Hospital to Home service
Speeds up when medically fit patients leave hospital, freeing up beds
Referrals are made from one digital checklist in hospital to multiple commissioned health, social care and third sector services.
Enabling flow
People ready for discharge are connected with a range of commissioned services as well as a wider group of community and third sector organisations.
Quicker discharge decisions
Via a Care Control Dashboard, ward staff can see whether these services are lined up or delivered for a person and make informed and confident decisions about a person's successful discharge.
〝For the first time, third sector partners can access a dashboard for patients receiving community services to help them join up and co-ordinate care. The dashboard also provides a live data feed from the hospital sharing information about a patient’s status so that the services can be put in place at the right time. The system is transformational.〞
〝The impact of this digital transformation is plain to see. For ward staff, the ability to easily make referrals to multiple organisations at the click of a button is revolutionary. However, the ability for Discharge Co-ordinators to then easily see when support has been put in place gives much more assurance that a person can return home safely. This platform is not just a tool; it’s a conduit for change, enabling us to reach those who need us most, right when they need us.〞
Connect people with third sector support
The 'Onward Admission Form' allows ward staff to discuss patient needs and make multiple referrals in one step, saving time. The form lists available community services, helping raise awareness of support options like food packs, transport, and urgent house repairs that may be needed for patients to return home.
Referrals are auto sent to a provider where they can be managed, or directly to teams working together on RIVIAM's Multi-agency Referral Hub.
Ward staff view a dashboard for clarity on provided support, eliminating the need for follow-up emails or calls that delay discharge.
〝As a voluntary sector organisation, having sight of seemingly simple information such as the ward someone was on, or their estimated discharge date, was often difficult to find out. Equally, it wasn't always easy to find out which organisations were involved with the person which could lead to duplication of support and not using everyone's time most effectively.〞
See how the service is improving patient flow in Bath and North East Somerset.
Speed up discharge times
The dashboard provides hospital teams with a clear overview of a patient's care and referral status, enabling informed discharge decisions and easy access to patient or ward-specific information through quick filters. Online communication between ward staff and community-based teams reduces the need for phone calls.
Access to discharge information
Community and third sector services receiving referrals access a dashboard providing information at a glance about a person's discharge status. RIVIAM's integration with the hospital's EPR provides the patient's latest ward and Estimated Discharge Date, aiding decision-making for timely service delivery.
More from Multi-agency Referral Hub
Multi-agency working
Collaborate and co-ordinate care together
Single view of a referral
See all referral information, related documents, notes and activities