Accelerated care pathways: Ripley Community Hospital

Xyla have provided patient centred care coordination and hospital discharge case management for CHC, local authority, and self-funding clients at Kettering General, Northampton General, and surrounding community hospitals since December 2016.

The Xyla team build strong relationships with local care providers, giving regular updates on capacity to support collaborative work to achieve efficient discharges into the right place-based care. Our team work closely with system partners to support discharge initiatives, an example of this being the recent focus on ‘Home First’ discharges.  

Our approach

Management of patient discharge and family liaison

• Patient referred to Acacium Group’s rapid discharge team who managed discharge and family liaison.
• Wellbeing calls to patient and family within 24 hours of admission to unit, with continued liaison throughout patient stay.
• Proactive coordination on all aspects of the patient’s journey, acting as a single point of access for families, system partners and providers.

Provision and management of nurse-led care on surge unit

• Assured provision of trained nurses and HCAs for 24/7 staffing to alleviate resource capacity.
• Patient’s needs reviewed to enable reduction of ongoing Pathway 1 and 2 point of care requirements.
• Efficient utilisation to ensure maximum productivity of Pathway 1 and 2 services.

Managed discharge into Pathway 1 and 2 services or brokerage of onward care

• Experienced brokerage staff to support with sourcing onward care as and when required.
• Full tracking and patient/next of kin liaison to ensure a safe discharge home.
• 24-hour follow up call post discharge home to avoid readmission to acute setting.

Outstanding report by Quality Always Assurance Team

We received twice-weekly visits by the Derby and Derbyshire ICB Quality Always Assurance Team. We listened and actioned feedback after every visit which resulted in our outstanding Quality Always Clinical Assessment and Accreditation Scheme (CAAS) report at the end of our time on the ward. The report was based and modelled on the CQC guidelines and assessments.

Impact