Pathway 3 Beds for Hospital Discharge

Somerset Intermediate Care Service is looking to open a test and learn pilot to help us look at new approaches for commissioning our Pathway 3 beds. Hospital discharge is the final stage in an individual's journey through hospital following the completion of their acute medical care, when they leave an acute setting and move to an environment best suited to meet any ongoing health and care needs they may have. This can range from going home with little or no additional care (simple discharge), to a short-term package of home-based or bed-based care and recovery support in the community, pending assessment of any longer-term care needs. Whether at home or in a community setting, individuals should be discharged to the best place for them to continue recovery (if needed) in a safe, appropriate and timely way. Other than in exceptional circumstances, no one should be discharged directly into a permanent care home placement for the first time without first giving them an opportunity to recover in a temporary placement before assessing their long-term needs. People do not have the legislative right to remain in a hospital bed if they no longer require care in that setting, including to wait for their preferred option to become available. Those on the discharge to assess pathway should be discharged to a temporary care home placement for an assessment of long-term or ongoing needs, after which the decision about their permanent care home placement should be made. In Somerset we work with both our community hospitals and a small number of care homes who provide short term reablement and recovery before assessing long term needs. However, there are a small number of people who are in hospital with long term needs where a seamless care journey is best, and should be discharged to the right place, at the right time, and with the right support that can meet their long term needs. We call this discharge option Pathway 3. This is a very small cohort of people who are considered as needing a new long term placement upon discharge from hospital and are likely to not return to their normal place of residence due to the level of long term needs.