This multidisciplinary team, made up of nurses, clinicians and allied health and care professionals provides a rapid response to people with a learning disability, autism or both who are at risk of being admitted into hospital. This may be because their needs have increased or they need additional specialist input so that they can be discharged to live in the community.
The service has been operational for over a year and there has been a noticeable improvement in the quality of care for this group of people:
- The intensive support service supports people to transition from hospital into the community. The dedicated staff provide flexible bespoke packages of care and use shared decision-making and robust care planning to make sure the service is truly person-centred.
- Staff from the service have stayed over in the person’s new home at night when they are settling in. This gives assurance to families and helps new care providers develop confidence.
- The team have been instrumental in facilitating effective engagement between the hospital setting and new community provider, which is a critical factor in providing seamless care.
- The team have prevented avoidable admissions to hospital, enabling several people to remain either with their families or in their supported living placement during times of crisis. This has been of particular value when a crisis has occurred on an evening, weekend and bank holiday, as the team is available 24/7.
- They work sensitively and deliver personalised care. When one person had to move at short notice to a new care provider, the team replicated their bedroom exactly, which helped them settle quickly into a new home. Another person was supported to remain in the community whilst coping and adjusting to the death of his mother.
- The team also give advice and support to other community teams who work with people with a learning disability. This leads to better quality of care and patient experience in community services.
Since it started 99 people have been referred to the service, of whom only three were then admitted to hospital. The service is currently actively working with 24 people. Most people are supported intensively for up to 12 weeks, although some people are supported for longer depending on their needs.
Arden TCP are reviewing the service to inform the future model and commissioning intentions. They are excited about the opportunities to further develop their community services for children, young people and adults with learning disabilities and autism.