Sheffield Frailty Pathway
Community and hospital staff meeting in the Frailty Big Room have successfully designed a new discharge process for patients at risk of entering a care home – while in development it has been called ‘Complex Discharge to Assess’.
The pilot has delivered this improved experience for 48 patients – 36 of whom have been able to stay in their own home.
For the other 12 there is wide agreement that timely holistic assessment at home was the best way to decide that they needed to enter a care home. Senior health and social care leaders have indicated that they are so impressed by the outcomes that the new process will be incorporated into the city’s ‘Home to Assess’ pathway.
The Frailty Big Room is now on tour meeting weekly at a community intermediate care unit. This provides the opportunity for community staff to assess and redesign processes in their care pathway.