Carers Support Community Hospital Discharge Team

Examples of Practice

All parts of the patient’s support system (the carer, acute and community care services etc) should work together to achieve the best outcome for both the cared for person and the carer.  Despite the policy and good practice advice which has been developed to guide us across this pathway, carers often report  that they feel ill-informed and that policy is often not reflected in practice.

Establishing Carer Support as a key component of the hospital discharge process addresses the need to identify carers at an early stage and ensure that they are well informed and supported.  It also addresses the need to support carers at key times of transition, eg where the admission meant the carer was no longer able to continue care at home and the person they cared for was being admitted to long term care.

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Reablement

Examples of Practice

Older people becoming dependent on Care at Home services and losing their independence after a change in circumstances, e.g. hospital admission or period of illness.

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Carers Link Worker

Examples of Practice

When someone is affected by a significant illness/condition such as a stroke, it impacts upon the individual’s lifestyle, and may result in the individual becoming dependent on another person such as a spouse, daughter, son, friend or neighbour, in order to remain in their own home.  Intervention from statutory/private/ voluntary services may be required in order to maintain the quality of life, and information and advice regarding the locally available services becomes essential for both the individual and their carer/family members.  The individual and their carer are then able to make informed decisions regarding support services, based on the information they have been provided with, which allows them to maintain control during their transition from hospital into their own home.

Early interventions with carers in the hospital setting will enable carers to be informed of systems in place, their right to a Carers Assessment and the process of that assessment, and the eligibility criteria for health and social care provisions.  It will also enable planning for support services such as, respite and support groups.

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Assessment of quality of care pathway and outcome for older patients

Examples of Practice

The project is targeting older people recently discharged from hospital to obtain feedback on their experiences of hospital care, discharge planning and accessing community support services.  In addition it has looked at the experiences of older people currently in receipt of home care and community services.  The research has focussed on quality of care, patient satisfaction and whether the service needs of older people and their carers are being met.

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Community Ward Service

Examples of Practice

Reducing emergency admissions for people with long term conditions (with focus on COPD, Heart Failure, Diabetes, Recurrent UTI/Infection & Falls).

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