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WINNER☆ - Introduction of an Intermediate Care MDT, Carmarthenshire

Outstanding Contribution to Transforming Health and Care Award

Hywel Dda University Health Board

Prudently utilising limited, valuable intermediate care resources is paramount to the aspiration of meeting the needs of an ageing population. Evidence confirms that discharging patients as soon as they become medically optimised significantly impacts positively on the deconditioning of patients.

A System Flow Improvement Plan was established by Hywel Dda University Health Board (HDUHB) in August 2021 with a significant focus on implementation of SAFER methodology in the acute hospitals of the Carmarthenshire Division of HDUHB. It was agreed that an initial pilot would take place, with a primary focus on discharge planning from day of admission and the implementation of discharge to recover and assess pathways. A specific focus was developed around ‘Home First’, and an Intermediate Care MDT (IC MDT) approach was developed to implement home first principles and to deliver on the vision – all patients are discharged from hospital as soon as they are medically optimised, for a period of rehab and assessment.

The MDT successfully aligns the 4 pillars of intermediate care into a single point of access which pools intelligence and resource of health, social care and third sector agencies together. The ‘Home First’ principle is strongly embedded, triaging away from statutory services and proportionally supporting individuals to receive a period of recovery and assessment as close to home as possible.

In the first 12 weeks of service, the MDT received 262 referrals, of which 179 were deemed appropriate and therefore were discharged from acute hospital sites through the team. The team aims to provide a response within 48 hours of receipt of referral. This has remained 100% achievable since the start of the pilot. Furthermore, the vast majority of referrals are actioned within 24 hours.

The team are in the planning stages of phase 2 of this project which is focused on the inclusion of Primary Care and Community Services.

Leah Williams