Agenda item

Supporting a Safe and Seamless Transfer From Specialist Care or Hospital Setting

[To consider a report from Manjeet Garcha, Director of Nursing and Quality in relation to the transfer from specialist care or hospital]


The Panel welcomed Manjeet Garcha, Director of Nursing and Quality to the meeting.  The report sought to provide an outline of the systems and processes in place to support a safe, timely and seamless transfer of patients from a specialist care or hospital setting to their usual or new place of abode.


Over the last few years there had been many reviews and publications on the statistics and effects of delayed transfers of care. The majority of patients that were admitted to hospital for an acute episode of care or planned surgery returned to their usual place of residence with either very little or no required support.  However, there were a growing number of a patients, in the main frail elderly but also patients with complex physical and mental health needs that did require discharge to be planned and executed in a safe and seamless manner for the best adjustment to their condition and surroundings.


In Wolverhampton a multi-agency ‘Discharge to Assess’ programme of work had commenced and it was anticipated that this would further improve the discharge arrangements for individuals from acute care settings. The new programme meant that patients did not always need to attend hospital and that the aim was to get them home first so that they could be assessed there by a physiotherapist or occupational therapist.


Children’s Services had also been streamlined and sometimes children had to be sent for specialist care including referral to the Birmingham Children’s Hospital and there could be complex planning required to bring them back home.


The Panel considered mental health and learning disability issues relating to patients who had been in an institution and had to undertake treatment reviews and it was confirmed that at the moment all patients were in the right place and that no one in Wolverhampton was waiting for a bed.


Members expressed concern in relation to patients in hospital waiting but unable to be discharged and those who were sometimes discharged too early and then had to return to hospital. Multi agency working was commendable but it would only work if the right resources were in place. The Panel queried whether the number of patients being readmitted after being discharged too early was monitored along with those still waiting to go home.


David Watts, Service Director – Adults stated that daily reports were received and that approximately 40 patients were delayed at any one time (about 60% from Wolverhampton) which was consistent with the national target of 3.5%. Mr Watts stated that it was very important to ensure that patients were discharged in good time to prevent them becoming less dependent or picking up infections. Mr Watts stated that he and his team were very aware of the concerns raised and were working hard to improve the service where possible through the multi-agency approach. Mr Watts confirmed that a report could be provided in relation to the figures along with readmissions and figures showing how many people were still at home 90 days after discharge.


The Panel queried what was working at the moment and whether the multi-agency approach appeared to be working. Mr Watts stated that the project was still in the planning phase and that the first set of results would not be available until the 91 days had passed.


The Panel questioned what needed to be done to support a reduction in bed blocking and a concern was raised in relation to the closure of forces rehabilitation homes and a lack of mental health provision with vulnerable residents with on-going addictions living in third sector landlord accommodation.


Mr Watts stated that his team were working with the CCG which had responsibility for this area of commissioning and that they were investigating the possibility of more large scale commissioning in relation to mental health provision. Mr Watts also stated that his team were aware of the importance of providing the appropriate resources for when a person was in a crisis.


The Panel also queried the situation regarding the Better Care Fund and requested an update on this for a future meeting.


Resolved:      (1)       That an update report be provided in 6 months to included detailed information on the discharge processes and up to date figures.

(2)       That an update on the Better Care Fund be brought to a future meeting.


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