How my role as a trusted assessor supports integrated working

Pam Ward, Care Home Trusted Assessor, Warrington and Halton, tells us more about her role and how it’s supporting smoother transitions from hospital to care home.

My role as a trusted assessor means helping to support people moving from hospital care to a care home.

I assess what the person’s care needs are so that care homes can decide whether they have the means to be able to support them.

The purpose of my role is to improve patient experience, streamline communication between the care homes and the hospital, and facilitate a timely and safe discharge.

It's about having a link and voice between the care homes and the hospital to ensure a timely and safe discharge as much as possible with all our patients. If we can get the right information and the right plan, then people aren’t going to be in hospital any longer than they have to be.

This is important because care home residents typically spend longer in hospital, often due to waiting time for assessments which can mean that someone who was fit and well to be discharged can pick up an infection or have their health worsen again while waiting to be assessed.

I’m based in the hospital conducting assessments on behalf of the care homes which cuts down this waiting time and reduces the chances of people deconditioning, which means overall time spent in hospital reduces.

And we have seen that since we’ve had this role in place there’s been a marked improvement in the length of hospital stays.

I really love my job. I’ve been in this role since it was developed in 2018, and prior to that I was a senior occupational therapist. I love that I’m able to use the transferable skills from my occupational therapy experience in this role too.

When I first saw the role advertised it read as if it was written for me. Key elements of my role include being a single point of access for care homes; being a voice for the patients and care homes; facilitating and supporting a safe and timely discharge; working alongside consultants, therapies, discharge team, social workers, and the palliative team; completing full holistic assessment on behalf of care homes, and working closely with the enhanced care home support team to avoid re- admission.

At my first ever meeting with the care home managers I did feel quite daunted as of course people can be hesitant about the introduction of a new role and perhaps felt I would be making decisions on their behalf. So, it was really important that I explained from the get-go that I was there for them, I was their voice in the hospital, I would gather all the information they required, and it would then be their decision if they had the resources to support someone based on my report. The feedback I've had from the care homes is the report that I send them mirrors the patient that arrives on their doorstep, which is a big trust.

Having worked in the hospital for 18 years myself as an occupational therapist, I knew what the care teams’ struggles and barriers were and that also really helped in building those relationships with the care home managers and ensuring I was best supporting them in my role.

I also enjoy being able to network with the care homes and educating the health team more about care homes.

I conduct all my assessments face-to-face, and having the relationship I have with the care home managers can really help me with supporting patients. I can speak to the care home providers to gain their insight on how best to engage with people because they know them best.

That’s a really positive example of how health and care can work together to best support the person drawing on support. Integrated working is important for seamless care between all health professionals, which is centred around the person.

My favourite part of my job is making a difference and improving patients’ journeys and their experience whilst in hospital, supporting complex discharges and working collaboratively with health, social and therapy colleagues.

I work closely with a lot of one-to-one patients that the hospital is struggling to discharge safely.

From my assessments we can often find solutions to the need for one-to-one care. For example, it might be that someone is trying to get up unsafely because they need the toilet but they’re not able to explain that and so by introducing a regular toileting routine we can combat that and reduce their need for one-to-one care.

By taking that care and time you can reduce those needs and really make a difference to someone, and that’s what makes my role so rewarding.

Learn more about what integrated working is and how it benefits people drawing on care with our ‘Integrated working and social care’ spotlight.

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