Tag Archives: Transition Between Inpatient Hospital Settings and Community or Care Home Settings

Statistical Process Control Applied to Delayed Transfers of Care (NHS Improvement)

Posted on June 22, 2019 by Dementia and Elderly Care News

Summary Delayed transfers of care (DToC) are widely recognised to be a significant cause of unnecessary harm to patients, and potentially avoidable financial costs to the taxpayer. NHS Improvement’s “Delayed transfer of care (DToC) improvement tool” incorporates the latest data from … Continue reading →

Posted in Acute Hospitals, Commissioning, Community Care, For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), For Social Workers (mostly), Integrated Care, Local Interest, Management of Condition, National, NHS, NHS Improvement, Person-Centred Care, Quick Insights, Standards, Statistics, UK, Universal Interest | Tagged Acute Hospital Care, Adult Social Care, Adult Social Care Services, Ageing Population, Areas With the Highest Delayed Transfers of Care, Care for Vulnerable Older People, Clinical Commissioning Groups (CCGs), Cross-Sector Partnerships, Dashboards, Delayed Transfer of Care (DToC) Improvement Tool (NHS Improvement), Delayed Transfers of Care, Delayed Transfers of Care (DTOC), Discharge From Acute and Mental Health Trusts, DToCs Dashboard, Efficiency Opportunities, English Local Authorities, Geographical Variations, Health and Adult Social Care Providers, Health and Social Care, Health and Social Care Integration, Hospital Discharge, Hospital Discharge and Transfers, Integrated and Community-Based Care, Integrated Home and Community Care Services, Integration of Health and Social Care, Local Authorities (LAs), Local Health Services: Variations, NHS Improvement's Delayed Transfers of Care Improvement Tool, Patient Discharge, Patient Flows, Pivot Table Slicers (Excel Tool), Post-Discharge Support, QI: Quality Improvement, Quality and Efficiency Opportunities, Quality Improvement, Quality Improvement Approaches, Reducing Bed Days, Reducing Waste in the NHS, Regional Variations, Social Care Delays (Impact on Hospital Bed-Days and LoS), Social Care Providers, Statistical Process Control, Statistical Process Control (SPC) Principles, Statistical Process Control Methodology, Sustainability, Sustainable Health and Social Care, Thinking Like a Patient and Acting Like a Taxpayer, Transition Between Inpatient Hospital Settings and Community or Care Home Settings, Unacceptable Variations, Unwarranted Variations, Variation in Performance, Vulnerable Older People, Wasted Resources, Whole System Dashboards, Whole System Patient Flows | Leave a comment

Intermediate Care Including Reablement: Quality Standard QS173 (NICE)

Posted on September 7, 2018 by Dementia and Elderly Care News

Summary National Institute for Health and Care Excellence (NICE) has produced a quality standard on intermediate care, including reablement. This is intended to contribute to improvements across many fronts, including: Integration of health and social care. Patient and carer-related quality … Continue reading →

Posted in Commissioning, Integrated Care, Local Interest, National, NICE Guidelines, UK | Tagged Alternatives to Hospital Admission, Alternatives to Hospital Care, Bed-Based Intermediate Care Services, Community-Based Interventions, Community-Based Rehabilitation Services, Community-Based Services, Community-Based Support, Crisis Response, Delayed Discharges, Delayed Transfers of Care, Demand for Intermediate Care, Discharge of Hospital Patients With Care and Support Needs, Discharge Planning, Home Based Intermediate Care, Home Based Services, Hospital Discharge, Integrated and Community-Based Care, Intermediate Care, Intermediate Care Including Reablement: NICE Quality Standard QS173, Multi-Agency Integration, Multi-Disciplinary Team (MDT), Multimorbidity, National Audit of Intermediate Care, NHS Benchmarking, NICE Quality Standard QS173, NICE Quality Standards, Partnership Working, People's Experience of Using Adult Social Care Services, Prevention of Avoidable Emergency Admissions: Intermediate Care, Quality Measures, Quality Statements, Re-ablement Services, Re-admission Avoidance Scheme (RAS), Reablement, Reablement Services, Reablement Services for People Leaving Hospital, Readmissions for Patients with Long Term Conditions, Recovery, Recovery Based Approaches, Recovery Rehabilitation and Reablement (RRR), Recovery Rehabilitation and Reablement Services, Recovery. Rehabilitation, Redesigning Services, Regaining Independence, Rehabilitation and Self Management, Rehabilitation Care Pathways, Rehabilitation Services, Services Maximising Independence, Services Reducing Use of Hospitals, Social Care for Older People With Multiple Long-Term Conditions, Social Care Reablement Services, Supporting Health Wellbeing and Independence, Transition Between Inpatient Hospital Settings and Community or Care Home Settings | Leave a comment

