Supported Discharge Social Worker

What was the issue you were addressing or working on?

Prior to this post East Lothian service users who are admitted to any of the Edinburgh Acute hospitals have to be referred to and assessed by the hospital SW if they require an assessment for a possible care home placement. Due to the demand on the hospital SW service, East Lothian service users often had to wait to be allocated and then once the assessment has been completed the SW has to liaise with East Lothian Council regarding vacancies and funding. This in turn could increase the length of stay in an acute bed.

What you did?

This project is aimed at working jointly across Health and Social Work to improve information sharing and communication in relation to planning appropriate and timely discharge for East Lothian residents who are receiving inpatient treatment in acute hospitals in Edinburgh.  It also aims to streamline referral methods; discharge planning processes; and to supplement and support the work of hospital social work teams through negotiation of the early allocation of work, to ensure timely assessment and intervention to expedite discharge and prevent unnecessary delay. It is also intended to ensure that we meet nationally agreed delayed discharge targets.

70 clients were worked with in total in 2012/13, most were referrals from hospitals to look at discharge planning, and the remainder consisted of enquiries where advice was given to ward staff.  All of these were allocated for assessment, and 24 of these were particularly complex. Advice and information given to families including Referrals to Carers of East Lothian. Reviews for clients recently moved to care homes, Support to carers / families to provide information regarding discharge; finances; access to appropriate resources. Advice given by phone to hospital staff. Talk given to OTs at the Western General and Royal Victoria Building about East Lothian resources and referral process.

What were the outcomes - benefits or otherwise?

Successes – clients are being allocated a worker more quickly and assessments are generally completed before the DD target.  Communication with hospital staff is improved.  Through early allocation and carer support, it has been possible to allay fears families may have, thus speeding up the assessment process and making the transition easier.

What I may do differently as a result of challenges: Greater use of existing data collection systems, such as Edison or Trak, would help with information gathering without the time-consuming and sometimes  limited process of going through ward records to gain basic information.

Contacts - to find out more

Gillian Neil,  01875 824078