Partners in Leicester have taken a five-stage approach to improving discharge and avoiding unnecessary admissions. This example of how local areas are working to implement overall system change forms part of our managing transfers of care resource.
This has involved:
- developing a collective concern
- understanding the reality
- working together
- monitoring impact
- sharing success and aiming higher.
Using the Better Care Fund (BCF) as a catalyst, partners have created a pathway of care, which includes:
- an Integrated Lifestyle Hub tackling the wider determinants of ill health
- GP-led care planning for patients identified via a risk stratification system
- clinical response team – emergency care practitioner-led teams roving the city and taking admission avoidance calls from 999/111, GP urgent referrals and care homes, supported via an integrated crisis response service and community health services on a two hour response basis
- wraparound rapid access to services such as assistive technology, falls assessment, equipment and handyperson
- daily patient tracking meetings in partnership with the acute site, with a dedicated hospital social work team
- enhanced community ‘beds at home’ via an intensive community support service
- integrated pathways for non-weight bearing patients plus discharge to assess services
- proactive discharge follow-up for at-risk groups.
As a result, in comparison to Q1 16/17, attendances at A&E in Q1 17/18 were down by 2.9 per cent. These figures include all age cohorts, including those age cohorts where there is traditionally a rise in attendance year on year. Although coding continues to be a challenge in terms of understanding the impact on admissions, figures indicate a net position of -0.1 per cent.
Director, Adult Social Care and Safeguarding
Leicester City Council