Healthcare for Older People
Early intervention programme
Discharge to assess
The Early Intervention team has implemented a revised discharge to assess system across Birmingham in line with COVID-19 guidance issued in March 2020.
50% of people: simple discharge, no input from health/social care.
45% of people: support to recover at home, able to return home with support from health and/or social care.
4% of people: rehabilitation in a bedded setting.
1% of people: there has been a life changing event. Home is not an option at point of discharge from acute.
This means that the following operational processes are now in place:
- Trusted assessor model in place for Therapists, OPAL team, Complex Discharge Nurses, Social Workers and Social Care Facilitators.
- All referrals to rehab/intermediate care beds are now managed through the Complex Discharge Hubs (CDH) following submission of a Transfer of Care (TOC).
- In partnership, Birmingham Community Healthcare Trust (BCHC) and Birmingham City Council (BCC) have set up a pathway 2 hub to manage all referrals into both BCHC rehab and intermediate care beds.
- There is a new BCHC in-reach Matron role within the Complex Discharge Hubs (CDH). The Matrons work alongside CDH members to help to develop a faster decision-making process to admit a patient to (a) one of the BCHC community hospitals, (b) refer to the Early Intervention Community Team (EICT) or (c) a long-term health and social care pathway.
- Allocation of beds to patients being referred to pathway 2 are now managed in a more timely manner, those referred before 14:00 should expect same day allocation of a bed and those referred after 1400hrs should expect next morning allocation. There is an escalation driven by the Complex Discharge Team to support this.
- BCHC and UHB across Moseley Hall Hospital, West Heath Hospital, Ann Marie Howes Centre, Perry Tree, Community Unit 27 at Good Hope Hospital and Norman Power Centre have introduced the one bed model. This means the only specialist rehab beds are now Stroke and Inpatient Neurological Rehab Unit (INRU).
- Pathway 2 beds are short term rehab. There is no patient choice but a best endeavour will be made to allocate the patient near to their home address. However, this is not a reason to keep a patient in an acute hospital bed.
- Transfer of Care Referrals (TOC) into the discharge hub should not identify discharge/referring location, however they should identify what a patient can do or not and what care support is required.
- Seven day working of hubs. A reminder that referrals, assessments and discharges can happen seven days a week.
For any queries, please contact Sarah Carmalt: