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Vulnerable patients are being discharged from hospital unsafely and sent home to situations where they have inadequate support because of lack of coordination between health, social care, and community services, an investigation by the healthcare consumer organisation Healthwatch England has found.
The investigation was based on the experiences of discharge of 3230 people considered as vulnerable (elderly people, homeless people, and people with mental health conditions) and on information gathered from trusts through freedom of information legislation and from surveys of patients.
Extract from HCS Care Coordinating
HCS Care Coordination Service to Focus on Reducing Preventable Hospital Readmissions
(May 7, 2013)
“East Cheshire NHS Trust is to partner with HCS, to help drive forward the development of integrated care across Eastern Cheshire’s Health and Social Care system. The HCS Care Coordination service will provide expert assistance to the Trust to support the delivery of integrated care as a key partner in Eastern Cheshire’s Caring Together Program, which aims to commission and deliver patient-centred joined up, pro-active care services.
Samantha Nicol, Caring Together Program Director at NHS Eastern Cheshire Clinical Commissioning Group, commented: “Our aim is for improved care for our local population in all areas: clinical, the care pathway and the experience for patients. In addition, we wish to improve the experience for the professional staff delivering that care. Working with HCS provides an opportunity for us to take advantage of a significant amount of expertise and resource that aligns completely with our Caring Together vision and which will help us deliver the success we are looking for.”
The HCS Care Coordination service will focus specifically on work at East Cheshire NHS Trust aimed at reducing the number of preventable hospital readmissions. This focus will involve project support to help the Trust develop appropriate clinical leadership and governance arrangements, as well as assistance in implementing two HCS Care Coordination service modules, Re-admissions Manager and MobileCare. These modules will be enabled by Net.Orange’s clinical Operating System (cOS™), a real-time cloud-based big data platform, which forms part of the HCS Care Coordination solution.
The first module, Re-admissions Manager, will allow East Cheshire NHS Trust to significantly reduce preventable hospital readmissions by identifying high-risk patients, enhancing the management of discharge planning, and supporting more effective transitions of these patients to non-acute care settings. The second module, MobileCare, will support pro-active management of patients across boundaries in all care settings — primary, acute and community — through applications running on handheld devices that can be used by clinicians, practitioners and members of multi-disciplinary teams both within the acute setting and when visiting patients at home.
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