The Hounslow Integrated Discharge Hub which is responsible for the seamless transfer of patients’ care and support into the community, scored outstandingly high on the recent Transfer of Care Hub (ToCH) maturity matrix based on the following:
- The high level of partner integration in the hub
- 7-day functionality
- Strong leadership with clinical input into the transfer function
- Detailed development on progressing maturity since the self-assessment in 2023
This incredible development is underpinned by robust data collection (analysis and insight); the innovative ‘Pentagon Model’ (a uniquely designed model for the multi-disciplinary triage of Pathway 1 referrals that’s takes place twice a day, 7 days a week) and a strong link with the Hounslow Borough Based Partnership leadership team who help the hub to address barriers and identify opportunities.
Since the ‘Pentagon Model’ came into effect because of the new Bridging Care scheme in November 2023, there has been an improvement in delay days by 0.5 days for faster discharges of Pathway 1 patients. This helped the model secure a nomination at the West London Trust’s Excellence Award 2024.
The Hounslow Integrated Discharge Hub was established in 2020, in response to the COVID-19 pandemic, and since then has been responsible for the seamless transfer of patients’ care and support into the community. It coordinates all discharges under:
- Pathways 1 (patients who need some health and/or care support),
- Pathway 2 (patients’ needs require rehabilitation bed placement)
- Pathway 3 (patients who need a care home placement)
This covers all discharges from West Middlesex Hospital, as well as all Hounslow patients no matter which hospital they are being discharged from.
The integrated team consists of:
- Chelsea and Westminster NHS colleagues
- Hounslow Community Health Services (West London NHS Trust)
- Hounslow Council Adult Social Care
- Voluntary sector partner (British Red Cross)
The hub is a great example of how partnership working can deliver ‘real’ change for patients and residents.