Organisation

Integrated Care System (ICS) for Devon.

What was the aim?

The aim was to support patients, and those that care for them, at home when they are discharged from hospital, providing a gateway between hospital and home which has proven pivotal to local hospitals.

What was the solution?

The solution is a widely promoted hospital carers scheme run by ‘Devon Carers’. The team of carers works within local hospitals to help patients and family members who are ‘carers’ themselves to ensure they are supported when discharged. This avoids unnecessary admissions into hospital, often due to carer breakdown or fatigue.

What were the challenges?

It was consistently found that 75% of the carers (looking after a loved one at home) were not known to services before and 25% were actually new to caring at the point ‘Devon Carers’ linked in with them.

What were the results?

The scheme was instrumental in getting patients home from hospital and supporting their loved ones to keep them at home. Discharges stay discharged and are not readmitted. This is because carers are now supporting patients and family members, often for a considerable length of time after leaving hospital.

The ‘Devon Carers’ have NHS Honorary Contracts which enable them to act as an integral part of hospitals, wearing hospital uniforms and using hospital “family and friends” language.

Once identified by the team in hospital family members who look after their loved one at home are contacted on the same day, and if consent is given, provided with the follow up service, designed to offer both practical and emotional support.

Follow up phone calls can often be daily and last for up to six weeks after the return home. There is help with information, service navigation and access, direct from the worker or ‘bought in’ help. This help includes almost anything that will support the carer such as the delivery of cooked meals, replacement of a broken washing machine or rapid access to supplies or voluntary sector support.

What were the learning points?

This was a partnership approach between the former CCG (now rolled into the Devon ICB), local council, Royal Devon and Exeter NHS Trust and Northern Devon Healthcare Trust with Devon Carers.

Simon Rapsey, Implementation Manager said, ‘This integrated way of working and focus on overcoming challenges as an Integrated Care System, as one organisation, has made a huge difference to patients and their carers. It’s about getting support to those that need it most. Our team is happy to make calls to people who may or may not be carers, and direct non-carers appropriately”.

Carer Ambassador Tony Bartlett, sponsor of the scheme said, “I want it to be rolled out across the NHS, so that all carers can get the right help, at the right place, at the right time”.

A video about the service is available to watch on YouTube.