Goal 6: Home first approach and reduce the risk of readmission

People will return home following a hospital stay – or to their local community with additional support if required – at the earliest and safest opportunity to improve their outcomes and experience, and to avoid deconditioning.

Quality Statement

• People who require additional support on discharge should be transferred from hospital onto the appropriate ‘discharge to recover then assess pathway’ (usually back to their normal place of residence) within 48 hours of the treatment of their acute problem being completed.
   
• Integrated health and social care teams should respond in a timely manner to ensure support systems are safely in place to respond to a person’s needs on discharge. Effective care coordination must be in place to ensure that, once recovery and assessment is complete, transfer to onward care arrangements is timely and seamless.
   
• Programmes are in place to help people develop the knowledge, skills and confidence to manage their physical and mental health, access the support they need, make any necessary changes and be better prepared for any deterioration or crisis.
   
• All patients on mental health or learning disability wards with admissions longer than 90 days must have a clear discharge plan in place. All patients cared for in specialist services outside of NHS Wales will have a repatriation plan in place.

To read more about Goal 6 including initial priorities, how health and social care systems will be supported to achieve this goal and how success will be measured, please refer to the Six Goals for Urgent and Emergency Care Policy Handbook.

Goal 6 Lead: Luisa Bridgman, Assistant Director of Transformation (Home First) for NHS Executive - sbu.duTransformation@wales.nhs.uk