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Supported Integrated Discharge – John’s story

on . Posted in Case Studies

When John was first taken into hospital, all he knew was that he didn’t feel well.

In fact, he’d had two heart attacks and ended up spending seven weeks in hospital.

As John, who is 78, has had osteoarthritis for a number of years, he was already finding it more difficult to walk before being taken ill.

So staff at Solihull Hospital knew he was going to need support after he was well enough to go home.

John was referred to Solihull’s Supported Integrated Discharge (SID) service, which helps patients aged over 65 to regain their independence and health as quickly as possible after a hospital stay.

The service offers both physiotherapy and occupational therapy assessment and treatment at home, rather than on hospital wards.

Health professionals from Heartlands and Solihull hospitals work alongside carers and occupational therapists from the Promoting Independence service at Solihull Council to help patients recover at home safely and avoid being readmitted to hospital.

SID is an example of the work of Solihull – Together for Better Lives. This is a partnership of local health and social care organisations that have put in place a programme, called Integrated Care and Support in Solihull (ICASS), to improve health and social care for older people.

John said: “When I first came home, carers visited me every day, three times a day. It was a matter of making sure I’d dressed and I’d eaten, or I was going to eat.

“Then I had physiotherapy and learned how to use a walking frame and get up and down stairs.

“The nurses and carers have been brilliant. I’m more or less back to normal now.”

Mandy Hannigan, Promoting Independence co-ordinator at Solihull Council, said: “Constant communication between the hospital staff and the Promoting Independence staff works extremely well for patients because we’re all working for the same aim, to make sure that people regain their independence.”

Pete Heald, SID physiotherapist at Heart of England NHS Foundation Trust, added:

“Traditionally, we hadn’t been able to link in with social care or follow up with therapy immediately after discharge. With SID, we can build relationships with patients from the first day of their inpatient stay and give them continuous, high-quality care when they go home, so that they can start therapy straightaway.

“It’s fantastic working with Mandy and her colleagues. We can solve problems together – they now have access to therapists and we have access to more help and support from social services than we’ve had before.”

Julie Blake, clinical lead for the Promoting Independence Service, said: “Supported Integrated Discharge (SID) is all about improving the quality of people’s lives and getting them home from hospital quicker. SID bridges the gap between primary care and community services. Through our partnership with colleagues at Solihull Hospital we have broken down the traditional (separate) social and medical ways of working.”

Karen Lewis, intermediate care lead at Heart of England NHS Foundation Trust, added: “This service is a great example of how staff in different organisations can work together for the benefit of patients. By challenging existing processes and systems, it has enabled us to provide continuity of care, which is centred on the individual patient’s needs.”

http://vimeo.com/nhsmediahub/review/108456278/6c80b4163b%5d

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