Carers Support Community Hospital Discharge Team

What was the issue you were addressing or working on?

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.

What you did?

The Change Fund allowed us to fund a Carers Support worker for the Community Hospital Discharge Team. This is an integrated team which includes AHPs, Nurses and Social Workers originally from both Health and Social Care. The team is contactable through a single point of access by a range of disciplines in the Acute setting. The Carers Support worker is an integral part of the team, and is co-located. The role is key to ensuring that carers are identified at the earliest point, ensuring that they are aware of their rights, particularly to an assessment, ensuring that they are linked to carers’ services for ongoing support and raising awareness of their needs within hospitals and positively influencing practice.

As part of our CIS work plan, Carers of WD carried out workforce Carers’ Awareness training. One emerging need which was identified was that carers required more support through the discharge process. CWD and WDCHCP took a partnership approach to address this issue. This involved negotiating funding, discussions about how best to achieve our joint objectives and research carried out by CWD into examples of good practice. Agreement was reached that this should be a key post (Hospital Discharge, Carer Support worker) with a particular focus on Carers Support at time of discharge.  Our aim was to establish Carers Support as a key component of the discharge process. This post would also provide a knowledgeable ‘resource’ for the multidisciplinary team to support them to identify carers at an early stage and carry out carers assessments. In November 2012 the post holder was recruited. The post is 28 hrs per week, initially fixed term for 18 months and is co-located between the Carers Centre and the HD team.

What were the outcomes - benefits or otherwise?

  • The initial target was that the project would identify and support 50 new carers. Between Nov 2012 and Aug 2013 it supported 30.
  • The project creates a seamless link to carer’s services offered by CWD, allowing carer’s access to a variety of support e.g. emotional support, access to services, benefits advice, peer support, short breaks, learning opportunities and Older Peoples support project.
  • It also complements other work streams within our Change Plan e.g. Re-enablement, Hospital Discharge Pharmacy Project, Respite and Enablers.
  • Referral pathways have been developed within the team and it enables colleagues within the HD team to have direct access to carer support advice.
  • The HD worker played a key role in the development of the Single Point of Access, ensuring that the carer’s component of the process accurately reflected the requirements for identifying carers.
  • The use of this co-located model of carer support has proved very positive. It has recently been replicated with the Community Older Peoples Team.

Contacts - to find out more

Kim McNab, 0141 941 1550