Transfer of Care

Following concerns raised over poor discharges, the NHS Devon Clinical Commissioning Group (CCG) published findings earlier this year of an independent review of acute discharges to local care homes. The report highlighted the challenges, gaps, risk and learning for hospital discharges to care homes and made a number of recommendations for improvements. Recommendations included improvements to communications and relationships between care homes and hospitals and improving the respect and dignity of individuals discharged to the care home sector, as well as transactional issues, such as providing up-to-date information on care needs, any incidents of concern and better/consistent discharge planning.

Representatives from the NHS, the Care Home Sector and Local Authorities across Devon are working together on a Transfers of Care Quality Improvement Programme to action the recommendations. Sally Robins has joined the CCG to lead the Transfers of Care programme. The programme will focus on changes that provide individuals with a well-managed and positive transfer experience between Devon hospitals and care homes, making sure that these are as smooth as possible and individuals are transferred with dignity, with their possessions and relevant medication and with a comprehensive handover.  The joint approach is critical so that improvements are resilient and sustainable and, most importantly, focus on a better experience for individuals who are transferring.

An initial priority is to develop a Devon wide standard description to communicate information about the person and their needs, which is both accurate and up to date, to support an improved transfer for the individual, their families and all involved in their care. The working title for this document is the Transfer of Care Information Sheet.  A Guide to Good Practice on how to complete the information sheet to support the transfer and an education programme will also be developed to make sure that implementation of the new approach is effective.

We’ll be keeping you updated on the progress of the Transfer of Care Information Sheet and also on the other activities in the programme, so please keep an eye out for further updates. If you have any feedback or suggestions regarding the programme, you can contact sally.robins@nhs.net. It’s important that we continue to hear about your experience of transfer so please do continue to send in PITCH referral forms.