The ITOC has 2 functions:
Supporting Discharges from Acute into community services and prevent a ‘delayed transfer of care’ occurring;
A delayed transfer of care occurs when a patient is ready to depart from the hospital, but barriers relating to their transfer mean that they are still occupying a bed. These delays can cause problems with patient flow which affect a hospital’s ability to admit new patients and can contribute to longer waiting times. Therefore, the aim of our hospital discharge team is to investigate and prevent a ‘delayed transfer of care’ from occurring.
We try to identify these patients early on in their stay in the hospital. We then work with the acute teams to carry out a holistic assessment of the patient, on receipt of the referral form, discussing and setting short-term goals to enable prompt discharge.
Discharge options are varied, a few are listed below:
- Home with no support
- Referral to voluntary agencies
- Home with a package of care
- Home with reablement
- Home with a referral to specialist services such as Adult therapy team
- Transfer to an Intermediate Care Bed
- Transfer to a Discharge to assess bed
We support with the relocation of patients from the hospital to the above settings.
We also provide Therapy and Nursing support to patients that have been transferred into a Discharge to Assess beds.
As part of the Hospital Discharge Policy, Discharge to Assess beds was created. ITOC provides Therapy and Nursing support whilst patients are in these beds until they move on to their next destination.
Our D2A team, with the support of the allocated social worker, will review patients on a case-by-case basis and facilitate the appropriate care and support from a range of Locala services, which might include
- rehabilitation support
- support as part of a reablement care package
- provision of nursing and complex healthcare to support the discharge from the hospital to their own home, a care home environment, or assessment of an alternative suitable discharge destination.
If you would like more information on the team please ring 0303 330 8999 or email [email protected]
Locala ITOC provide support via several workstreams, including:
- Supporting patient discharges from acute on Pathways 1-3 - The team work together to support with patient/service user assessments, support planning and identification of ongoing care required in the community. They work in partnership with community providers, taking an MDT approach to ensure all patients with a health and/or social care needs are supported on their journey into the community whether at home (home first is the priority) or a residential setting (either long or short term).
The pathways are as follows; Discharge to access model – Hospital discharge and community support: policy and operating model - GOV.UK (www.gov.uk)
- A&E and Frailty Assessments - The team provide on-site assessments to A&E and following these pts once home under the North or South frailty service providing the person resides in the Kirklees council boundary. Patients admitted to the frailty wards are also followed up to optimise opportunities to discharge early. D2A Beds Therapy support the MDT discharge approach from Acute for both North and South, including supporting complex discharges once in a community bed.
- Therapy and Nursing Support within D2A and Non-Weight Bearing Beds - For those patients/service users who are medically ready to be discharged from hospital, following appropriate assessment of need, they will be discharged onto the next destination with appropriate support. Where there is a need for further assessment, or their next destination is not ready then they will move onto a D2A pathway / caseload either in a D2A bed or at home with an interim offer of support. The ITOC team outreach support contact the residential setting as part of the initial contact to identify urgent needs and support with immediate care needs and then within 7 days to complete a health and therapy assessment with a plan of care identifying the interim support required whilst they are in the D2A bed. Where an ongoing destination has not been identified, the Locala ITOC team will work with the social worker as part of determining the ongoing package of care when they move home or onto a longer-term residential setting.
