Category Archives: health

Stay Well @ Home

by Emma Ralph from Stay Well @ Home

We are pleased to announce that the Stay Well@ Home Team will be presenting at this year’s ‘I’m a patient, get me out of here’ event. We thought it would be useful to give you a flavour of our exciting new service model before the event. But to truly hear about the fabulous work that the team are undertaking, please join us at one of the workshops that we will be hosting in both South and North Wales.

SW@H is a new and innovative way of working, where partners across Cwm Taf University Health Board, Rhondda Cynon Taf and Merthyr Tydfil Country Borough Councils have joined forces to create a truly integrated way of working together to support those being discharged from hospital.

How do we do this? We are an integrated, multidisciplinary hospital based team made up of Assistant Therapy Practitioners, Occupational Therapists, Physiotherapists and Social Workers, whose primary focus is to either prevent individuals being admitted to hospital unnecessarily by providing early assessments in our A&E departments, but we also work to reduce an individuals overall length of stay by completing timely and robust ‘person focussed’ assessments and through using community based services to support someone in their own home rather than a hospital bed.

What’s new about this? Well, we work across 7 days, 12 hour shifts patterns but more importantly, we have enhanced our community based services across health and social care, such as the RCTCBC Support@Home and CTUHB @Home nursing service who also provide a 4 hour response and work across 7 days in order to provide robust support to individuals upon their discharge home. In a nutshell, we can deliver the following:

  • Through the development of the ‘Trusted Assessor role’ we can set up packages of support within a 4 hour time frame, 7 days per week
  • Rapid community response services to support the hospital based team (both health and social care)
  • Restart or increased packages of care to facilitate discharge to home, 7 days per week
  • We utilise a variety of problem solving options at A & E (including third sector services)
  • Everyone discharged home via us will have a individualised review of their needs within a 14 day period

Come and join us at our workshops where we will be talking through some real life cases and discussing how this model of practice has improved the quality of the services provided. #noplacelikehome #rightcareattherighttimeintherigthplace #personattheheart

Three questions…

If you read our previous blog, you will know that our upcoming seminar, I’m a patient get me out of here, is about hospital discharge planning and the services around that process.  Looking at this from another angle, I started thinking about how I would feel if I was a patient.  How would I want my hospital discharge planned?


I’m an *overly* organised and efficient person in work.  I know that if I went in to hospital, I would start trying to meticulously plan my escape as soon as possible (no offence to hospitals of course, just would rather be at home!).  I would want to know what was happening to me, why it was happening and when it was happening.  And I would certainly want to know how soon I could go home and what I need to do to help that happen.  This led me to the three questions below, which I think should help any patient ensure that they can help in their own discharge planning.

What’s going to happen to me while I’m here?

I want to know why I’m in hospital and if it is the best place for me, the type of care I might receive and what I can do to help myself.  What care/treatment do I need to have to get me well and when will those things happen during my stay?  Will other health and care professionals be involved in my care (e.g. social workers, therapists or community workers), and will I meet them while I’m in hospital or after I get home?

I want to start planning for my discharge straight away, not once I’m told I can go home.  That leads us to the next question…

When am I going home?

I want to know as soon as arrive (within 24-48 hours) when I’m likely to get home.  I have a job, a four year old and a life to get back to and I have to make plans (again with the planning) for what is happening at home whilst I’m in hospital.  I understand that this date may change as my treatment progresses, but I want this reviewed regularly and to be kept updated.

What do I need to do to get home?

This question is much more than just being ‘medically fit’ to leave hospital, I can be medically fit without being discharge ready.  This means that staff should ask me how I currently manage at home and about the types of support, formal or informal, that I already receive.  But there are other questions that need answering as well.  For me these questions would involve what I can do to help myself, but also whether everything I am going to need is prepared for my move back home and my recovery.  I’m lucky, my answers would be fairly straightforward – I know where I’m going is safe and that there are people at home to care for me.  For others, this might be much more complex.  I’m thinking about things like:

  • Is my home suitable for me to live in at the moment? Is it warm, dry, safe and/or accessible?
  • Do I have clothes to wear home?
  • Who is going to take me home?
  • Do I have food at home?
  • Does anyone know I’m going home (family/other services/support/carers)?
  • Will you tell my GP that I was hospitalised and why?
  • Will you give me information about what to do if I become unwell after I get home?
  • Should I expect a home visit or will I receive an appointment for further support or follow up?
  • Will my medication be ready for when I leave?
  • Are there any other factors which may affect my discharge?

If you find yourself in hospital as a patient, or if you’re caring for someone and they end up in hospital (knock on wood), keep these questions in mind.  This dialogue between patients and staff can reduce delays by highlighting potential issues early during your hospital stay.  This will help to ensure that you, or your loved ones, are discharged in a safe and timely way.

I’m a patient, get me out of here

Our seminars on hospital discharge planning are coming up on March 14th and 22nd.  The Good Practice Exchange has worked together on this one with the Health team at the Wales Audit Office.  Sara sat down with Anne to talk about why this seminar is happening now.

If you only had 1,000 days left to live,

how many of them would you choose to spend in hospital? (#last1000days)

Discharge planning is an ongoing process for identifying the services and support a person may need when leaving hospital (or moving between hospitals).  The Wales Audit Office has recently completed reviews of the discharge planning arrangements across all the health boards.  The reviews showed that whilst health boards have the frameworks in place to support discharge planning, there were a number of reasons that were preventing discharge from being as effective as it could be.

The majority of hospital discharges are relatively straightforward, but for approximately 20% of patients, discharge is much more complex for a variety of different reasons.  The number of delayed transfers of care has been steadily increasing during 2017 and the number of patients delayed 13 weeks or more is rising.  These delays in discharge lead to poorer outcomes for people through the loss of independence and mobility.

For every 10 days of bed-rest in hospital, the equivalent of 10 years of muscle ageing occurs in people over 80-years old, and reconditioning takes twice as long as this de-conditioning. One week of bedrest equates to 10% loss in strength, and for an older person who is at threshold strength for climbing the stairs at home, getting out of bed or even standing up from the toilet, a 10% loss of strength may make the difference between dependence and independence. [Professor Brian Dolan, more info can be found at this website.]

One of the common themes coming out of the reviews was that there was opportunity to have greater integrated working throughout the discharge process, including stronger links to services in the community, to make sure the patients are receiving the right care, in the right place, at the right time.

We felt that this theme, in line with the Well-being for Future Generations (Wales) Act 2015 and the Social Services and Well-being (Wales) Act 2014, was tackling a key part of discharge planning – putting the patient at the centre.  Patients are not concerned with who is providing which service, they just want to be assisted to achieve the best possible individual outcomes.

In essence, patient time as the key metric of performance and quality is best measured from the perspective of the person and is a journey not an event. [#last1000 days]

So at this seminar, you will find projects that are working across the sectors, navigating links to services in the community, showcasing truly integrated partnerships and joint working throughout the discharge planning processes and, most importantly, keeping the individual at the centre of the service.  They are finding solutions to the variety of reasons which cause the delays in complex discharges, whether they are related to transfers of care, safety, homelessness, mental health, housing, assessments, or all of the above.

These projects are looking to provide you with food for thought, ideas you may be able to adapt to your own environment, or to spark new ideas.  See what you can take back to your organisation or working environment which will help your patients to have better outcomes.


We would like to note that our background research also highlighted all the work that is going on to prevent admissions in the first place.  In fact, there were so many that we decided that this area deserved a seminar all to itself, so that one will be coming up in February 2019.