Helping Hospital Patients Stay Active and a Winter Framework For Speedier Discharge (NHS England / BMJ / BJN / NIHR Signal / JAN)

Posted on December 29, 2017 by Dementia and Elderly Care News

Summary Jane Cummings, the Chief Nursing Officer for NHS England has written about a Winter Framework designed to reduce delayed discharges by maximising the use of care homes across each Sustainability and Transformation Partnership (STP). Therapy-led units, too, will be … Continue reading →

Posted in Acute Hospitals, Commissioning, Community Care, For Carers (mostly), For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), For Social Workers (mostly), In the News, Integrated Care, Local Interest, Management of Condition, National, NHS, NHS England, NHS Improvement, NICE Guidelines, Non-Pharmacological Treatments, Person-Centred Care, Personalisation, Physiotherapy, Quick Insights, Standards, UK, Universal Interest | Tagged 2018 Chief Nursing Officer Summit, 70-Day National Challenge: End Pyjama (PJ) Paralysis, Accountable Care Organisations, Accountable Care Organisations (ACOs), Accountable Care Systems, Accountable Care Systems (ACSs), Acute Care, Acute Hospitals, Adults With Social Care Needs, Ageing Population, Assessment Before Discharge, Australian Institute for Musculoskeletal Science (AIMSS): University of Melbourne, Barriers and Challenges in Discharge Planning, BBC Radio 4, BBC Radio 4's Inside Health Programme, Birmingham Council, Birmingham Cross City Birmingham South Central and Solihull (Proposed Transforming Care Partnership), Birmingham Cross City CCG, BMJ Publishing Group Ltd, British Journal of Nursing, British Medical Journal (BMJ), Care Home Digital Tools, Care Homes and Therapy-Led Units for Patients Medically Fit for Discharge, Care Transitions, Care Transitions Involving Adults With Social Care Needs, Care Transitions of Older People, Chief Nursing Officer's Summit (2018), CNO Summit (2018), Collaboration, Collaborative Care, Collaborative Care Planning, Colombia, Colombia Department of Science Technology and Innovation (COLCIENCIAS), Community Health Services Ease Winter Pressures on Hospitals, Criteria Led Discharge, Daily Transfers of Care (DTOC), Deconditioning, Deconditioning in Hospital, Delayed Transfers of Care, Delayed Transfers of Care (DETOCs), Department of Rehabilitation Medicine: Nepean Hospital, Destination on Discharge, Discharge, Discharge at a Reasonable Time, Discharge Coordination, Discharge Coordinators, Discharge From General Inpatient Hospital Settings, Discharge Into the Care Sector, Discharge Planning, Discharge Support, Discharge to Assess (D2A) Model, Early Mobilisation, Early Mobilisation in Hospitals, Early Patient Mobilisation, Eat Drink Move, End Pyjama (PJ) Paralysis, Excessive Bed Rest (Patient Harm), Frailty Care on Surgical Ward: Lavenham Ward at Ipswich Hospital, Frailty Care on Surgical Wards, Framework for Maximising Use of Care Homes for Patients Medically Fit for Discharge, Framework for Maximising Use of Therapy-Led Units for Patients Medically Fit for Discharge, Framework to Support Winter Pressures (2017-18), Fundación Cardioinfantil - Instituto de Cardiología (Bogotá Colombia), Get Up and Dressed, Get Up For Breakfast, Harms of Bed Rest, Hawkesbury District Health Service - St John of God Health Care (New South Wales), Health Care of Older People (HCOP) Specialty: Nottingham University NHS Trust, Hospital Discharge, Hospital-Associated Deconditioning, Hospital-Associated Functional Decline: Role of Hospitalisation Processes, Hospital-Related Deconditioning, Hospital-Related Deconditioning: Cognitive, Hospital-Related Deconditioning: Physical, Hospital-Related Deconditioning: Psychological, Hospital-Related Deconditioning: Social, Implementation of Care Home Digital Tools, In-Hospital Mobilisation, In-Reach Teams, Initiatives to Decrease DTOCs, Integrated Discharge Process, Integration of Health and Social Care, Integration of