Seasonal pressures this winter have hit hard and its recognised that our hospital and community operational teams are working relentlessly to keep our residents well and supported, and we are incredibly thankful for their dedication and commitment over this period.
To help alleviate admission pressures and provide a faster and more inclusive discharge, and home support offer, we listened to staff feedback and ideas in conjunction with reviewing a range of data sources to ensure discharge funding was used efficiently to deliver:
Bridging Care:
The Bridging Care scheme launched in November 2023 to support patients who are medically optimised and no longer need to remain in hospital but may have some ongoing care and/or support needs which will be delivered in the community. It manages, and oversees live actions, to improve patient outcomes and flow at West Middlesex University Hospital by reducing the number of days a patient is delayed being discharged.
This innovative scheme involves the Hospital SW team (LBH), Community Recovery Service - Reablement (LBH), Integrated Community Response Service (ICRS), Discharge Hub (WLT), Home First (WLT). They meet twice a day, 7 days a week to jointly triage all suitable Pathway 1 referrals.
Hospital @ Home (H@H)
This pilot was launched in 2024 to reduce delayed discharges of patients who typically end up requiring a prolonged stay in hospital before being medically optimised. It is designed to support patients who are admitted to hospital with dementia, delirium, or challenging behaviours who may end up on Pathway 3. However, they may benefit better from medical treatment in their own homes if it is safe and suitable to do so.
Currently, H&H provides four virtual beds in the community, and one physical bed at Fern Gardens Care Home (full capacity will be scaled up to eight virtual beds in the community with the option of two physical beds in Fern Gardens). This pilot can provide a better patient experience and help individuals avoid unnecessary and prolonged treatment in the hospital environment.
It is funded via the Better Care Fund – Additional Discharge Fund 2024/25 (runs from Aug-March 2025) and involves teams from: Integrated Community Response Service (WLT), Hospital Social Work team (LBH), Discharge Hub (WLT), Dom care and brokerage (LBH).
Between August – December 2024 the pilot triaged 110 referrals, admitted 41 patients, and discharged 38 patients. YTD (28 Aug 2024 – 31st Dec) has reduced the average number of days a patient is delayed being discharged to 8.79 from 10.35. H@H is supporting patients who would otherwise be at high risk of converting to a P3 discharge pathway.
CHILs (Care Home Inreach Liaison service):
West London NHS Trust is piloting a new service to support older people with dementia in five care homes in Hounslow. The CHILs Team (Care Home InReach Liaison Service) launched in December 2024; and is funded by the Better Care Fund and will run until March 2025.
CHILs utilises skills from occupational therapy, psychiatry, and specialist nursing to support care homes care for older people who may have behaviours that are challenging. The service aims to avoid an escalation for additional services and hospital presentation. Care Home teams receive enhanced training, and training to undertake medication reviews.
Since launching, CHILs has completed training plans for each of the five care homes, and staff training within those settings has commenced. The team has also received more than 30 referrals and has completed assessments for more than 10 care home residents (January 2025 data).