1. INTEGRATED DISCHARGE TEAM ehabilitation & ssessment irectorate Rehabilitation & Assessment Directorate Acute Hospitals Division

2. Working in partnership with

3. Integrated Discharge Managers – North / South Head of Older People Services & Physical Disabilities GCC Partner Local Authorities Operations Managers Social Work Hospitals ( GCC) Senior Bed Manager Senior Discharge Co-Ordinator Supported Discharge Manager Practice Team Leaders & Hospital Social Work Teams (GCC) Bed Manager Discharge Co-ordinators & Discharge Co-ordinators Supported Discharge team

4. Provides a visible structure with clear aims and objectives across all agencies. Brings together and builds on existing knowledge and expertise which promotes effective joint working. Reduces barriers between organisations and agencies. Promotes collective ownership of service and performance Encourages and embraces innovation. Why an Integrated Team?

5. Our aims? Our aims? Provide a whole systems approach to Discharge Management for all patient groups within Glasgow Acute Hospitals.Provide a whole systems approach to Discharge Management for all patient groups within Glasgow Acute Hospitals. The Integrated structure ensures smooth, safe and seamless patient journeys, minimising gaps and delays and providing clarity of roles within the single team framework.The Integrated structure ensures smooth, safe and seamless patient journeys, minimising gaps and delays and providing clarity of roles within the single team framework. Improve and monitor performance across the raft of discharge activity (including the reduction in delayed discharge) and to set agreed joint performance targets within the team framework.Improve and monitor performance across the raft of discharge activity (including the reduction in delayed discharge) and to set agreed joint performance targets within the team framework. Streamline and strengthen links across the internal and external discharge network.Streamline and strengthen links across the internal and external discharge network. Provide a significant contribution to overall joint service planning and development within current agendas.Provide a significant contribution to overall joint service planning and development within current agendas. Further develop policy and practice for the whole range of discharge activities which will be fully inclusive to all patient groups.Further develop policy and practice for the whole range of discharge activities which will be fully inclusive to all patient groups.

6. Our challenges ? Reduce delayed discharges in line with current Scottish Executive targets. Manage Acute admissions and patient flow in line with current Unscheduled Care Collaborative (UCC). Engage with Community Health & Care Partnerships (CHP/CHCP’s) to deliver a consistent approach to admission & discharge service delivery. Develop and monitor protocols for sharing of information and create a single framework of data collection, collation and analysis of discharge information (including delayed discharge) that can be shared with all partners with resultant action plans. Develop patient, carer and staff information which assists and advises on all aspects of the discharge process. Monitor and meet best practice guidelines i.e. SIGN and NHS Quality Improvement Scotland. Monitor and manage “Choice of accommodation on discharge from Hospital” process. Working across different organisations

7. Key to our success? The Team (willing, enthusiastic, flexible, innovative). Talking Knowledge and understanding of partner organisations. Promoting & evidence of best practice through audit & education Blurring of roles that reduce duplication, particularly in assessment process. Senior management support.

8. Work in progress Pan Glasgow approach within new structures. Pan Glasgow approach within new structures. Promoting effective multi-disciplinary working at ward level within acute settings. Promoting effective multi-disciplinary working at ward level within acute settings. Continual quality improvement of Discharge planning. Continual quality improvement of Discharge planning. Moving nearer the front door! Moving nearer the front door! Unscheduled Care Collaborative (UCC) Unscheduled Care Collaborative (UCC)