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Innovative liaison nursing role providing vital link to support patients’ safe return home

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A recently introduced nurse-led initiative to help get patients out of hospital and back home is “going from strength to strength” and is now being expanded, according to a Welsh health board.

Clare James began working as community discharge liaison nurse between Morriston and Gorseinon hospitals in Swansea during October 2016, but already her job has been extended.

“It’s a simple idea and not a new one – it’s about co-ordinating services better for the patient”

Clare James

Her role, created by Abertawe Bro Morgannwg University Health Board, involves her acting as a link between hospital staff and health and social care teams in the community.

Focusing on reablement and independent living, she identifies the kind of support that a patient requires so they can be safely discharged home.

Ms James said: “This role is all about the early identification of what needs a patient has and the assistance they might require to go home. It’s a simple idea and not a new one – it’s about co-ordinating services better for the patient.”

The role was put in place by Karen Gronert, the board’s head of nursing for primary and community care, and Nicola Williams, Morriston Hospital’s nursing director, following a successful three-month pilot.

The job has now been developed so Ms James is also supporting admissions to Gorseinon Hospital by screening patients to see if they are suitable for reablement there, as well as reviving the hospital to home pathway.

“Before the pilot, there were large waiting lists for people who needed packages of care. There was an average of 20 referrals each week in Morriston alone,” she said.

“We have eliminated waiting lists for the rehabilitation team by working as the gatekeepers for our service and introducing a direct referral system and criteria, as well as educating hospital staff about our service,” she noted.

“We are delighted to see the positive impact Clare’s role has had”

Nicola Williams

Each week between 130 and 140 people across Swansea are supported by a team of 75 community care assistants, three occupational therapists, managed by senior care assistants, the home care manager, Ms James and community reablement nurse Rebecca Jenkins.

The nurses attend weekly meetings in Morriston, Singleton and Gorseinon hospitals to identify potential patients and promote early assessments.

The nurses then work with the hospital teams towards discharge and to advise on community support.

Ms James said: “We start on average 30 new packages of care every week, with over half of our referrals coming via the hospital to home pathway. This method of referral has sped up the process for discharge.

“We are also very busy with community referrals, offering a rapid response service to prevent admissions to hospital or a care home,” she said. “We are work closely with care staff and occupational therapists as well as with social workers and hospital teams.”

Ms James said one of the many positive aspects of her new post was seeing members of the reablement team growing in enthusiasm and confidence for their work.

“Initially the senior community care assistants were nervous about going into hospital and assessing patients but they have gained confidence,” she said. “It has definitely helped build a bridge between hospital and community.

“As soon as a patient is identified for reablement, we visit the ward and assess them,” she said. “If they are appropriate for reablement and we have the capacity, patients are discharged the following day.”

The reablement period is up to six weeks, but patients are reviewed at regular periods and often need less time after reaching goals set by occupational therapists.

Abertawe Bro Morgannwg University Health Board

Innovative nursing role providing vital link to support patients’ safe return home

Nicola Williams

She added: “A large proportion of our patients will go on to require no further service and high number of those needing long-term support will see a reduction in the amount of care they require.”

Meanwhile, Ms Williams said: “We are delighted to see the positive impact Clare’s role has had and the close working relationships that have developed with social care staff.

“Getting patients back home so they can recuperate in familiar surroundings is one of our top priorities,” she said. “Having Clare and her team working to make that happen as soon and as smoothly as possible is reducing those risks to our patients.”

Ms James added that she was delighted at how well received and effective her role has been and now wanted to develop it by working more closely with third sector and other community teams.

“I am passionate about promoting independence among our older people, to support them to be back at home and to remain at home,” she said.

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