1. THE INTEGRATED DISCHARGE TEAM

2. Where we came from In August 2004 five different teams were amalgamated into one. The five teams were: Social Worker and Physiotherapist from Chichester ward 2 Social Workers and an Occupational Therapist from A&E 3 Nurse Discharge Co-ordinators 1 Social Work Discharge Co-ordinator Fast Track Team: 1 Nurse, 1 Care Manager, 1 Social Worker, 2 Occupational therapists, 1 Occupational Therapy Assistant These teams were brought together in response to evidence based research. This identified that working from the front door of emergency care reduces a person’s length of hospital stay, reduces the risk of the person being delayed in hospital and avoids unnecessary admission to hospital. This underpinned the new Integrated Discharge Team’s remit.

3. Who we are The team is a partnership of both interdisciplinary and inter- organisational professionals Socia l work er Nursi ng Occupatio nal Therapy Administratio n Physi o- thera py Team manag er

4. Aims of the team To avoid unnecessary admission to hospital Reduce the number of delayed transfers of care within the Trust Reduce average length of hospital stay through early discharge planning Improve patient care pathways

5. Who we work with and reasons for referral People from any geographical area Anybody over 18 years People whose activities of daily living are compromised due to: Infections Cardiac conditions Respiratory conditions Drug and alcohol issues Falls Reduced mobility Musculo-skeletal problems Neurological conditions Chronic pain Fractures And people who are unable to cope in the community, homeless people, people with carer needs, mental health issues, chronic diseases, physical and learning disabilities and those with sensory loss.

6. Equalities We celebrate diversity and believe that everyone is entitled to be treated fairly and valued equally. We do not discriminate anyone on the basis of their age, gender, marital status, disability, nationality, ethnic origin, religion or faith, sexual orientation or domestic circumstance.

7. What we do Rapid assessment for people over 18 yrs who present to A&E/MAsU Provide multi- disciplinary intervention and assessment Liaise with relevant primary, community and voluntary health and social care and housing services. Create personalised careplans to meet people’s assessed needs Provide home assessments and OT equipment as appropriate

8. How do we do it Proactive and early identification of people using inter-organizational IT systems, clear and robust communication channels with our partners in the acute and community sectors. We work across A&E, medical assessment unit, Observation ward and short stay Chichester ward with people who have short term acute medical needs. We proactively screen peoples’ needs in liaison with department coordinators and stream people to appropriate care pathways. We work a split shift system ensuring provision of service from 08:30am to 18:00 6 days per week and 09:00 to 13:00 on Sundays. We provide joint multidisciplinary assessments of peoples’ needs at the earliest opportunity. We interskill within the team. We work very closely with the Rapid Response Service who provide assessments and medical care in people’s own homes to avoid hospital admission and to facilitate timely discharge. We constantly work to build better, person-centred care pathways within both the acute and community sectors. We actively challenge discrimination and work to promote peoples’ independence within their own homes while considering all issues of equalities.

9. How do we do it contd We all work from one office We challenge aversion to risk management and use all available resources to ensure people leave hospital as soon as they no longer require acute medical care. One manager across team disciplines We proactively promote the care management model of care, seamlessly assessing peoples’ needs and working in partnerships to provide appropriate care.

10. The Role IDT Plays Our service has been inherent to reducing the length of people’s stay in hospital. We play an integral role in meeting the government’s targets on ensuring people are assessed and transferred from A&E department within 4 hours. We see on average over 200 people per month. We have actively prevented these peoples’ unnecessary admission into hospital by setting up appropriate care and support for them in their own homes (60%) or finding transitional, respite and rehabilitation care beds in the community. We have built excellent, robust relationships with our community health, social care & housing, independent, voluntary and charitable partners. We actively lead on implementing the Single Assessment Process. We contribute to the consistent reduction in numbers of older people who are cared for in care homes as outlined in the National Service Framework for Older People. We have raised the profile of the protection of vulnerable adults and provide training for acute medical staff in the early identification of abuse in vulnerable adults using shared, inter-organisation policies and procedures.