Home First for Wiltshire – What is it? A simplification of discharge from hospital and direct support for the complex and intense post hospital period: Using ‘meet and greet’ / D2A a) 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
Who? The recruitment of 30.6 RSW’s to increase the capacity of the 11 Community Team bases, across three localities. Recruited since Started since 1 December 2016 February 2017 Sarum 4.96/ 8.6 North and East 8.8/ 11.0 1.8 WWYKD 9.4/ 11.0 0.8 2.6 Total 23.16/ 30.6
Current New Full assessment of care needs in • No detailed inpatient setting Streamlined pathways – clear assessment criteria. Referral with specified package in inpatient Social Care of care setting needs only Referral for HomeFirst – information and intellgence • All home shared Access to Care (Medvivo) based Triage and Information Gathering patients – Access to Care (Medvivo) no Processing Only Referral to Community Team separation Triage and Information Gathering between Community Team confirm ready to health and receive – discharge timed Community Team refer to HTLAH Social work team refer social care Provider requesting care as to H2LAH prescribed Meet & greet and initial assessment • Discharge in home. All support needs covered not by community team dependent on separate No care available – No care Full Care No care referral/ available – available – available- Request for bridging from brokering of HTLAH agency start date Council puts Medvivo Urgent care at H2LAH refers to sub- given out to spot Home and/ or divert Therapy – led contractor purchase nursing/therapy resources assessment, • Transfer to case H2LAH H2LAH management after initial Patient Care available- reablement Mixed Care Care available- start date and discharged start date given support settling in available- start rehabilitation given, 72 hours max for Care starts date given and needs UC@H identified at home Therapist case Social care case management management Long term needs /assessment Care provider
Streamlining discharge pathways – work in progress Pathway 0 Pathway 1 Pathway 2 Pathway 3 No additional support Additional support needed, but Additional support needed, Straight to long term care/ but can’t go home can go home specialist care 1. Medically able, with no 1.Medically able but additional 1.Medically able but 1.Medically able but additional post discharge post-inpatient support required additional post-inpatient additional long term support support required support required required 2. Safe to be discharged 2. Safe to be left between visits 2. Not safe to be left 2.Known and settled long to home (includes no (including no safeguarding between visits (includes term complex needs which safeguarding concern) concerns present) safeguarding concern) prevent returning home Essential Criteria 3. Has access to a normal 3. Has access to a normal place AND/OR OR 3. Doesn’t have access to place of residence (this of residence (includes 3.Known and settled long includes nursing and residential care homes but not a normal place of term complex needs which residential home settings) nursing homes) residence (includes can be managed at home existing care /nursing through a bespoke, planned home) discharge package OR 4. Additional support needs could be met in existing care /nursing home subject to assessment/ planning of discharge
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