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Delivering quality care for 30 years
Hospital Fast-Track & Discharge Service


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& Reablement Team

01305 231 340

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Hospital Fast-Track & Discharge Service

A Responsive Solution to Bed Blocking and Hospital Re-admission

The Agincare Live-in Care service is rated Good by CQC and works with over 20 local authorities throughout England and Wales. We know from experience that each local demographic and geography presents its own combination of challenges and opportunities to commissioners and providers.

Our Fast-Track Discharge Service is designed as an interim service to enable patients to be discharged safely and promptly from hospital once medically fit. Where local providers are failing to provide the required care for patients on discharge, our service ensures discharge dates are met whilst patients return home with the necessary care in place. Supplying live-in care staff as the interim care service on hospital discharges has proven to reduce the percentage of hospital readmissions.

It works because our diverse workforce can move to any location and work in a variety of flexible ways according to client’s and commissioner’s needs. The live-in care recruitment market is not challenged like the domiciliary market and means solution based services such as this can be implemented quickly and safely. In other areas where this service is commissioned, the Council have commissioned us to step in to maintain their discharge schedules whilst they work with local providers to improve their workforce recruitment and retention.

Live-in Care Reablement Case Study

Once home our support worker was able to build a good working relationship with SP. It took some time for her to build SP’s confidence in carrying out tasks around the home, but with the support of the PRRT team and gentle prompting and encouragement from our care worker SP began to come on in leaps and bounds. It was a great achievement when SP took a shower for the first time since being home. The pride in herself and the pride the care worker felt was brilliant to see and well justified. SP’s skills and confidence continued to grow. The support worker was able to spend greater lengths of time away from SP to encourage her independence and prevent over attachment or reliance on the support worker. It was a great achievement when SP spent the first night without support. It has been fantastic to be able to offer a service that could meet SP’s needs so effectively. As SP’s dedicated support we could work with her at a pace and level that suited her needs without having conflicting...

SP had spent a long time in hospital. She had originally been admitted due to a fall where she fractured her neck of femur. SP went from the ward to the rehabilitation unit where unfortunately she fell and fractured both her wrists. This then required a further stay on the ward and then more time on the rehabilitation unit.

Understandably SP was nervous of returning home, was still a falls risk and had become unable to self-manage her care or daily living tasks. SP hated being on her own and was nervous of remaining at home without support. There were also some concerns around fluctuating capacity. It was agreed that the best thing for SP would be to return home with a 24hr reablement support worker to assess her abilities at home and work on increasing her confidence and abilities to determine what level of ongoing support would be needed. Or indeed whether remaining at home was a viable option.

Mrs J had been in hospital due to an accidental overdose of prescription medication and deterioration in her mental capacity. Mrs Jones had been ready for discharge from hospital for some time prior to our involvement but there were concerns that she would not be able to manage at home without full-time support. Mrs J family felt strongly that she would not be able to manage at home without full time support and that she needed to go into a residential home. Mrs Jones wishes had always been to return home; despite the family’s concerns the social worker involved and the reablement team felt that this could be a reality. They looked to Agincare for assistance. Within 24 hours Mrs J had been discharged home with our support. Initially this was 24hr care in her home. Working with the reablement team at the hospital our support workers assisted Mrs J to achieve realistic and set goals within her abilities. Our team was able to feedback on her progress and make suggestions for ways to...

It is almost certain that without the involvement of our team Mrs J would have ended up in a residential home or returned to hospital. Therefore, it is wonderful that she gets to stay in her familiar home environment as she wished. Her family have been converted and agree that she is safe at home, where she wants to be, and that she does not need to go into residential care. What an amazing result all round.

Mrs H lives at home. She is a poorly lady with long-term health needs and mild confusion and requires assistance in all aspects of daily living. Her primary carer was her husband. Mrs H was also supported by the Portsmouth reablement team attached to the hospital to enable her as far as possible. Tragically her husband died suddenly and un-expectedly. Not only did Mrs Hammond lose her husband, she lost her primary carer, which left her future uncertain. Mrs H has a close and loving family, but they were unable to manage her care needs. In a time of intense grief they were faced with the decision that Mrs H may have to go into residential care or risk a deterioration in her health and end up admitted to hospital. We were contacted directly by the Portsmouth reablement team to see if we could help. We agreed to assist and we were able to provide a support worker within a few hours of being contacted, the day that her husband passed. Initially it was a period of assessment and...

“We could not believe that there was a service that could provide support so quickly. We were so surprised when we were told about it. We usually have to fight to get support, but this was so easy. She (the support worker) has been fantastic and made such a difficult time easier. She is such a hard worker and my Mother (Mrs Hammond) told me that she is wonderful. If she says that, it is high praise indeed. We could not have done without her and we are happy to tell anyone this that wants to hear.”
Mrs H's Son

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