Improving Care Coordination between Adult Social Care and the Acute Sector

While getting ready for work and thinking about how I would embrace the day, I overheard a conversation on TV that got my attention. Care Minister Stephen Kinnock mentioned on BBC Breakfast News, Government plans around a National Care Service, tackling the crisis in the labour market and introducing the fair pay agreement and Health Plan.

However what really struck a core with me was his following quote below,

"We are going to create a much better interface with Adult Social Care and the Acute sector 14% of the people currently in Hospital are medically fit for discharge but are not being discharged because they don't have a care package."

This highlighted me the need to Improve Healthcare-Social Care collaboration for timely patient discharges. I started to recall previous conversation I've had around this, and how we might address this pressing issue.

A couple question sprang to mind, how do we improve coordination Issues:

How do we improve or ensure seamless coordination between Councils and the NHS for crucial and effective care planning?

What are the current challenges/blockers?

Seamless coordination between Councils and the NHS is challenging due to fragmented Healthcare systems then the added complexities of connecting with Adult Social Care Systems.

So how would one go about trying to improve this? I have some ideas of which some may already exist, if so please do tell me more.

Joint Care Planning:

• Shared Assessments: Develop standardised assessment tools and processes that involve both council and NHS staff to ensure a comprehensive understanding of patient needs.
• Joint Care Plans: Create integrated care plans that outline clear goals, responsibilities, and timelines for both sectors.

Improved Communication and Information Sharing:

• Dedicated Liaisons: Appoint dedicated liaisons within councils and the NHS to facilitate communication and coordinate care transitions.
• Electronic Health Records (EHRs): Implement interoperable EHR systems that allow for secure and efficient sharing of patient data.
• Regular Meetings: Establish regular meetings or forums for council and NHS representatives to discuss patient cases, identify issues, and develop solutions.

Community Involvement:

• Patient-Centred Care: Involve patients and their families in care planning to ensure their needs and preferences are met.
• Community Partnerships: Collaborate with community organisations to provide support services and resources to patients.

The reason I’ve mentioned all of the above is to ask the following questions

If we can help streamline processes and Integrations of various Healthcare and Council systems, what benefit would that be to those patients??

If we could improve collaboration across Adult Social Care and the Acute Sector, what would be the benefit to the patients?

Will this ultimately help reduce the delays in patient discharge and more importantly help to ensure patients have the right care package?

We must help enable a roadmap for both the patient and their caregivers, ensuring continuity of care and preventing readmission. To get there I do think Adult Social Care & the Acute Sector have a greater requirement for real-time data sharing and improved communication between healthcare providers.

This would mean at the time of declaring a patient medically fit and needing to discharge them, the relevant teams will have the following information available to them in real time.

• Patient Demographics
• Medical History
• Discharge Summary
• Care Plan Goals
• Home Care Services
• Follow-Up Appointments
• Medication Instructions
• Patient Education
• Community Resources

I could go on but it's much better to get some of your thoughts on this

I will end by saying the pressing issue of delayed patient discharges due, highlights a need for improved collaboration between Adult Social Care and the Acute Sector.

I think better human, team and departmental collaboration with assistance from technological innovation is essential to addressing this complex challenge of delivering better care for patients.

These were my initial thoughts following that Breakfast News discussion but keen to get your thoughts here or over a Dirty Chai Latte to further discuss.

Have a good day all.