Bridge health, social services to improve discharges

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Investing in social work can lead to significant savings for hospitals by speeding up patient assessments and therefore reducing delayed discharges, according to a U.K. project.

Established in November 2011, the Enhanced Intermediate Discharge Team and Community Care Project brought together hospital social care and nursing staff from St Helens Council, the St Helens and Knowsley Teaching Hospitals NHS Trust, NHS commissioners and community services, and the St Helens Home Improvement Agency.

Amid winter pressures and care gaps between settings, the project aimed to create a long-term sustainable model that integrated health and social services, according to the results.

For instance, a hospital discharge nurse calls the St Helens Home Improvement Agency, informing the agency support services manager that a 92-year old patient will be discharged the following day, Community Care reported. However, the patient needs furniture, including her bed, moved downstairs in her two-story house. The patient's daughter is 100 miles away but will let the handymen in the home to move the furniture and install rails and intercoms.

"If they hadn't stepped in so quickly, she wouldn't have been able to come home that day," the patient's daughter said about the discharge services.

Such interventions and communication led to better patient management and more timely care.

Researchers found that the number of monthly social care assessments carried out rose from 59 to 143, increasing 140 percent.

Delayed discharges from acute beds dropped by 17 percent. The number of medically fit people in beds dropped from 40 to an average of 5 people per week, essentially freeing up an entire ward of 35 beds at Whiston Hospital in St Helens.

Other common hospital discharge improvements, particularly in the United States, focus on transitional care and include coordination with primary care physicians, better patient communication, improved patient education to self-manage care, and pharmacy interventions for medication reconciliation and adherence.

For more information:
- see the Community Care article
- here are the project details (.pdf)

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