Overview
Working across organisational boundaries and as an integral part of the Surrey Downs Health and Care system, the integrated health and care team is responsible for providing rapid access, enhanced, short term health and care support for people who would otherwise need emergency hospital admission as well for those medically stable to return home from an acute hospital but requiring enhanced short term support as one stage in their ongoing care pathway. The Surrey Downs Health and Care Home First service spans the acute and community providing joined up, co-ordinated care to local citizens with health and social care needs. The service aims to support people living as independently as possible by offering rapid multidisciplinary assessment and support at times of crisis.
Responsibilities
* Lead the NHS CHC led D2A and Continuing Healthcare processes within the acute hospital setting, facilitating discharges and supporting the Transfer of Care Hub and Hospital Staff with the undertaking of referrals for CHC led D2A assessments and CHC Fast-Track assessments throughout the acute environment, and to make recommendations to the relevant CHC services.
* Be an integral part of the Discharge to Assess (D2A) pathway, selecting in conjunction with social care practitioners the appropriate candidates, planning for the CHC eligibility assessment to be undertaken post discharge, in the community.
* Work closely with the CHC Placement and D2A administrative teams, ensuring communication, and timely sourcing for Packages of care or placements in Care homes, for the patients eligible for the D2A and FT pathways.
Organisation and Partnerships
Surrey Downs Health and Care deliver care closer to people’s own communities through our Primary Care Networks, Community Hospitals, Specialist Services and our innovative partnership of local NHS organisations. Surrey Downs Health and Care has a track record of providing person centered care that goes beyond organisational boundaries to do what is best for the individual. This partnership includes:
* The three GP federations GP Health Partners, Dorking Health Care and Surrey Medical Network representing practices that operate in the Surrey Downs area
* CSH Surrey
* Epsom and St Helier's University Hospitals NHS Trust
* Surrey Council County
Historically, there have been boundary lines between the organisations that provide care to people in their homes, in GP surgeries and in hospitals, but we have always been united in our mission to provide great care to the people who need us. It’s on those grounds that the Surrey Downs Health and Care was formed - we want local people to receive the care that they need in the right environment. By bringing together our expertise, we can improve patient care and enable local people to access the right support, care and treatment more easily than ever before. In bringing this partnership together, we are working to the same set of values that will translate into better care for our residents.
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