Enhanced discharge and admission avoidance – Wirral PCN

As part of work to support NHS hospital trusts to safely discharge patients, Healthier South Wirral Primary Care Network have developed the enhanced discharge and admission avoidance programme. The main aim of the programme is to give enhanced support to patients who have been discharged from hospital and to reduce the likelihood of them being readmitted.  They can also support patients who could possibly be admitted and put measures in place to avoid this.

People identified for support are contacted and regularly followed up by PCN clinicians and social prescribing colleagues, which happens within 48 hours of discharge.  The multidisciplinary team can also include Age UK, Fragility team and pharmacists, ensuring a full package of care is offered for everyone.

The team recently supported a 70-year-old man, who lives at home with his wife, and was recovering at home from a Thoracic Vertebra closed wedge fracture. He contacted his GP Practice as he was experiencing pain and difficulty getting around.  The GP carried out a telephone consultation and given the pain and mobility problems the patient was experiencing; a home visit was arranged by the GP for a thorough assessment.

When the GP visited the patient at home, he indicated he would prefer to be managed at home if possible and didn’t want to go into hospital.  The doctor prescribed painkillers but unfortunately the patient did not improve and his wife found it difficult to manage him at home.

A virtual call took place including the PCN and clinical assessment unit consultants at his local hospital and they agreed that the patient would need to be admitted to manage his pain however could be discharged early and followed up once home.

Once discharged, the patient was assessed by a GP from the enhanced discharge and admission avoidance service.  The GP spoke to the patient who was managing much better at home following the additional support put in place via the PCN and hospital.  A further home visit was agreed the next day.

Over the next couple of days, the patient was contacted by the GP and had daily support from Physiotherapists from the Rapid Response team.

In addition to supporting the patient, care co-ordinators also offered important support to the patient’s wife and registered her as a carer with her GP Practice, and a referral was made to Ask us Wirral for benefits advice, she is also under the support of a Carer wellbeing Practitioner.