In East Surrey, adult social care and the CCG are working together to pilot the use of discharge to assess for all continuing healthcare (CHC) assessments. This example of a local initiative forms part of our managing transfers of care resource.
Via social care, the partnership has commissioned beds in a specialist dementia care home, and a nursing home specialising in end of life support.
Patients are identified at multi-disciplinary discussions with adult social care and a CHC liaison nurse based within the integrated discharge team. Admission into care homes is co-ordinated through a trusted assessor model, directly from adult social care or the CHC liaison nurse, thus eliminating the need for the care home to assess the patient prior to admission.
Nurse-to-nurse discussions (CHC liaison nurse and nursing providers) support the development of professional working relationships and improve willingness to talk through issues and challenges. Patients who have a dementia need such as wandering, or challenging behaviour, are placed in a specialist dementia care home, where they can be best supported or stabilised in order to complete the CHC decision support tool and give an accurate depiction of their needs.
Project Manager Health and Care Integration
Surrey County Council