The Transfer of Care Hub team
As Blackpool Teaching Hospitals continues to tackle the complexities and challenges of discharging patients in a safe and timely manner, one team has been at the heart of solving that problem, and this month they celebrated their first anniversary at the Trust.
The Transfer of Care Hub is a multi-disciplinary team of Health and Social care professionals and services which aims to organise, coordinate and facilitate safe, timely and effective discharge plans for our patients following on from their hospital stay.
Brought together in September 2021, the Transfer of Care Hub is going from strength-to-strength and is now looking at ways of expanding the service to better support discharge at the Trust.
“Over the past 12 months we have successfully integrated, co-located and started working together with all the different organisations and systems that support hospital discharge,” said Charlotte Howard, Hospital Discharge Lead.
“Being on site at the Trust we are able to go and speak to the patients, speak to the ward staff, link in with other professionals that are involved in making sure that we’re organising the right discharge pathway for each patient.”
Patients have a variety of different pathways in which they may ultimately be discharged from the acute hospital beds, and with the Transfer of Care Hub facilitating a ‘Discharge to Assess’ process, it can involve a number of different agencies to ensure a patient receives that safe and timely discharge.
Charlotte explains that the first twelve months of the Transfer of Care Hub have provided a number of challenges to ensure that all parties are happy with the chosen pathway.
She said: “I think the main challenge has been capacity to support discharge. Whether that’s our own capacity to triage the significant number of referrals that we get on a daily basis or the ongoing capacity within social care to support patients returning home, or going into a placement.
“You have to balance the pressures of the hospital and the needs of the patient. It’s a difficult role and you’re trying to pull everybody’s different, professional opinions together. You’re listening to everybody’s recommendations but also what the patient wants as well.”
The Transfer of Care Hub leads
The success of the last twelve months has ensured that already the Transfer of Care Hub is aiming to expand their footprint and their services. Already there has been a dedicated Hub also set up at Clifton Hospital, while the acute team has also incorporated A&E social workers from Blackpool Council and is now exploring ways to meet mental health provision.
“Overall the first year has been a success,” Charlotte says. “But we are always looking at what we can implement to keep improving.
“We’ve built a strong team at the Transfer of Care Hub, they do a difficult job, particularly in these challenging times, but I believe we all work together to facilitate each individual discharge that we genuinely feel is the best possible plan for our patient’s safety.”