New Programme Launches to Help Patients Leave Hospital

Patients who are ready to leave hospital will be supported to return directly home, more quickly, following the launch of a new programme.

A new “Discharge to Assess” programme in Oxfordshire will change the process and speed in which patients are offered social care support after a stay in hospital, helping people to leave hospital sooner and supporting them to recover safely in the place they call home.

The approach brings together teams from health, adult social care, therapy and reablement to plan a patient’s best route out of hospital as well as a more joined up way to receive support once at home.

Councillor Tim Bearder, Oxfordshire County Council’s Cabinet Member for Adult Social Care, said: “We work closely with health and social care partners throughout the year, supporting residents to live happily and independently within their own communities. We call it The Oxfordshire Way. After a stay in hospital, it’s important that we enable people to return home as soon as possible, maximising their chances of regaining their independence in a familiar environment. The new Discharge to Assess system will help the council’s adult social care teams to speed up this process while offering a more holistic approach to providing relevant support in the comfort of a patient’s home.”

A pilot of the programme has been running in Oxford and north Oxfordshire since July and has already supported 116 people to leave hospital more quickly, enabling them to recover at home, supported by social workers arranged by the county council.  The system is now being rolled out across the county from today (15 November).

The plan is for patients who are fit to leave hospital to be discharged within 24 to 48 hours. In the days leading up to this, the relevant information relating to them is taken to the Transfer of Care (TOC) hub meetings, where a team of nurses, social workers and therapists will consider each person’s case individually, planning their best route out of hospital.

Discharge to Assess will support patients who will be leaving hospital and returning home but who the TOC team feel may need some additional social care support.

Under the programme, instead of remaining in hospital and waiting for long term support arrangements to be made, people will be offered immediate care to leave the hospital.

Within 72 hours of returning home, they will then receive an assessment to ensure they get the right type of ongoing support, tailored to their individual circumstances. They will also receive advice in the comfort of their own home about any potential costs of care following that assessment, enabling people to make decisions that are right for them.

Dan Leveson, Place Director for Oxfordshire at Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board (BOB ICB), said: “This is great news for the people of Oxfordshire. Last year we introduced our Transfer of Care Hub, run by a team of professionals, to identify the best way for people to leave hospital as soon as they are medically fit and avoid unnecessary delays.

“Now, we are providing an increasing amount of care and support in people’s homes helping them recover safely and regain as much independence where they want to be.”

This plan is the strategy behind BOB ICB’s decision to close the step-down beds at Chilterns Court Care Home next to Townlands hospital at the end of the year.