24hrs post discharge phone calls

24hrs post discharge phone calls: Creating wrap around community care between patients, the NHS and Age UK Lincoln and South Lincolnshire.

In April 2020, with the threat of COVID-19 becoming a clear reality, all NHS trusts were instructed that patients who were well enough should be discharged from acute hospital beds as soon as possible, to either return home, be transferred to a care home or receive rehabilitation support at a community hospital or a transitional care bed.

As part of this process, Lincolnshire Community Health Services (LCHS) NHS Trust was responsible for supporting the discharge of patients to their own home who did not need a specific care package to support them. This is formally known as Pathway Zero.

Recognising that patients needed a safety net to ensure that their physical and mental health needs were being met on their return home, LCHS approached Age UK Lincoln and South Lincolnshire (LSL) for support.

Working collaboratively, an innovative new wrap-around service was introduced; all patients returning home would receive a phone call within 24 hours from an Age UK LSL representative to find out how they were getting on and to check whether they needed any additional help.

About the LCHS pathway zero discharge service

  • Working with Age UK LSL, LCHS established the new 24-hour follow-up call service for patients within just two weeks.
  • The discharge service supported 845 referrals to the Pathway Zero service in June – the busiest month on record.
  • The Age UK LSL service is staffed by a team of three co-ordinators.
  • Comments from service users show that they value the service and are pleased and grateful to receive a call.

Liana Arnold, Clinical Service Lead for Transitional Care and Flow from LCHS explains“The new service we created with Age UK LSL was designed to address the holistic health needs of our patients – not just their medical requirements.

Our focus was to consider not only the immediate medical needs of our patients but also their social, mental and general wellbeing requirements to help improve their overall quality of life. This is where Age UK LSL’s connections with ground level community and charitable organisations really came into their own.

For example, during conversations with patients, Age UK LSL has been able to resolve concerns about new medication by making sure the local pharmacy provides tablets in easy to use blister packs to increase people’s confidence. They have been able to signpost and involve local charities and smaller specialist services to make a real difference to the quality of life for our patients at home, such as arranging talking newspapers, installing grab rails and ensuring access to local community social groups.

By creating this safety net, staff at our acute hospital wards have a better understanding of the support available in the local community and the reassurance that patients will get the wrap-around care they need to recover at home.

The support from Age UK LSL has been amazing, providing support in just one month to over 800 people. The fact that they were able to deliver this service from scratch in just two weeks is a true testament to them”.

Rosie Davidson, Head of Care and Support at Age UK LSL said“61% of patients discharged from hospital via Pathway Zero are over 51 years of age. As a provider of services for people over 50 years, our expertise ensures patients are supported and referred on to appropriate services efficiently. However, the relationships we have and partnerships we nurture with our third sector colleagues mean anyone we engage with can be guided into services that they need at the time they need them.

Whilst under the care of the hospital, those needs may not be apparent to the patient or those around them until they return to their home. This transition can often highlight emotional and social needs as well as the needs of those with a caring responsibility.

We have been able to guide people into practical support provided by Adult Social Care Teams, Carers First, The Wellbeing Service, support for Veterans and serving military personnel and mental health support to name a few. Where appropriate, we maintain contact with patients to ensure they are moving towards the support they require.

The opportunity to work with LCHS to create and develop this innovative way of providing wrap-around support has enabled us to focus on the entire wellbeing of patients, not just their medical needs. So far, we have referred 380 patients into ongoing support services. And those that have not required further support are incredibly grateful for our contact post discharge, making them feel cared for beyond the walls of the hospital and valued as a member of their community”.

Case study: avoiding breaking point for a vulnerable patient

  • Patient A was discharged from hospital as part of the Pathway Zero approach.
  • Upon speaking with Patient A, the Age UK LSL co-ordinator was advised that he was still in pain with his stomach and back and that his GP had told him he needed to eat and drink more. The patient confirmed that he was struggling to prepare meals for himself as he felt unwell, required help to prepare his meals and was worried about when and how to take his medication.
  • Recognising that the patient needed additional support, and with his consent,  the Age UK LSL co-ordinator made a referral to the Neighbourhood Team.
  • The Neighbourhood Team made an onward urgent referral to HART (Hospital Avoidance Response Team), delivered by Age UK Lincoln & South Lincolnshire and commissioned by LCHS.  HART accepted the referral and phoned the patient twice a day.
  • HART provided care and support to Patient A for six days and saw an improvement in his ability to look after his own needs and manage his medication.
  • Contact was maintained with the Neighbourhood Team and it was agreed that as Patient A was in a position manage his own care needs, support from the HART team could be withdrawn.
  • A representative from the Neighbourhood Team commented that without the Pathway Zero phone call, this patient “…would have been heading for trouble, as he was not coping at all”.