Purpose

The ‘Going Home’ service supports
people to be discharged safely from hospital through Pathway 0 and
Pathway 1 as part of the wider Discharge To Assess (D2A) model in
Bristol. This initiative is funded via the Discharge Support Grant.
The funding associated with this initiative is time limited up to
31st July 2024. However additional resource for this initiative to
cover 1st August 2024 to 31st March 2025 has been made available
through this grant after consultation with Sirona. Funding beyond
this Project will be via a tender for service if the pilot is
successful and will be administered via other means and
communicated to all interested parties in due course.
This derives from the Discharge Grant Fund approved in July ASC PC
ModernGov - bristol.gov.uk (item 8- delegated authority to Exec
Director in consultation with Chair of PC).

Content

The current service is already starting to
evidence the value of the provision in terms of bed-days saved and
swifter more sustainable discharge back into the community.
Continuation of the service will provide further evidence of the
value to all partners (ICB and Adult Social Care). Allocate grant
funding to voluntary and community social enterprise (VCSE)
organisations in Bristol to pilot a new way to support people to be
discharged safely out of hospital through pathway zero back into
the community. The VCSE partners in this Project are
•Age UK Bristol (Hospital based Linkworkers and
“Front-Door” service)
•Southmead Development Trust (Community-based
Linkworkers)
•Wellspring Settlement (Community-based Linkworkers)
•Knowle West Health Park (Community-based Linkworkers)
All of the above are members of the “Make It Local”
Partnership.
it is well understood this is a system wide issue and multi
solutions, new service design and improved pathways need to be put
in place to fully address this issue. However, one small solution
is to bring in additional paid for VCSE support directly into the
current discharge pathway. The funding attached to this grant has
been identified to trail the implementation of VCSE Link workers as
a resource into both Southmead and Bristol Royal Infirmary
Hospitals. This funding will also trial community navigators/link
workers based in specific localities to support people whilst they
are settled at home, connect them in with their local community and
support the prevention of hospital readmission.
This pilot is part of the wider discharge to assess (D2A)
transformation programme. The pilot includes hospital link workers
based in University Hospital Bristol and Weston Trust and North
Bristol Trust co-located within the integrated discharge teams.
There is also a BCC ASC facing “front-door” service
with a worker co-located alongside the ASC team at City Hall. Age
UK Bristol will provide a co-located Link Worker presence in the
Adult Social Care (ASC) Front Door (Swift Response Team (SRT) and
Care Direct) responding to phone and written contact and referrals,
to facilitate onward referral and signposting to voluntary,
community and where appropriate social enterprise services ('VCSE')
in Bristol where it is agreed and appropriate to do so. The Link
Worker will not undertake any work that requires a Care Act
Assessment and wider statutory intervention. The responsibility for
meeting callers' statutory needs will at all times remain with
Bristol City Council ASC.
The aim of the hospital link workers will be to enable people to be
discharged without the need to go through clinical discharge
pathways. Community link workers will be based in voluntary
organisations around Bristol localities. Link workers primary role
is to do whatever is necessary to help people to return home and
make sure they have links in their local community to remain well.
This is achieved using the extensive knowledge that VCSE colleagues
have of services in Bristol. If the scheme is extended, funding
beyond this term will be via an alternative source to be determined
through the Integrated Care System partnership work. BCC will not
be liable for any funding beyond the use of this grant-sourced
resource.