Tucked away in a Warwickshire nursing home, a team of health and social care practitioners are working together to plan care for people who, not so long ago, were patients in the nearby hospital wards. But the atmosphere at Kenilworth Grange is a far-cry from the bright, white lights and clinical environment of a hospital.
Instead, this cosy office is alive with passion, debate and strong partnerships between the professionals who make up Warwickshire’s Discharge to Assess (D2A) team. It’s not difficult to see why the nursing home is the ideal setting for the team to develop their multidisciplinary approach to delivering services, as well as providing a comfortable space for service users discharged from hospital to recuperate.
The Discharge to Assess scheme (recently recognised as an example of good practice in a report by the College of Social Work) is a joint partnership between Warwickshire County Council, South Warwickshire NHS Foundation Trust, NHS South Warwickshire Clinical Commissioning Group and NHS Arden Commissioning Support.
The pilot was set up in 2012 to enable service users to be discharged into nursing care for a maximum of six weeks, with the aim of reducing delayed discharges and cutting the overall spend on continuing health care.
“This is an environment where people are more medically stable, they may not be at their optimum but they have time to recover, time for assessment, time to talk to people and it doesn’t all have to be done in two or three days,” says Fiona Smith, the D2A physiotherapist and member of South Warwickshire’s Community Emergency Response Team (CERT). “They can come to terms with decisions and gain an understanding of what their true capabilities are.”
The right environment
The average age of a D2A participant is 80 and the scheme includes three different pathways of care. Patients will either be discharged directly to their own homes with reablement support or intermediate care or to a bed in a community hospital or to one of the three participating nursing homes, depending on their level of need.Today, we’re looking at pathway three, where service users with continuing health care needs will receive nursing or residential care following their time with D2A.
“Anybody that triggers the need for continuing health care assessment when they are in hospital is eligible for a D2A bed,” says Debbie Reid, discharge coordinator. “After spending time in the scheme, patients either go on to a nursing home which is the right place for them but we’ve also known patients who have come into D2A thinking they are going to go to nursing and then have gone to residential so that is another positive.”
According to the team, approximately one fifth of patients are eligible for continuing health care once they have entered the scheme. “In hospital around 40% of these patients would have been eligible and it was the wrong decision – here the right patients are getting the funding,” Reid points out.
The remaining patients are either self-funders or are eligible for social care funding, and if the outcome of assessment is a need for adult social care then the local authority social worker takes over the case.
‘Empowering is definitely the word’
The social work arm of D2A comprises team leader, Joanna Salmon, who was involved in setting up the scheme and social workers Georgina Everitt, who has been practising for nearly sixteen years, and Schola Sjurseth, who qualified in 2006. All three practitioners have a background in health and hospital social work and are responsible for overseeing the social care needs of D2A service users at the participating nursing homes.
“Having the opportunity to move into D2A was empowering, that’s definitely the word,” says Salmon. “You have time, you are a respected member of the multidisciplinary team (MDT) and therefore it enables you to have that empowering role for both your service user and your own professional autonomy – I think as social workers we often question our professional autonomy and within the D2A it is massively transparent.”
But setting up the scheme “hasn’t been easy” and finding the right care homes to take part and the right staff has been key. “When it went out to tender a lot of care homes wanted to be involved and you had to be able to unpick the structure and the management and the ethos with that individual home,” says Salmon. “We’ve found that using care homes who get the ethos of community care, of what social workers do – that has had a better outcome.”
“I do think the reason this is such a success is because we picked the right people to go in and do the job,” she adds. “With any pilot it is about having the right people on board and Georgina and Schola are breath-taking in what they do.”
Communication is key
For Sjurseth and Everitt, their day-to-day role is about understanding the needs and social care history of service users, communicating with the family, or the service user themselves, and communicating the service user’s needs to other members of the MDT. “You could put a fence around your role and say this is what I do but it is very much about the service user being in the middle and everyone around that person trying to work out their needs,” says Everitt.
“I might do a joint access visit with the occupational therapist or be part of the continuing health care discharge assessment with Debbie – all our roles interplay together, they match together and we are very much a team,” she adds.
That communication has enabled the social workers to get support in place for service users more quickly. “I had a gentleman who was sent home from D2A with a walking stick but within two weeks he became very unstable on his feet and needed more physiotherapy input,” says Sjurseth. “Because of D2A, I see the physiotherapists every week and I have that contact so I was able to pick up the phone and ask them to go in and see him.”
A different kind of pressure
One of the most striking things about these three social workers though is how upbeat they seem. It is a far-cry from the crippling caseloads and burnout that is a reality for so many practitioners. “We don’t have the pressures that our colleagues working within acute have,” agrees Sjurseth. “We have time to plan things with a client and their family and to find out exactly what works.”
“I’ve been a frontline social worker for approximately 16 years and you’ve got to have a strong stomach for it,” adds Everitt. “We know the pressures that we have aren’t as timely as the pressures our frontline colleagues have – we have the privilege of getting to know our clients and not having to facilitate for them to make decisions while they are sat in their jimjams next to an unmade bed.”
But the social workers are still working incredibly hard to meet tight timescales. Although they have a six week window for assessing service users, they try to do it sooner. “If we can get someone out on week three then we will and what that then enable us to do is have some flexibility,” says Salmon. “If these social workers worked to those six week deadlines there would never be that scope.”
And it seems that the hard work is paying off. An evaluation of the overall redesign of community services in Warwickshire, which includes D2A, found that average lengths of stay in hospital had fallen by one-third and hospital discharge rates were up by more than 30%.
“The D2A is all about the outcomes for the patient and that’s why it is win-win and there are no lows. Every social worker, every health professional, they will all say to you I am in this because I care – it’s person-centred and that’s what we all strive for,” says Salmon.