Experiences of 'Discharge to Assess' pathways in Coventry
Some of the people we spoke to were some of the frailest and most vulnerable, who sometimes do not have their voices heard. We spoke to them so we could understand their experiences of short term care after being discharged from hospital.
We looked at different types of care provided for up to 6 weeks either to help people to regain their ability to live independently at home through therapy support and personal goals, or to have their ongoing care needs assessed away from hospital.
In Coventry these types of short term support/care are known as ‘Discharge to Assess' pathways and 'Reablement Support'. With support being provided to individuals in a care home, a housing with care flat, or in their own home.
These types of care involve a number of different NHS and care organisations.
We found that:
- It was hard to understand the pathways and people did not receive enough information about their care in a way they could understand
- We heard that individuals do not necessarily fit within the defined approaches and whilst the intention is for person-centred care, we saw that this was not always achieved
- There was variation in staff training to support people to be 're-abled'
- There were positive examples of inter-agency working at a care delivery level
- Strategically the NHS organisations and the local council did not have sufficient measures and data to be able to determine how effective the packages of care were or if changes were needed to approaches