As we reach our 100thpatient moving through the Discharge to Assess Service at Wilfred Geere, I’ve taken the opportunity to reflect on the great work we’ve done to help support those who have needed it.
 

I have been in post as Clinical Lead for the Discharge to Assess Service since December 2016, and was drawn to the role because of an interest in elderly care and a strong awareness of the importance of a holistic and individual approach to looking after an older person with complex needs. I wanted to put that in to practice, and encourage others in a team to work together to help people get home.

Discharge to Assess is a service that takes older people who have been in hospital and no longer need medical inpatient care (for example, their infection is cleared or they’ve had the operation they needed) but are not yet safe to go back to their own home. They can come to Wilfred Geere, a residential and respite home with experience managing those with dementia or similar disorders, for around four weeks and they and their families work with the team of carers, supervisors, social workers, pharmacists and technicians, mental health nurses, GPs, volunteers and therapists to plan for their onward care. Often these people are struggling with confusion – either temporary due to a delirium, sometimes longstanding and permanent due to living with dementia or similar, or a combination of the two. The time in Discharge to Assess gives that confusion a chance to settle in a place of safety and the person the chance to develop more independence in order to have the best chance of success at home.

We are proud to provide the GP support and leadership for this project from the Federation, and have a team of GPs who are particularly interested in complex elderly care working with Wilfred Geere. We can provide continuity from the patient’s own GP surgery but provide more intense support than might be offered in this time of need if someone were at home.

The team of professionals we have working alongside the Federation are all keen to think outside the box and help get people home (if safe and what they want) however we can. Everyone goes above and beyond and get to know the people we have in Wilfred Geere as individuals. We meet weekly (but talk together far more often) to try and structure plans for home, and the therapists and Age UK volunteers will then follow people up at home once they’ve left our care.

The numbers are good, with 45% of patients who would otherwise have gone into long-term care making it back to their own home. We can assist with setting up care packages, day centre sessions and carer support as well as linking in to respite to ensure people can live well at home for longer.

The feedback is positive, with a recent person discharged reporting that his new accommodation is ‘good, but not a patch on Wilfred Geere’, and that the staff were wonderful. We are regularly asked why we can’t provide long-term care as people would like to stay!

I’m so proud to be a part of this service and to work alongside such dedicated professionals and with such an interesting group of patients. Here’s to the next 100 people we can support!

Dr Laura Barnfield
Wilfred Geere Clinical Lead