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New programme helps patients leave hospital on time


Patients who are ready to leave hospital will be supported to return directly home, more quickly, following the launch of a new programme.

A 'Discharge to Assess' programme in Oxfordshire will change the process and speed with which patients are offered social care support after a stay in hospital, helping people to leave hospital sooner and supporting them to recover safely in the place they call home.

The approach brings together teams from health, adult social care, therapy and reablement to plan a patient's best route out of hospital as well as a more joined up way to receive support once at home.

Councillor Tim Bearder, Oxfordshire County Council's Cabinet Member for Adult Social Care, said: "We work closely with health and social care partners throughout the year, supporting residents to live happily and independently within their own communities. We call it the Oxfordshire Way.

"After a stay in hospital, it's important that we enable people to return home as soon as possible, maximising their chances of regaining their independence in a familiar environment.

"The new Discharge to Assess system will help the council's adult social care teams to speed up this process while offering a more holistic approach to providing relevant support in the comfort of a patient's home."

A pilot of the programme has been running in Oxford and north Oxfordshire since July 2023 and has already supported 116 people to leave hospital more quickly, enabling them to recover at home, supported by social workers arranged by the County Council.

The system is now being rolled out across the county from Wednesday 15 November 2023.

How it works

The plan is for patients who are fit to leave hospital to be discharged within 24 to 48 hours. In the days leading up to this, the relevant information relating to them is taken to the Transfer of Care (TOC) hub meetings, where a team of nurses, social workers and therapists will consider each person's case individually, planning their best route out of hospital.

Discharge to Assess will support patients who will be leaving hospital and returning home but who the TOC team feel may need some additional social care support.

Under the programme, instead of remaining in hospital and waiting for long-term support arrangements to be made, people will be offered immediate care to leave the hospital.

Within 72 hours of returning home, they will then receive an assessment to ensure they get the right type of ongoing support, tailored to their individual circumstances. They will also receive advice in the comfort of their own home about any potential costs of care following that assessment, enabling people to make decisions that are right for them.

The pilot to date has shown:

  • a 50 percent reduction in the number of days people are waiting to return home
  • 16 percent (19) returned to independence with no ongoing care needs
  • 11 percent (13) of people had reductions in their care needs once they had returned home, with relevant support offered based on what would add value to their daily lives
  • 28 percent (33) of people were moved onto the Council's Home First reablement pathway, supporting them to regain their independence
  • the programme also reduced the number of patients who may have been moved to a short stay hub bed, as support was immediately available for patients at home.

Dan Leveson, Place Director for Oxfordshire, Buckinghamshire, Oxfordshire and Berkshire West ICB, said: "This is great news for the people of Oxfordshire. Last year we introduced our Transfer of Care Hub, run by a team of professionals, to identify the best way for people to leave hospital as soon as they are medically fit and avoid unnecessary delays.

"Now, we are providing an increasing amount of care and support in people's homes helping them recover safely and regain as much independence where they want to be."

The difference it's making

Jefferson Lee is a social work coordinator for Oxfordshire County Council and now carries out care and financial assessments in people's homes rather than in a hospital ward. 

Jefferson said: "The difference I see in people is amazing. After three days of being at home, people who may have been considered as needing a long-term care package have adapted so well that they can change onto the reablement pathway. Reablement offers a person the opportunity to regain their independence, so that they don't need to access long-term chargeable care services. Very often we see that just two or three weeks of this support can make a very big difference to people's lives.

"I am also able to see people in their usual setting, so I can make more relevant recommendations about potential adaptions, like grab rails or ramps, better supporting people to regain their independence."

Tamsin Cater is Head of the Transfer of Care Hub and has already seen improvements to the discharge rates due to Discharge to Assess.

Tamsin said: "This system is good news for all patients being admitted into hospital. For a person medically fit to be discharged, they may notice a greater sense of urgency to leave the ward and we would greatly appreciate the support of friends and family to help with this process. But with three days of free social care support planned for when a person gets back home, the outcomes are much better for people by recovering in their own home.

"We have already seen how more than a hundred patients have been supported through the system this summer and anticipate these trends to continue as we roll out the programme more widely throughout Oxfordshire."