Its first thing in the morning, the phone is already ringing with a social worker stressed to the maximum, needing our help. They have a client who is bed blocking and they need them discharged and as soon as possible but the client’s mobility is poor and they can no longer get up and down the stairs at home.
Today the hospital is at Level 4. Level 4 is like a Code Red and it means it’s full to capacity, ready to close its doors and to turn people away. This is something that cannot happen so social workers, discharge facilitators and bed managers all work with our Revival Hospital Discharge Support Team to ensure that it doesn’t.
So far the client has been assessed by a social worker and it has been arranged for carers to help in the home. They’ll help them get washed and dressed etc. and come in up to three times a day if needed. In the meantime, we are asked to assess the client’s property to check if it is a safe environment for the client to go home. There had been some concerns raised after the client had fallen at home and wasn’t found for a few days.
We attend the hospital, meet with the client to carry out a quick bedside risk assessment and read through the nursing notes to understand their background and history. We then take the keys and head to the property on a joint visit, because it is (or should be) an empty property. From this point the hospital social worker will have no further involvement in this case and will move onto their next client.
When we arrive at the property we start a visual assessment. So what does the property look like? Is it well maintained? Is it safe and secure? What about access – is it clear or is there something that could trip the client up on the way in? Would a grab rail help the client to get through the front door?
Once inside we look to see if the electricity is connected and if they have any form of heating. We also check if there is food in the property and if there are any signs of neglect. We look to see why the client may have fallen over. We also check to see if there is a telephone land line at the property.
In this case we find that the property is poorly maintained, it hasn’t been cleaned for a long time and there are old rugs lying around. There is central heating but it is not working, however there is electric and there is a telephone line.
From this initial assessment we can organise the following for the client, before they are discharged:
The client is now able to be discharged from hospital safely. We then arrange to meet the client at their home with a food parcel and help get them settled back home. If the client is well enough we carry out a support plan using the Independent Outcome Star to help us identify any further support and put together action plans so that the client does not get readmitted to hospital. If they are not well enough we can go back in a couple of days. We then support the client for the next few weeks and after 30 days carry out a second Outcome Star to see how much they have improved.
This is a scenario for one client. Last week we had 58 new referrals, 42 of them were home visits. Last month we had 175 new referrals, an increase of 133% on this time last year. It costs approximately £400 per night for a client to stay in hospital. The Hospital Discharge service cuts the average stay for its clients by one night saving the NHS a considerable amount of money each year.
The results speak for themselves.
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