“If you see a person in hospital, it’s quite difficult to get a sense of who they are and what their strengths are,” says Beth Appleton, team manager for the Watford General Hospital integrated hospital discharge team. “When they’re home, they are in their own clothes, in their armchair, so you can build up that relationship and start working towards their outcomes.”
This, in a nutshell, is the rationale for the discharge to assess model that now determines how people discharged from hospital are supported across the country.
While it is now national policy, brought in to help free up hospital beds and control infection in the wake of Covid-19, discharge to assess has long been seen as the best way to manage hospital discharge for the reasons Beth says. In Hertfordshire, it has been the direction of travel for several years, and its implementation has been accelerated by the pandemic.
Her hospital-based team is part the Herts Valley integrated hospital discharge service, which is responsible for the assessment and ongoing support of people discharged from hospital who live in the west of the county.
While around 20% of patients are assessed on the ward, because of their complex needs or safeguarding concerns, 80% are identified as suitable for assessment at home, following triage by hospital-based social workers.
These assessments are carried out by the post hospital review team, who work with the person to identify how they can best be supported to regain independence, through the provision of short term care and support, by two care agencies with whom the team work closely.
The outcomes are generally much better for people, says Beth.
“If someone is assessed in hospital they often are not feeling very well, so may end up with a higher level of care and that would stay with them for longer. Under discharge to assess, people are discharged with the care they need in that initial transition home, this is quickly reviewed, where we find people can actually manage with less support.
“They can be fully reabled when they get home. The longer-term outcomes are more beneficial. There’s a reduction in length of stay, which is good as people lose muscle mass and strength for every day they spend in hospital where they don’t need to be.”
And it’s a way of working that generates significant job satisfaction.
Lisa Norton, a social worker in the post hospital review team, says: “I moved here last year at the start of Covid and I can say my work has been really diverse, with really challenging cases, which I really enjoy.”
In respect of her hospital-based team, Beth says: “I’ve recently done a piece of work with the team about why we do the job we do – and it’s that we want to get people home as soon as possible. That’s what people want out of our job.”
Besides the Watford and post hospital review teams, the service also includes: an out-of-county hospital team, a Barnet General Hospital team, for Hertfordshire patients in that hospital, and a community hospitals team, for people discharged from acute to community hospitals.
‘Keeping the focus on people’
When the pandemic hit in March 2020 and the Department of Health and Social Care required hospitals to free up 15,000 beds within a week, the pressure on the service was immense.
“It was about keeping the focus on getting people to the right place in the right time,” says Beth. “The cases were so high that we knew that it was a matter of hours, the difference between catching and not catching Covid, so we needed to ensure people left the hospital as quickly as they could to keep them safe. People felt a lot of responsibility during that time.”
‘Every day matters’
Now that Covid cases are not at the levels they were during the first and second waves, the focus is on patients who are in hospital for other reasons; however, practice has changed as a result of last year’s experience, says Beth.
“It’s perhaps changed people’s mindset that every day matters for people – now it’s that if we get people home today rather than tomorrow they will be stronger and have more of a chance of getting better.”
Strong relationships with ward staff are critical to good hospital social work. However, there are times when hospital social workers have to advocate for patients on the wards.
Beth adds: “There can be a risk aversion in hospitals about people going home and possibly going to nursing or residential homes instead. The role of the social worker is to ensure – that the person is happy with their discharge plan or that it is in their best interest, if they are unable to make that decision.”
‘It was good to achieve what he wanted’
Miroslava, a senior social worker in the out-of-county team, recalls one such case.
“The was a young gentleman who was quite poorly – he had cancer and had had a stroke, and all he wanted to do was go home,” she says. “All the professionals in hospital were very risk averse and wanted him to go into a care home.
“There was a lot of discussion over it within the team. I understood the risk and why they didn’t want him to go back home, but that was his end-of-life plan – he wanted to stay at home.
“We managed to get him home with a significant level of support. Having supportive managers and team has also been essential and having them involved right at the beginning helped because they knew the case and knew how challenging it was and knew his wishes. He has passed away since then, but it was good for us to achieve something that he wanted.”
This is exactly what the whole service is focused on – and it is now recruiting service-wide.
Beth adds: “Across the service, whatever you are looking for, there will be a job to suit you.”
If you are interested in a role in the Herts Valley integrated discharge service, see the latest vacancies here.