Health and Social Care for Older People, Integration of Primary Secondary and Community Care, Ipswich Hospital NHS Trust, Ipswich Hospital User Group (IHUG), Jane Cummings: Chair of the Transforming Care Delivery Board, Jane Cummings: Chief Nursing Officer for England, Journal of Advanced Nursing, Journal of Geriatric Physical Therapy, Last 1000 Days, Lavenham Ward Reablement Project (Ipswich Hospital), Lavenham Ward: Ipswich Hospital NHS Trust, Length of Stay (LoS), Local Monitoring to Identify Care Homes at Risk of Closure, Local Sustainability and Transformation Plans (STPs), Local UEC Delivery Boards, Managing Transitions, MDTs: Multidisciplinary Teams, Medically Fit for Discharge Ward (MFFD), Mobility Bundle, Musculoskeletal Ageing Research Program: Sydney Medical School Nepean, National Institute for Health and Care Excellence (NICE), National Institute for Health Research (NIHR) Signal, Nepean Hospital (New South Wales), Newcastle upon Tyne NHS Foundation Trust, NHS East of England 100 Day 100000 Patient Days Campaign, NHS South Warwickshire CCG, NIHR Signal, Nottingham University Hospitals NHS Trust, Nursing Department of Clínica FOSCAL (Bucaramanga Colombia), Nursing Department of Clínica: Palermo-Congregación de las Hermanas de la Caridad Dominicas de la Presentación de la Santísima Virgen, Operating Model for Therapy-Led Units (TLUs), Operational Models to Optimise Care of Patients Who are Medically Fit for Discharge (MFFD), Oxford Institute of Nursing Midwifery and Allied Health Research (OxINMAHR), Palermo-Congregación de las Hermanas de la Caridad Dominicas de la Presentación de la Santísima Virgen (Bogotá Colombia), Patient Deconditioning Effect Related to Hospital Bed Rest (aka Pyjama Paralysis / PJ Paralysis), Patient Discharge, Patient Flows, PJ Paralysis, Post-Discharge Support, Proactive Specialist In-Reach, Professor Brian Dolan: Founder of Time-Valuing Movements, Professor Brian Dolan: Oxford Institute of Nursing Midwifery and Allied Health Research (OxINMAHR), Pyjama Paralysis, Pyjama Paralysis on Hospital Wards, Re-ablement Services, Reablement, Reablement Guidance, Reablement Services, Real Time System Surveillance, Real Time System Surveillance Enabling Technology, Real Time System Surveillance Tools, Recovery Rehabilitation and Reablement (RRR), Recovery Rehabilitation and Reablement Services, Red2Green, Reducing Bed Days, Reducing Delayed Transfers of Care, Reducing Early Hospital Readmissions, Reducing Waste in the NHS, Research Department and Nursing Department: Fundación Cardioinfantil - Instituto de Cardiología (Bogotá), SAFER Patient Flow Bundle, South Warwickshire Foundation Trust: Castle Brook Transitional Unit, South Warwickshire NHS Foundation Trust, South Warwickshire NHS Foundation Trust (SWFT), South Warwickshire NHS Foundation Trust: Wasps Team, Stranded Patient Metric, Surgical Wards: Frailty Care, Sustainability and Transformation Partnerships, Sustainability and Transformation Plans (STPs), Sydney Medical School Nepean: University of Sydney, The Last 1000 Days: Poem / Video by Molly Case - Commissioned by Professor Jane Cummings, Therapy-Led Units, Therapy-Led Units for Patients Medically Fit for Discharge, Time-Valuing Movements: #endPJparalysis, Time-Valuing Movements: #last1000days, TLUs: Therapy-Led Units, Transition Between Inpatient Hospital Settings and Community or Care Home Settings, Transition Planning, Transitions, Transitions Between Health and Social Care, University of Melbourne, University of Sydney, Warwick Hospital, Western Health (Australia), Whole Winter Framework, Winter Framework, Winter Pressures, Winter Pressures: Role of Community Health Services, Winter Support Package (2017), Worcestershire Acute Hospitals NHS Trust (Evergreen Ward), Yeovil District Hospital: Intermediate Care in Cookson’s Court Nursing Home | Leave a comment

A Tipping Point in the Sustainability of Health and Care? (BBC News / King’s Fund / Nuffield Trust)

