In 2015, a whole-system review looked at the interface between social care and health. This improved working relationships, and enabled open and honest system challenges. This example of a local initiative forms part of our managing transfers of care resource.
Daily ‘board rounds’, ‘breaking the cycle’ weeks and new local policies for delayed transfers of care (DTOC) counting were introduced, and an integrated liaison hub was established.
The hub acts as a liaison point supporting service users and ensuring good multidisciplinary team (MDT) planning and care, including:
- administering arrangements with nursing homes, with GPs and clinicians
- managing the logistics of communication with patients and families and escalating any concerns and issues as appropriate
- maintaining a tracking system on all patients who have moved and their onward destination
- making a daily check with nursing homes to proactively support patient management.
The liaison hub is staffed by a MDT including qualified nurses and therapists with expertise in discharge planning, discharge planners, administrators and staff from adult social care (in-reaching). Each nursing home has an assigned MDT attached to it, with a named nurse who makes daily contact. A communication log is kept in the hub to ensure responses are systematic and timely, and there is a dedicated phone line and email address with a separate phone line for GPs to have direct contact with the duty senior interface physician.
The liaison hub has brought together health and social care professionals in a positive way and delivered a fully integrated service, which has resulted in a reduction in delays and the release of acute beds. Service users are cared for in a more appropriate environment and for some patients rehabilitation occurs earlier in their pathway.
Deputy Director for Adult Services
Oxfordshire County Council