Enfield discharge to access service

The Discharge to Assess model has been designed to reduce hospital stays because patients are discharged as soon as acute medical treatment is complete.

The model comprises of four pathways, delivered by different services:

• Pathway 0 – delivered by Enfield social services
  • A patient doesn’t require any additional support compared to what was in place in their usual place of residence before admission.

• Pathway 1 – delivered by Enfield Discharge to Assess (this service)

  • A patient  receives additional care or reablement needs that can safely be met at home.

• Pathway 2 – delivered by Enfield Community Services

  • A patient is unable to return home for a short period of time as they require further rehabilitation or reablement.

• Pathway 3 – delivered by Continuing Healthcare

  • A patient requires intensive time limited support outside of the acute hospital whilst a comprehensive assessment of their complex and ongoing care needs is completed.
     

In Enfield, Discharge to Assess (Pathway 1) is an integrated health and social care community service providing therapy and/or care for adults in Enfield. The team consists of Single Point of Access occupational therapists, physiotherapists, social workers, therapy assistants and support workers. The service offers short-term intensive therapeutic intervention and care for up to five days.

Under Pathway 1 patients are safely discharged home where other functional and care assessments can take place. Not only is this setting more appropriate as the environment is familiar to the individual, but it gives us a sense of functional capability. It also prevents decisions about long term care being made in crisis, offers an insight into how patients cope and gives the professional an accurate assessment.

Assessments that take place in the home environment include:

• Functional assessments
• Environmental assessments
• Medication review
• Care needs assessment with rapid access to reablement care, if required.

At the end of assessment the team will support the transition to long-term support (if required) as well as develop care plans with patients, and where appropriate their carers, to help alleviate the risk of crisis.

Therapists will also make sure referrals for ongoing therapy input are made prior to discharge from the pathway.

The service is available from 8am to 8pm, seven days a week.

Who is the service for?

The service is for adults over the age of 18 who live in Enfield.

The service is not suitable for people who are medically unstable, have received a new diagnosis of a stroke or where mental health is the main presenting problem.