Independent Transfer of Care Coordinators
In 2018 Cheshire West and Chester came to Retain to see if we could develop the role generally referred to as a Trusted Assessor as part of a project we were fulfilling at that time. The Local Authority wanted an organisation to manage two roles, one in The Countess of Chester Hospital and the other in Leighton Hospital. They wanted to help improve the outcomes for those patients who had been admitted to hospital and who were well enough to be discharged into a care setting. They understood that some care providers were finding it difficult to visit patients to decide if they could meet their needs and some hospital staff could not always access all the information required by the Providers. The IToCC has access to all of the information available via patient notes and IT systems, can liaise with hospital staff, visit the patient and speak to families to help smooth the transition from an acute setting into Care. The information gathered is then shared securely with selected individuals on a need to know basis so that the most appropriate home can be selected by all concerned and discharge can happen in a timely and safe manner. Because we are independent, the IToCCs are not under the same pressures as hospital staff and can think of different ways to find solutions to difficult problems. We act as a point of contact for all concerned, advocate for patients who have no support network, work flexibly over seven days depending on demand, facilitate discharge where possible and request clarity where there is doubt.
The first year was a resounding success with very positive feedback from hospital wards, patients, families and Car Providers. Care Providers no longer felt the need to visit patients in hospital if other pressures took precedence which saved on their time and travel costs. Financially, there was a significant saving on the cost of care per patient and more beds were readily available for new patients coming into the hospital. It was agreed to extend the pilot scheme for a further year due to the positive difference the role had made.
As the second year started, we were also informed that we had won the tender for the same role for Cheshire East working out of Macclesfield General and Leighton Hospital. In Macclesfield it quickly became apparent that the beds in the hospital were being blocked due to short term care provision being under pressure. The IToCC role is flexible and so we were happy to change the way we operated for the benefit of the residents of Cheshire East.
COVID19 has meant that our service and skills have been in even more demand with restricted visiting, shielding staff and key positions missing in the chain of care. We have been the focal point of contact for families who could not visit loved ones and for health and social care professionals unable to meet the patients themselves.
Currently, the ITOCCs are looking at helping those patients who are in Discharge to Assess beds, as well as those moving into care homes. Next steps include working with the hospital teams who help people return to their own homes with professional support.
Based at Leighton Hospital.