To make it easier for people to understand the different levels of care and treatment available, Joined Up Care Derbyshire has developed a ‘pathway approach’. This aims to both prevent people from going into hospital in the first instance, but also support people to return home, or close to home as soon as possible, should an inpatient stay be unavoidable.
The ‘pathway approach’ defines how health and social care teams will work in partnership with one another, to assess a person’s needs, and put in place the right type of care and treatment that will enable them to regain their confidence and independence to return to the place they call home if at all possible.
Going home (pathway 0)
A person can stay at home or return to the place they call home without further assessment.
Need for a home assessment (pathway 1)
A person can stay at or return to the place they call home with an assessment for community care and support needs, for example, daily visits from a carer, or community nurse.
Need for a temporary community support bed (pathway 2a)
Staying at or returning to the place they call home is not an immediate option for the person, so the person is discharged to a ‘community support bed’. This is provided in a residential home setting with 24-hour care available, such as assistance with daily living, like dressing and eating, but nursing care is not needed. The person is supported to recover and return to the place they call home as soon as possible.
Need for a temporary community nursing bed (pathway 2b)
The same as the pathway above, apart from 24-hour nursing and clinical support services are also required. For example, the person has complex medical conditions that require the specialist knowledge of registered nurses, or a person’s medical condition requires monitoring.
Need for a permanent 24-hour place of care (pathway 3)
A patient requires 24-hour nursing care or a residential home providing 24-hour support which is likely to be a permanent situation subject to the continued assessment of needs.