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Most people appreciate their own bed after a stay on a ward and a new model in North East Lincolnshire is enabling local care home residents to experience planned and timely discharges to make going back to their home from hospital as smooth as possible.

All care homes in North East Lincolnshire have signed up to the Care Home Trusted Assessor model (CHTA) which was launched in April 2018.

The trusted assessors, who include social workers and members of nursing staff, work as part of the hospital Integrated Discharge Team to liaise with the resident and their family, and their care home to plan for them leaving hospital and pre-empt any difficulties that could delay the discharge. 

Trusted assessors receive a raft of important information about the resident when they are admitted including details of their general health, state of mind, prescribed medication and their mobility and nutrition needs. They are then followed through their hospital journey and when they are ready to return to their care home, the assessors provide a written report on how their needs may have changed following the stay in hospital.
 
Since the model was introduced, improvements have been seen in: 

• speed of discharge
• the way different agencies across health and social care who are involved in a person’s care communicate and work with each other
• experience for residents
• outcomes for the residents  

A recent example

Recently a care home resident was deemed able to be discharged from hospital on a Friday. Initial communication between all required parties suggested the repatriation of the resident to their care home would need to be Monday which would mean they would have to stay in hospital over the weekend. The involvement of the trusted assessors meant that all parties worked collaboratively together to ensure the resident made it home to their care home on the Friday afternoon. This was an improved outcome for all concerned.