What is the challenge your project is going to address and how does it connect to the theme of 'How can improvement be used to reduce delays accessing health and care services'?

Norfolk and Norwich University Hospital currently admit 2 – 3 people per week who don’t need hospital care but need a safe place to be.  This is often due to carer breakdown for some reason including illness.

Our project would see these ‘social’ admissions either being supported to stay at home or to come into residential or housing with care for a short stay

We would link this with our Trusted Assessor Service and use the funding to provide and facilitate wrap around services including ongoing assessment and reablement for the person themselves.  We would then work to get the person back home and restore the previous caring relationships where possible.

What does your project aim to achieve?

SPECIFIC – A reduction in hospital social admissions, 2/3 residents per week are admitted along with their carer.

MEASURABLE – Yes – Can track the volume of residents admitted to hospital.

ACHIEVABLE –  Yes, “Duty desks” were previously in place in Norfolk in social care. since the removal of this role, admissions have increased.

RELEVANCE – This will help to ease hospital pressures, social care placements for people waiting and someone occupying a medical bed. It helps to prevent a resident from becoming unwell and helps them to retain their independence.

This would remove discharge barriers and delay where a cared for erson is referred to social services to source a placement.

TIMELY – It would take c3 months to implement / recruit into the role. We already have the infrastructure in place to deliver, we would need to employ into the role for this specific aim of reducing hospital admissions.

How will the project be delivered?

The Trusted Assessor role already exists in NorseCare working closely between health and social care.

We would appoint a second  Trusted Assessor as an extension which would integrate social care locally with the “front door” team at the acute hospital to support placements. This role would act like a care co-ordinator.

There is a need for this role – and conversations are about to take place with the acute trust to confirm extending the arrangements.

Caseholding the patient / resident.

How is your project going to share learning?

We would evaluate the service continuosly with service beneficiaries, their families and other professionals involved in each case (across Helath and Social Care)

Identifying what worked well, what we need to learn and implement changes.

Locally we would share the information with health and social commissioners

There is a Trusted Assessor network nationally in which we would share our work and findings.