Posted on September 19, 2016 by Dementia and Elderly Care News

Summary A King’s Fund / Nuffield Trust report identifies a 26% decline in the number of older people receiving social care, due largely to six years of cuts to local authority funding. Social care providers are found to be under pressure … Continue reading →

Posted in Age UK, BBC News, Charitable Bodies, Commissioning, Community Care, For Carers (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), For Social Workers (mostly), In the News, Integrated Care, King's Fund, Management of Condition, National, NHS, Non-Pharmacological Treatments, Nuffield Trust, Person-Centred Care, Personalisation, Quick Insights, Standards, Statistics, UK, Universal Interest | Tagged Adult Social Care, Adult Social Care Funding, Adult Social Care in England, Adult Social Care Services, Ageing Population, Association of Directors of Adult Social Services (ADASS), BBC Health News, Bed Availability and Occupancy: NHS Performance Indicators, Bed-Blockers, Bed-Blocking Patients (Non-Recommended Term), Better Care Fund (BCF), Better Care Fund Plans, Care for Vulnerable Older People, Caroline Abrahams: Director of Age UK, Coordinated Health and Social Care, Costs and Cost Pressures, Cross-Sector Partnerships, Delayed Discharges, Delayed Transfers of Care, Delayed Transfers of Care (DETOCs), Delayed Transfers of Care (DTOC), Delayed Transfers of Care: NHS Performance Indicators, Discharge, Discharge Programme Board, Efficiency Opportunities, Eldercare Vouchers, Elderly Failed By Shameful Care System (Allegation From Age UK and Alzheimer’s Society), Elderly People With Complex Health and Social Care Needs, Endless Winter in NHS (Allegation), Eternal Winter, Financial Constraints, Financial Context, Financial Difficulties, Financial Performance, Fragility of Adult Social Care Provider Market, Health and Social Care, Health and Social Care Configuration, Health and Social Care in the Community, Health and Social Care Integration, Health and Social Care Providers, Health and Social Care Services, Home Truths: Social Care For Older People (2016), Integration of Health and Social Care, Integration of Health and Social Care for Older People, Interdependencies, Lady Ros Altmann, Length of Stay (LoS), Lost Beds Problem (sic), Making Our Care and Health Systems Fit for An Ageing Population, NHS Funding, NHS Funding Gap, NHS Overspends, NHS Performance, NHS Performance Indicators, NHS Productivity, Patient Flows, Population Winter Pressures, Quarterly Monitoring Report, Quarterly Monitoring Reports, Richmond Group of Charities, Social Care For Older People: Home Truths, Society of Acute Medicine: Meltdown Warning, Submissions Ahead of Chancellor Philip Hammond's Autumn Statement (2016), Sustainability, Sustainable Care, Sustainable Funding, Sustainable Health and Care Services, Sustainable Local Funding, Tax Breaks on Saving For Care, Thinking Like a Patient and Acting Like a Taxpayer, Transition Between Inpatient Hospital Settings and Community or Care Home Settings, UK Home Care Association, UK Homecare Association (UKHCA), Unacceptable Variations, Unwarranted Variations, Upward Spending Pressures, Variation in Performance, Variations in Quality of Care, Variations in Service, Variations in Spending, Vulnerable Older People, Waiting Time Standards, Waiting Time Target Breaches, Wasted Resources, Whole System Patient Flows, Winter Pressures, Winter Pressures Beyond Winter (Winter Re-Defined?), Winter Pressures: Role of Community Health Services | Leave a comment

“Poverty of Ambition” on Reducing Delayed Transfers of Care? Improvements Recommended (BBC News / House of Commons PAC / NICE)

Posted on July 27, 2016 by Dementia and Elderly Care News

Summary The House of Commons Public Accounts Committee’s latest report challenges the government, NHS Improvement and NHS England to tackle the extent of (i) the harm to patients and (ii) the financial costs, arising from delays in discharging older patients … Continue reading →

