Focus has developed a new Hospital In-Reach Team called HIT. The aim of the team is to efficiently support the discharge of individuals from hospital who have an adult social care need. The team works with multi-disciplinary partners to identify individuals with needs who consent to social care support.
Focus independent social work will be supporting current hospital discharge activity by delivering a pro-active discharge function for people with adult social care needs, working with individuals and professionals involved with their care from the day of admission to hospital and developing discharge plans that enable people to be ready to leave within 24 hours of them “not requiring care in an acute health setting”. The Hospital In-reach Team (HIT) will manage individuals who are likely to be admitted for longer than 72 hours. The HIT will work collaboratively with the Home from Home Team and The Home Team. Individuals will be identified by the bed management team, followed by multi-agency decision making, determining discharge planning responsibility. This will be backed up by daily visits to the wards. The HIT will work collaboratively with community based providers of residential and domiciliary care.
It is still too early in the process to provide data on the team’s success but below are a selection of ‘good news’ stories which the team consider reflect their daily workload.
This Service User’s health has been very unstable over recent months. The person is the main carer for their partner who has dementia. With the ability to be both in and out of the hospital, the worker was able to go and meet with the partner, discuss with the family and build a more holistic picture to hopefully provide support for the whole situation, rather than just the service user. Additionally, our proactive case management model allowed the worker to be able to follow the case on the ward and be more proactive. This service user’s fitness status changed a few times, but the needs hadn’t drastically changed. So when the individual was fit, rather than awaiting the Discharge Notice to be reinstated, we were able to facilitate the discharge that day.
Therapy team – Very proactive in getting us involved with cases earlier on. They are referring directly to us, face to face or by phone as per the model. This is giving a great handover/ information sharing opportunity as they have often met the patient so know information about them.
Had this case been subject to the usual hospital process the Service User may not have been picked up by the team as the individual’s needs were low level. However, in a discussion with the service user and family, the worker was able to establish that the family were struggling to support the individual and they didn’t know where to seek support for managing from a carers perspective. The worker was able to spend an hour discussing carers services, identifying areas of carer stress/ pressure and appropriately signpost to support services that may assist with this. Hopefully, allowing the family to manage independent of statutory support.