda of what they can do and what they would like to do we can develop short term interventions which support them to achieve these goals. These are often around basic daily living skills such as dressing, meal preparation and mobility. It is not uncommon for an individual to have lost confidence around their ability to carry out certain tasks after spending time in hospital.
  • Our traditional home care approach has been to assess people around what they no longer can do and provide a service to meet these deficiencies.  As a result services are embedded into people’s lives, often for length periods of time.  While this is perfectly acceptable for a number of people who suffer from severe and complex conditions it has the potential to create a dependency for people who may have had the potential to relearn or regain skills. Reablement focuses on this potential and research suggests that many people who would have received a traditional service leading to risks of dependency can eventually become more confident and lead fulfilling lives when they regain lost skills.

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