Care from hospital to home

Dr Chris Duffy, NHS HMR CCG Chair and local GP

A team of nurses from Pennine Care NHS Foundation Trust now work in hospital sites across Rochdale, Bury and Oldham to help patients return home safely and quickly.

The transfer of care team works with ward staff at Rochdale Infirmary, the Royal Oldham Hospital and Fairfield General Hospital to plan and coordinate a patient’s care when they are well enough to leave hospital. This includes trouble-shooting problems that are preventing a patient from being discharged and making sure community health and social care services are in place to provide on-going care and support.

The nurses work closely with the patient and their family or carer to coordinate their care, relieving them of the burden by navigating the complex health and social care system.

Patients that require support from the transfer of care team include those with complex health and social care needs, patients requiring rehabilitation, nursing or residential care and people who live alone or are unable to care for themselves.

Steve Wall, Transfer of Care Team Leader at Pennine Care NHS Foundation Trust, said: “When a patient has been in hospital they often need further care that can be provided safely and more appropriately in the community by expert services. We ensure that this is in place safely and timely so that we can provide patients with a seamless transfer from hospital to home.

"Our determined team really does their upmost to ensure each patient gets the care they need, no matter how complex or difficult it might be to put in place.”

Steve Taylor, Divisional Director for Medicine and Community Services at The Pennine Acute Hospitals NHS Trust, said: "The hospital teams work with patients and relatives to ensure that patients are discharged home safely. The recent addition of the transfer of care teams at our hospital sites is helping to support the discharge home of patients with complex needs.

"Joint working between the hospital and community staff is important in providing all plans and support are in place for patents when they are discharged from hospital."

Dr Chris Duffy, local GP and Chairman of Heywood, Middleton and Rochdale Clinical Commissioning Group, said: “We welcome this initiative which will coordinate and speed up appropriate hospital discharge. It already appears to be well received, both by patients and hospital staff.”