Home First for Wiltshire What is it? A simplification of discharge - - PowerPoint PPT Presentation

A simplification of discharge from hospital and direct support for the complex and intense post hospital period: a) Using ‘meet and greet’ / D2A b) Responsive care and rehabilitation while needs are rapidly changing c) Arranging a managed transfer of care to HTLAH on or before 10 days post discharge (2 day target) d) A managed transfer of case management when longer term needs can be assessed

Home First for Wiltshire – What is it?

The recruitment of 30.6 RSW’s to increase the capacity of the 11 Community Team bases, across three localities.

Who?

Recruited since December 2016 Started since 1 February 2017

Sarum 4.96/ 8.6 North and East 8.8/ 11.0 1.8 WWYKD 9.4/ 11.0 0.8 Total 23.16/ 30.6 2.6

Current New

No care available – Request for bridging from Medvivo Urgent care at Home and/ or divert nursing/therapy resources Access to Care (Medvivo) Triage and Information Gathering Referral to Community Team Triage and Information Gathering Community Team refer to HTLAH Provider requesting care as prescribed Full Care available- start date given No care available – HTLAH agency refers to sub- contractor Full assessment of care needs in inpatient setting No care available – Council puts

• ut to spot

purchase Social Care needs only Social work team refer to H2LAH Referral with specified package

• f care

Patient discharged Care starts Care available- start date given Mixed Care available- start date given Care available- start date given, 72 hours max for UC@H Therapist case management Social care case management Care provider Access to Care (Medvivo) Processing Only Community Team confirm ready to receive – discharge timed Meet & greet and initial assessment in home. All support needs covered by community team Streamlined pathways – clear criteria. Referral for HomeFirst – information and intellgence shared H2LAH reablement support Therapy –led assessment, case management and rehabilitation Long term needs /assessment

• No detailed

assessment in inpatient setting

• All home

based patients – no separation between health and social care

• Discharge

not dependent

• n separate

referral/ brokering of H2LAH

• Transfer to

H2LAH after initial settling in and needs identified at home

Streamlining discharge pathways – work in progress

Pathway 0

No additional support

Pathway 1

Additional support needed, but can go home

Pathway 2

Additional support needed, but can’t go home

Pathway 3

Straight to long term care/ specialist care

Essential Criteria

• 1. Medically able, with no

additional post discharge support required 1.Medically able but additional post-inpatient support required 1.Medically able but additional post-inpatient support required 1.Medically able but additional long term support required

• 2. Safe to be discharged

to home (includes no safeguarding concern)

• 2. Safe to be left between visits

(including no safeguarding concerns present)

• 2. Not safe to be left

between visits (includes safeguarding concern) 2.Known and settled long term complex needs which prevent returning home

• 3. Has access to a normal

place of residence (this includes nursing and residential home settings)

• 3. Has access to a normal place
• f residence (includes

residential care homes but not nursing homes) AND/OR

• 3. Doesn’t have access to

a normal place of residence (includes existing care /nursing home) OR 3.Known and settled long term complex needs which can be managed at home through a bespoke, planned discharge package OR

• 4. Additional support needs

could be met in existing care /nursing home subject to assessment/ planning of discharge