Posted in Acute Hospitals, BBC News, Commissioning, Community Care, Department of Health, For Carers (mostly), For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), For Social Workers (mostly), In the News, Integrated Care, Local Interest, Management of Condition, National, NHS, NHS England, NHS Improvement, NICE Guidelines, Person-Centred Care, Quick Insights, Standards, Statistics, UK, Universal Interest | Tagged Accountability and Integration, Acute Hospital Care, Adult Social Care, Adult Social Care Services, Ageing Population, Areas With the Highest Delayed Transfers of Care, BBC Health News, BBC Radio 4, BBC Radio Four: Six O'Clock News, Bed Days, Bed-Blockers, Bed-Blocking Patients (Non-Recommended Term), Care for Vulnerable Older People, Cross-Sector Partnerships, Cumbria County Council, Delayed Discharges, Delayed Discharges Higher in Mental Health Trusts, Delayed Transfers of Care, Delayed Transfers of Care (DTOC), Delayed Transfers of Care by Responsible Organisation, Discharge From Acute and Mental Health Trusts, Discharge Programme Board, Efficiency Opportunities, Financial Incentives Across Local Health and Social Care Systems (Proposals), Fragility of Adult Social Care Provider Market, Geographical Variations, Good Practice, Good Practice Standards, Health and Adult Social Care Providers, Health and Social Care, Health and Social Care Integration, Hospital Beds, Hospital Beds Use: Variations, Hospital Discharge, Hospital Discharge and Transfers, Hospital Long-Waiters, House of Commons, House of Commons Public Accounts Committee, Inpatient Beds, Integrated and Community-Based Care, Integrated Home and Community Care Services, Integration of Health and Social Care, Integration Transformation Fund (aka Better Care Fund), James Paget University Hospitals NHS Foundation Trust, Length of Stay (LoS), Local Health Services: Variations, Local System Resilience Groups, Local Variations, Long Hospital Stays, Lord Carter Review, Loss of Mobility During Long Hospital Stays, Loss of Older Patients' Muscle Strength Per Day of Hospital Treatment, Measures to Capture the Number of Older People Who No Longer Benefit From Acute Hospital Care (Proposal), Meg Hiller MP: Chair of Public Accounts Committee, Mental Health Trusts, National Audit Office (NAO), National Discharge Programme Board, National Institute for Health and Care Excellence (NICE), National Market Position Statement, NHS Mental Health Trusts in England, NHS Sustainability, Northumbria Healthcare NHS Foundation Trust, Parliamentarians, Patient Care, Patient Discharge, Patient Flows, Patient Safety, Personal Budgets in Adult Social Care, Post-Discharge Support, Public Accounts Committee (PAC), Public Accounts Commons Select Committee, Reducing Bed Days, Reducing Waste in the NHS, Regional Variations, Sharing Good Practice, Sharing Patient Information, Sir James Munby: President of Family Division of the High Court, Social Care Delays (Impact on Hospital Bed-Days and LoS), Social Care Providers, Sustainability, Sustainable Health and Social Care, Thinking Like a Patient and Acting Like a Taxpayer, Transition Between Inpatient Hospital Settings and Community or Care Home Settings, Unacceptable Variations, Unwarranted Variations, Variation in Performance, Variations in Quality of Care, Variations in Service, Variations in Spending, Vulnerable Older People, Wasted Resources, Whole System Patient Flows | Leave a comment

Unsafe Discharges From Hospitals Breach NICE Guidelines (BBC News / PHSO)

Posted on May 11, 2016 by Dementia and Elderly Care News

Summary The Parliamentary and Health Service Ombudsman (PHSO) has reported on complaints received about hundreds of vulnerable and elderly patients, sometimes including those with dementia and / or frailty, who have been discharged inappropriately from hospital. It seems likely that … Continue reading →

Posted in Acute Hospitals, BBC News, Commissioning, Community Care, For Carers (mostly), For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), For Social Workers (mostly), In the News, Integrated Care, Management of Condition, National, NHS, Patient Care Pathway, Person-Centred Care, Quick Insights, Standards, UK, Universal Interest | Tagged Acute Care, Acute Hospitals, Adults With Social Care Needs, Ageing Population, Avoidable Harm, Avoidable Mortality, Avoidable Rehospitalisations, Barriers and Challenges in Discharge Planning, Breakdowns or Failures in Communication, Care Transitions, Care Transitions Involving Adults With Social Care Needs, Care Transitions of Older People, Collaboration, Collaborative Care, Collaborative Care Planning, Collaborative Communication, Communication, Communication During Handovers, Compassionate Care, Coordinated Health and Social Care, Culture of Compassionate Care, Dame Julie Mellor: Parliamentary and Health Ombudsman Service, Deficient Checking and Oversight, Delayed Transfers of Care, Delayed Transfers of Care (DETOCs), Destination on Discharge, Dignity, Dignity and Respect, Discharge, Discharge and Out of Hospital Care, Discharge at a Reasonable Time, Discharge Coordination, Discharge Coordinators, Discharge From General Inpatient Hospital Settings, Discharge Guidelines, Discharge Information, Discharge Planning, Dysfunctional Patient Flow, Geriatric Assessment and Care, Handover, Health and Social Care, Health and Social Care Integration, Hospital Admissions, Hospital Discharge, Hospital Readmission Risk Factors, Improving Patient Safety, Information Sharing, Information Sharing: Care Plans, Information Sharing: Communication Needs, Integrated Discharge Process, Integration of Health and Social Care, Integration of Health and Social Care for Older People, Managing Transitions, MDTs: Multidisciplinary Teams, Multi-Agency Collaboration, Multi-Disciplinary Teams, Parliamentary and Health Service Ombudsman, Parliamentary and Health Service Ombudsman (PHSO), Partnership and Collaboration, Patient Dignity, Patient Safety, Patient Transitions of Care, Post-Discharge Support, Promoting Dignity in Dementia, Quality Improvement, Reducing Delayed Transfers of Care, Reducing Early Hospital Readmissions, Safe and Compassionate Care, Transition Between Inpatient Hospital Settings and Community or Care Home Settings, Transition Planning, Transitions, Transitions Between Health and Social Care | Leave a comment

