PERTH & KINROSS COMMUNITY HOSPITALS

1. PERTH & KINROSS COMMUNITY HOSPITALS Evelyn devine, head of older peoples servicescrispinoakley, team leader occupational therapist

2. PURPOSE: Review community hospital provision across Perth & Kinross to demonstrate how these facilities function within the wider health and social care system for the benefit of the patients that they serve. It is also necessary to make changes to these facilities to ensure they are delivering care that is safe, effective and person-centred based on the current and future needs of the local population.

3. Development of a Discharge Pathway in Perth and Kinross through the use of a whole systems approach Key themes • Variation and Delays in Hospital • Analysis of current state prior implementation • Joint inter agency approach in solving the issue • Discharge pathway created with intensive training and support offered • Audit undertaken for all areas of implementation

4. The pathway itself is really simple…… • The patient is admitted • Discharge planning starts and is proactive and focussed throughout the patients journey. • There is a Planned Date of Discharge which the whole MDT including SW are working towards. • There is MDT agreement as to when the patient is clinically fit for discharge • The patient is discharged home with all relevant services in place on their planned date of discharge.

5. Training on active discharge planning for the whole MDT. this includes medical, nursing, AHP, pharmacy, SW and this training is done at ward level as a team. Board rounds (introduced/updated) specific to discharge planning in areas where these existed we found they were more like nursing handovers Functional Screening Tool to ensure staff are aware of relevant background information on the patient prior to admission Staff are expected to complete this within 48hrs of patient admission (adapted from work done by Liz Myers, Dougie Louden) SBAR tool for potential and actual DD’s. This allows SCN’s to escalate any blocks they are encountering to our DD coordinator who hopefully resolves these. What Changes have we introduced?

6. Streamlining all SW processes that impact on discharge • Introduction of a named SW for every ward in P&K • All SW referrals are now allocated to the named ward SW with the exception of existing adult protection and guardianship causes • All SW referrals are screened , allocated and SW assessments commence within 48hours of receipt of referral from the ward

7. The consequence of all this is… Active, integrated, multidisciplinary discharge planning taking place throughout the whole patient journey until we reach the point where the patient is clinically fit to leave hospital. This is their PDD and they go ‘home’ with all services in place