Transforming Services with Care Elevation Consulting

 The Challenge:

During the winter months, hospitals often face increased pressure on bed availability due to a higher number of patients requiring admission. To address this issue, there was an urgent need to establish multi-site intermediate care services for a Health and Social Care Partnership, providing a bridge for patients transitioning from hospital to home or long-term care.

The Solution:

Phil and Janey led the initiative to map, plan, coordinate, and implement these intermediate care services. Their goal was to create a seamless, efficient system that would alleviate hospital pressures and ensure patients received the appropriate care and support during their transition.

Leadership and Team Development:

Phil and Janey focused on assembling a multidisciplinary team to support the implementation of the intermediate care services. The team included:

• Registered Care Home Managers
• Social Workers
• Nurses
• Occupational Therapists
• Physiotherapists
• Community Development Staff
• Reablement Staff

They ensured each team member understood their role and contribution to the project’s success.

Establishing Criteria and Processes:

To ensure the service operated effectively, Phil and Janey developed criteria for access to the intermediate care services. This involved:

1. Accurate Information Collection: Collating detailed and accurate information about patients to inform planning and decision-making.
2. Criteria Development: Establishing clear criteria for patient access to the service, ensuring only those who would benefit most were admitted.
3. Pathway Planning: Designing care pathways aimed at achieving the best possible outcomes for patients transitioning from hospital to the intermediate care services.

Goal Setting for Patient Independence:

The team of professionals and care staff worked together to set individualised goals for each patient. This focused on maximising the potential for patients to return to their own homes rather than moving to a care home. This involved:

• Personalised Goals: Setting specific, measurable goals tailored to each patient's needs and abilities.
• Interdisciplinary Approach: Collaborating across disciplines to ensure a holistic approach to patient care.
• Regular Assessments: Conducting regular assessments to monitor progress and adjust goals as needed to ensure the best possible outcomes.
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Project Development and Implementation:

Over the course of the project, Phil and Janey led the team through the following key steps:

1. Stakeholder Engagement: Engaging with health and social care partners to align on goals and expectations.
2. Service Mapping: Mapping out the service requirements across multiple sites to ensure comprehensive coverage and accessibility.
3. Process Coordination: Coordinating efforts across various professionals to streamline the referral and admission processes.
4. Implementation: Rolling out the service across multiple sites, ensuring all team members were trained and supported.

Results and Impact:

The development of the intermediatecare services led to significant improvements in managing hospital pressures during the winter months. Key achievements included:

• Reduced Hospital Bed Pressure: The establishment of intermediate care services provided a timely and efficient solution for patients ready for discharge, reducing hospital bed occupancy.
• Enhanced Patient Outcomes: Patients benefited from personalised care pathways, ensuring they received the right care at the right time.
• Improved Collaboration: Strengthened collaboration between health and social care partners, fostering a more integrated approach to patient care.
• Increased Independence: Many patients were able to return to their own homes thanks to the focused goal setting and support provided.
• Team Recognition: Phil and Janey’s leadership and coordination were recognised as critical to the project's success, with positive feedback from both staff and patients.