Barriers and Challenges in Discharge Planning (QNI / BBC News)

Posted on March 30, 2016 by Dementia and Elderly Care News

Summary The following report from the Queen’s Nursing Institute (QNI) summarises known barriers and challenges which can prevent effective discharge from hospitals. Case studies illustrating best practice are supplied, along with recommendations. Full Text Link Reference Pellett, C. (2016). Discharge … Continue reading →

Posted in Acute Hospitals, Charitable Bodies, Commissioning, Community Care, For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), For Social Workers (mostly), Integrated Care, Management of Condition, National, NHS, Person-Centred Care, Personalisation, Quick Insights, Standards, Statistics, UK, Universal Interest | Tagged 2020 Vision 5 years on: Reassessing the Future of District Nursing, Acute Care, Acute Hospitals, Adults With Social Care Needs, Ageing Population, Assertive In-Reach, Assertive In-Reach Teams, Assessment Before Discharge, Association of District Nurse Educators (ADNE), Barriers and Challenges in Discharge Planning, BBC Health News, Care Transitions, Care Transitions Involving Adults With Social Care Needs, Care Transitions of Older People, Collaboration, Collaborative Care, Collaborative Care Planning, Collaborative Communication, Communication, Coordinated Health and Social Care, D2A Model of Discharge for Frail Older People, Daily Transfers of Care (DTOC), Delayed Transfers of Care, Delayed Transfers of Care (DETOCs), Destination on Discharge, Discharge, Discharge at a Reasonable Time, Discharge Coordination, Discharge Coordinators, Discharge From General Inpatient Hospital Settings, Discharge Guidelines, Discharge Information, Discharge Into the Care Sector, Discharge Planning, Discharge Records, Discharge Summaries, Discharge Support, Discharge to Assess (D2A) Model, Discharge to Assess Programme, Early Supported Discharge (ESD), Geriatric Assessment and Care, Handover, Health and Social Care, Health and Social Care Integration, Hospital Admissions, Hospital Discharge, Hospital Readmission Risk Factors, Hospital-Based Multi-Disciplinary Teams, In-Reach Teams, Information Sharing, Information Sharing: Advance Care Plans, Information Sharing: Care Plans, Information Sharing: Communication Needs, Integrated Discharge Process, Integration of Health and Social Care, Integration of Health and Social Care for Older People, Lincolnshire Community Health Services NHS Trust, Management of Medicines, Managing Transitions, MDTs: Multidisciplinary Teams, Medication Reviews, Medicines Management‎, Medicines Optimisation, Multi-Agency Collaboration, Multi-Disciplinary Teams, National District Nurses Network (NDNN), Norfolk Community Health and Care NHS Trust, Partnership and Collaboration, Patient Transitions of Care, Queen's Nursing Institute (QNI), Queen’s Nurse Network (QNI), Rapid Assessment Team at Queen Elizabeth Hospital (Norfolk), Reducing Delayed Transfers of Care, Reducing Early Hospital Readmissions, Serco / Suffolk Community Healthcare, Transition Between Inpatient Hospital Settings and Community or Care Home Settings, Transition Planning, Transitions, Transitions Between Health and Social Care, Western Sussex Hospitals Foundation Trust, Workforce Development, Worthing Hospital: Welcome Home Packs | Leave a comment

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