Hospital In Reach

What was the issue you were addressing or working on?

  • Identifying Midlothian residents that have been admitted to one of the Edinburgh hospitals.
  • Outcomes focussed assessment to determine if they can facilitate an earlier discharge either to Highbank Intermediate Care facility or home with a package of care and/or rehab.
  • Assessment to facilitate earlier discharge to care homes where appropriate.

What you did?

A hospital in-reach team was established. The service consists of Social Workers and Occupational Therapists who work in close partnership with the Rapid Response Team (RRT) based in Highbank care home to facilitate earlier discharge.  Each member of the team is affiliated with a specific hospital which includes Royal Infirmary of Edinburgh, Western General Hospital, Liberton, Astley Ainsley and the Midlothian Community Hospital working closely with hospital ward staff and Allied Health Professionals for Midlothian residents.

Two in-reach workers were employed in November 2011 through Change Fund which added to an existing social work practitioner who was already undertaking hospital discharge assessments through the Rapid Response Team.  We recruited a team leader to manage and develop the team and also co-ordinate the Intermediate Care beds at Highbank.  The team promoted the service developing partnerships and good working relationships with key hospital staff to ensure a flow of appropriate referrals.  We are now developing a client focussed process in partnership with the JIT using the IoRN tool and outcomes approach at assessment and review to develop more seamless pathways.


What were the outcomes - benefits or otherwise?

  • Facilitates early discharge (consistently achieving the four week delayed discharge target and working towards two weeks).
  • Speedier needs led assessment.
  • A significant increase in percentage of people returning home with a package of care and support, who might previously have been admitted to care home from hospital.
  • Decrease in care home admissions direct from hospital from 75% down to 45%.
  • Shorter length of stay.

Affiliating the workers with specific hospitals has improved communication and links with acute staff, and more seamless pathways for clients/patients.

The statistics have proved its benefit and would intend to continue this service beyond change fund.


Contacts - to find out more

Adrian Fleming, Adrian.fleming@midlothian.gov.uk  0131 270 5607