Transfer of Care
Stroke Improvement Programme National Project 2009-10
Quality Marker 12
The Transfer of Care national project were about implementation of Quality Marker 12 of the National Stroke Strategy:
‘Seamless transfer of care: a workable, clear discharge plan that has fully involved the individual (and their family where appropriate) and responded to the individual's particular circumstances and aspirations …developed by health and social care services, with other services such as transport and housing.’
(National Stroke Strategy, 2008)
Project objectives
• To identify drivers for improving transfer of care within and between organisations.
• To develop partnership working between health and social care and the third sector.
• To establish qualitative and quantitative measures used in social and health care to record the impact of service change on transfer of care.
• To raise awareness of transfer of care issues in stroke among health and social care and third sector
agencies.
• To influence key national stakeholders to effect particular strategies affecting transfer of care.
• To share learning from service improvement and examples of good practice nationally.
Project sites
• Dudley PCT
• NHS Lewisham
• Lincolnshire Community Health Services
• NHS Milton Keynes and Milton Keynes Council
• Nottinghamshire County Council and Nottinghamshire Community Health
• Poole Hospital NHS Foundation Trust and NHS Bournemouth and Poole
• South West London Cardiac and Stroke Network
• Stoke-on-Trent City Council's Adult Social Services
• The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust
Measures/anticipated outcomes
Project outcomes will stem from the implementation of improved systems for transfer of care, resulting in:
•More efficient pathways of care, potentially saving bed days and building stroke unit capacity for acute admissions.
• Implementation and enhancement of stroke specific community services, potentially improving access to and quality of services and reducing waits for treatment.
• Involvement and engagement of patients and families in the process, potentially improving patient and carer experience and satisfaction and supporting adjustment to living with stroke.
• Enhancement of integrated working between health and social care and the third sector, potentially increasing numbers of patients able to live independently at home, and who access support to live a long term good quality of life with stroke.
National policy/strategy
This project is clearly aligned with the National Stroke Strategy (DH, 2007), and brings together the principles of the government policy in ‘Our health, our care, our say’(DH, 2006) and ‘Putting People First’(DH, 2007) which provides direction for transforming health and social care and improving these
partnerships, with clinical guidance for managing transfer of care after stroke (RCP, 2008)
.
Learning from the projects
• Going up a gear: practical steps to improve stroke care publication, June 10
• Project case studies
• Presentations and posters from the Accelerating Progress in Stroke Care event, 22 June 10
Contact details
Project lead: Sarah Gillham
National Improvement Lead
NHS Stroke Improvement Programme
Email: sarah.gillham@improvement.nhs.uk
Tel: 07920 081197
Resources
Joint Commissioning in Early Supported Discharge: Creating patient and carer-centred pathways through joint commissioning
National Stroke Strategy Quality Marker 10, 12, 13 and 15
NHS Knowsley have set up an early supported discharge (ESD) service to meet what service users consider to be their unmet needs. By integrating both health and social work components, the ESD team has been able to extend its scope of practice, and be more responsive to the needs of the both the service user and their family. To find out more about this service, please click here.
Useful links
• Department of Health (DH)
• National Institute for Clinical Excellence (NICE)
• Stroke Care Networks
• The Royal College of Physicians (RCP)
• Association of Directors of Adult Social Services (ADASS)
• Care Quality Commission (CQC)
• The Stroke Association
• Different Strokes
• Connect
• Crossroads Care
• Collaborative Leadership in Applied Health Research and Care (CLAHRC)
• The Chartered Society of Physiotherapy
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