A CCG-funded pilot was initiated in 2015, starting with 15 patients and running in parallel to other winter resilience schemes, including an admission avoidance team, hospital at home service and out of hours social work.
In September 2016 these separate schemes were merged to form the admission avoidance and discharge service (AADS). This example of a local initiative forms part of our managing transfers of care resource.
AADS consists of:
- rapid response in the community
- an admission avoidance team in the Royal London Hospital (RLH) A&E department
- in-reach nurses and AADS screeners based at RLH
- an intermediate care team using a discharge to assess model and offering up to six weeks intensive rehabilitation in the community.
In addition, there is an out-of-borough social worker, and social workers who work out of hours, to respond to referrals from the admission avoidance team and the acute admissions unit. The Discharge to Assess pathway sitting within AADS includes social workers, occupational therapists, physiotherapists, nurses, reablement support workers and case finders/screeners. It is offered as a seven-day service from 8am to 6pm, with up to six weeks community input following discharge.
The minimum information to ascertain what support is required on the day of discharge is gathered by the screeners and follow-up takes place in the community within 24 hours. Where possible, full social care assessment then starts in the community, with most packages provided by the reablement team to support the goals set by therapists. The approach has shown improved recovery for patients assessed in the familiar environment of their own home, with recent data showing 66 per cent of people requiring either reduced or no care packages on discharge from the pathway.
Despite the challenges of developing new cultures and new ways of working, the model continues to impact on delayed transfers of care, improving patient flow and reducing length of stay – with AADS following up patients who have been assessed by the admission avoidance team in the A&E department and were admitted to hospital.
It has also enabled the closure of two 24-bed wards and reductions in continuing healthcare assessments and admissions to residential and nursing care homes. Success has been down to partnership working and a whole-systems approach, with a strong shared emphasis on supporting people in their home.
Contact
Patricia Oguta
Adult Social Care Lead
Tower Hamlets Council
[email protected]
Fiona Davies
Clinical and Project Lead
Admission Avoidance and Discharge Service East London Foundation Trust
[email protected]