The model in Hull, which forms part of a system- wide approach to reducing delayed transfers of care, is based on the principle of ‘active recovery’. This example of a local initiative forms part of our managing transfers of care resource.
This principle aims to:
- support timely discharge from hospital
- maintain independence where possible
- reduce the level of long-term care packages
- achieve a net neutral impact on social care spend.
Active recovery builds on the idea of reablement, underlining the importance of recovering as much independence as possible, with active input from service users and staff. It is something that happens throughout – from assessment, through short-term intensive input and into longer-term support. Clear goals give the person and the practitioner something to aim for and provide a focus for tasks and future work. They provide an objective measure of achievement and help build confidence through reflection.
The transfer to assess pilot commenced in July 2016, supporting people who were being discharged from the acute trust and intermediate care facilities to their home address.
Staff work with a solution-focused approach and a commitment that supporting people to regain their independence is one of the most important things they do.
When a person is deemed medically fit, a health or care practitioner will see the person on the ward or intermediate care facility. If support is required to facilitate discharge they will create a basic support plan agreeing achievable goals for active recovery, and discharge will take place.
A practitioner will then undertake the assessment within the person’s home.
Between July 2016 and August 2017, of 364 people discharged through transfer to assess:
- 51 per cent have become fully independent
- 13 per cent have decreased levels of support following active recovery
- 36 per cent have been moved on to long-term support but had a reduced hospital stay.
Supporting Independence Team Hull City Council