Welsh Government 10-point Winter Resilience Plan for successful hospital discharge in 50 days

This initiative placing greater emphasis on cross sector coordination was launched as part of the Welsh Government’s Winter Resilience Plan to improve hospital discharge times and care at home for the remainder of the year.

The 50-day Integrated Care Winter Challenge aims to help more people safely return home from hospital and ease winter pressures on the health and care system.

The Challenge, closely linked to the Hospital Discharge Guidance (opens new window), published by the Welsh Government in September, is designed to ensure the NHS and local councils collaborate and ensure the right support is available to help people recover at home, or in the community. Health boards and local authorities will work together to adopt a 10-point action plan to support more people who have experienced lengthy delays in being discharged from hospital, to return home.

The 10-point action plan of best practice interventions includes steps to remove the blockages in the health and care system so people can be discharged home promptly. This includes improving hospital discharge procedures; planning for discharge from the point of admission; ensuring there is proportionate and effective seven-day working to enable weekend discharges; undertaking more assessments in the community and providing community rehabilitation and reablement to help people recover fully.

Community health and social care services also have a pivotal role to play in supporting people to remain well in the community. They assess what help people need, including access to rehabilitation, home adaptations or personal care in the community.

The 50-Day Integrated Care Winter Challenge 10-point action plan of best practice interventions: 

1. Embedding the Optimal Hospital Flow Framework to proactively integrate community rehabilitation and reablement across Health and Social Care. 
2. Implementing 7-day working across Health and Social Care to enable discharges during weekends. 
3. Moving Decision Support Tool (DST)/CHC processes into the community. 
4. Establishing ‘integrated navigation hubs’ to support hospital discharge and community admission avoidance. 
5. Weekly Health and Social Care reviews of patients with a Length of Stay (LOS) over 21-28 days, targeting the 20 longest stays. 
6. Proactively managing the 0.5% highest-risk population through multi-professional community teams. 
7. Expanding GP enhanced services for care homes and providing Proactive/Urgent Care for high-risk groups. 
8. Establishing a Trusted Assessor model for all care settings. 
9. Adopting a ‘Home First’ approach, beginning discharge planning upon admission. 
10. Developing community-based 7-day falls response pathways.