A TEAM focused on helping get patients home as soon as they are well is already seeing positive results just a few weeks after the pilot project was launched at Basildon Hospital.
Alongside normal discharge processes, the team is concentrating on working with social workers and therapists to make sure that each patient is sent home as soon as they are medically fit, with the right support in place to prevent them returning to hospital.
The project is being piloted on four older people wards at Basildon Hospital and the rehabilitation ward at Brentwood Community Hospital and so far the response from patients, relatives and staff has been positive.
Karen Fashanu, Lead Nurse for General Medicine, explains: “No one wants to spend longer than necessary in hospital, so we are working with our partners to make sure each patient is assessed and supported properly, to get them home quicker and stop them from being readmitted.”
Some of the patients on the older people’s wards have end stage dementia, so the team work with the patients and their families to look at whether it is safe for them to return to their home or if their needs would be better met somewhere else, such as a residential home.
Karen Scott, Nurse Specialist for Older People, said: “Often because the right support is not in place for older people when they are discharged from hospital they end up being readmitted. They tend to stay in for longer, are at more risk of developing complications and in some cases, they become dependent on the care the hospital provides.
“Sadly sometimes older people are simply unable to care for themselves anymore and it isn’t appropriate for them to return home. The team works closely with social care around discharge and our common goal is to support patients to the most appropriate place, making sure thorough care plans are in place and where necessary, end of life care instructions are communicated.”
There are eight members of staff in the discharge team, which is made up of nurses and clinical support workers. They work closely with the hospital social workers, residential homes, therapists and community staff to make sure care plans are in place before a patient is sent home.
Karen Scott added: “The team has been a great support to our staff and we plan to do more education and training around the importance of discharge planning and begin thinking about getting each patient home from the moment they are admitted. Having a social worker on the wards has been effective as it has given medical staff a better understanding of their job and the role they play in working together to ensure our patients are discharged with appropriate support.
“The next step for us is to meet with the residential and nursing care home managers across Basildon and Thurrock so we can better understand each other’s needs. At the end of the day it’s all about the patients and making sure they are getting the care they need, whilst being treated with dignity and respect.”
Hannah Coffey, Chief Operating Officer, said: “Understandably most patients want get home as soon as they are able to. By planning a patient’s discharge thoroughly and working with our partners to put the appropriate support measures in place, it means the patient has the best possible experience.
In addition, prompt discharge leads to improved capacity within the hospital, which in turn decreases the number of patients who have to be moved between wards, and it reduces readmissions. It’s very encouraging to see the early results of this team’s work and the feedback from patients, partners and staff has been very positive.”