Implementation: getting started
This section highlights 3 areas of the transition between inpatient hospital settings and community or care home settings for adults with social care needs guideline that were identified as a focus for implementation. It explains the reasons why the change needs to happen (given in the box at the start of each area). The section also gives information on resources and examples from practice to help with implementation.
See recommendations 1.1.1 to 1.1.3, recommendation 1.1.5, recommendations 1.3.3 and 1.3.6, recommendation 1.4.6, recommendation 1.5.7, recommendation 1.5.14, recommendation 1.5.24 and recommendations 1.5.29 to 1.5.31.
Providing person‑centred care can ensure that:
everyone with care and support needs is recognised as an individual and as an equal partner who can make informed choices about their own care
when a hospital stay is needed, people who need care and support continue to experience a seamless service that suits their needs and meets their goals for care, rather than the needs of services
carers are recognised for the understanding they bring about a person's life and preferences, and are given the support they need to sustain their own wellbeing
practice is safe and effective, this in turn can reduce the long‑term costs associated with poor quality care.
Managers and practitioners working in multidisciplinary hospital‑ and community‑based teams need to develop a common understanding about person‑centred care. That way they can better organise services around the needs of each person, especially as they transfer between care settings. But current pressures on services can mean that they feel unable to offer personalised care and support.
The challenge: changing how community‑ and hospital‑based staff work together to ensure coordinated, person‑centred support
Changing working practices across multidisciplinary teams is likely to lead to:
a better experience of transitions between hospital and home and improved wellbeing for people with care and support needs, their carers and families
greater job satisfaction
more efficient and cost‑effective use of resources
To achieve person‑centred coordinated care for people moving between care settings may need changes in culture and local practice.
Managers need to assess the factors affecting integrated working in their areas, and motivate and support practitioners to adopt attitudes and behaviours that support person‑centred approaches. Changing attitudes can be challenging, particularly if there are pressures on staff time and resources, and local capacity (or knowledge of alternative sources of support) is limited.