Integrating skills between health and social care workers

In 2015, the health and social care systems in East Lancashire committed to transform hospital discharge services.

Health workers with social care skills support patients’ safe and timely discharge.

Initially, Complex Case Management health staff integrated step-down pathways from acute hospital admission. They developed an out of hospital plan for patients at the earliest opportunity.

Since then, the trust has developed this innovative way of working to support its patients towards discharge. Planning for discharge starts as soon as the patient is admitted. But this approach can start at any point in the patient journey.

The integrated way of working has operated around keys skills that have been developed through collaborative training, multi-professional working, and experiential learning with a case management style approach.

East Lancashire Hospitals NHS Trust (ELHT) health staff have developed social care skills which have enhanced their specialist discharge skills and supported ward multidisciplinary teams to assess care at the earliest opportunity for patients. To achieve these enhanced skills the Complex Case Managers have developed:

• shared access to social care systems
• assessment skills to commission re-ablement care plans
• enhanced skills in best interest decision making and mental health capacity assessments
• worked on a ‘personalisation’ approach to planning care, with our patients at the centre of the care planning
• a multi professional trusted assessment document
• case management approach, via a twice daily electronic sharing of information which supports integrated progress chasing and wider system support, at pace
• a daily multi professional meeting to ensure our patients are reviewed by the most appropriately skilled professional

The result of this transformation is a patient focus on home first, rehabilitation and re-ablement, an avoidance of long-term placements, with earlier intervention and personalised support packages for our patients. Since 2015 the trust has significantly reduced its delayed transfers of care. As a result of this way of working and innovative discharge methods, the trust has high rates of staff retention. It has improved patient experience and enabled patients to leave hospital sooner. In some cases, patients return home when they did not think this was going to be possible.