Referral to admission: working with Social Workers to promote seamless integrated care

9 March 2021

Home Manager sat at a desk talking to a social worker

This Social Work Week, we’re sharing how Exemplar Health Care works with hundreds of Social Workers in the UK, to support adults living with complex needs to find the right care, from the right team, in one of our care homes.

During the Coronavirus (COVID-19) pandemic, Exemplar Health Care has continued to work with CCG, local authority and NHS colleagues to ensure that adults living with complex needs can move out of hospital and receive the specialist care that they need.

Our expert Clinical Assessors and Home Managers have safely welcomed over 250 people to our care homes during the pandemic, and we’re taking referrals where it’s safe and appropriate to do so.

We understand the pressures on the local health and social care system, which is why our teams are working extra hard to ensure an efficient enquiry to admission process, without compromising on quality.

This Social Work Week 2021, here’s everything that Social Workers need to know about our referrals and admissions process.

“I am a social worker who has recently placed a client at Tyne Grange. She is a complex lady with a number of failed placements in her past. I have been very impressed with Tyne Grange - from the initial referral they demonstrated genuine curiosity regards the client and were interested in how to create a care plan to keep her safe and meet her needs. Since she moved she has continued with her recovery and is happy and settled within the unit. Communication with the staff has been excellent and I recommend Tyne Grange to my colleagues.”

Dedicated Referrals Team

Deciding where a person is going to live for the next few weeks, months or even years, is not an easy decision, and should not be taken lightly.

Admissions to care homes shouldn’t be just about filling beds – they should be about creating a community, and meeting the social, emotional and psychological needs of the people within that community.

We have a dedicated Referrals Team who can discuss your referral and identify the right care home for the individual, based on their needs, goals and interests.

You can contact the team in different ways, whatever suits you.

Community fit assessment

Over 60% of residents who live in one of our 32 care homes come from failed placements, often because their needs were not being met. This can cause unnecessary stress for the individual and their family, which is why it’s important to complete a community fit assessment prior to them moving into a new home.

Our team of Clinical Assessors will carry out an assessment with the individual to make sure that our home is the right fit them and they’re the right for our home. The assessment can usually be done within one - two days of the initial referral.

Conducting a community fit assessment is all about putting the individual at the centre of your assessment, finding out what makes them ‘tick’, their likes and dislikes, and who and what is important in their life.

It considers aspects such as people’s age, interests and cultural values, to ensure the home is going to be right for the individual. 

The assessor will also advocate for the residents already living in the home; thinking about how they might react to their new housemate and if it's someone they will get along with. 

When the assessment has been done, we’ll send you a formal report and costings, and when approved, work with you to agree the placement and care plan.

We’ve found that this approach ensures that people get the right care and support, at the right time, the first time round - which reduces re-admissions to acute settings, facilitates faster returns to lower-cost community living and brings an end to the cycle of failed placements.

Enquiry to admission in as little as four days

Our Nurse-led teams work with in-house experts and other healthcare professionals to ensure safe and timely admissions to our care homes.

In December 2020, we welcomed Brian to our Church Walk care home in Rochdale. Brian has complex needs and had spent time on a respiratory ward at the local hospital, before getting in touch with the home.

A Clinical Assessor went to see Brian to do a face-to-face assessment on the same day that the enquiry was made, and sent a costings report to the commissioner the next day. The placement was agreed on day three, and the admission was planned for the following week, pending a negative COVID test.

Thanks to the dedication of our Referrals and Assessment Team, Brian was in his new home before Christmas, and has already settled in well.

Regular care plan and costing reviews

When an individual moves into one of our care homes, we work with them, their loved ones and professionals to design a care plans that’s personalised to their needs and goals.

We review the care plan regularly against their expected outcomes and goals, with reassessments, costing reviews and planning for next steps.

When the time’s right, we’ll work the individual and wider care team to explore their discharge options, including transition to one of our OneCare services.

About Exemplar Health Care

Exemplar Health Care is a leading provider of specialist nursing care for adults living with complex and high acuity needs.

Our community-based homes provide person-centred care and rehabilitation that focuses on maximising independence, building everyday living skills and empowering people to live as fulfilled lives as possible.

We support people on their journey from being in hospital or living in a secure setting to community-based living, as well as offering longer term support for people living with degenerative or life-limiting illnesses.

We have over 30 homes across Yorkshire, the Midlands, North East and North West that provide a welcoming and supportive environment where people can access the specialist care that they need, and remain closer to family, friends and loved ones.

Find your local care home and get in touch to make a referral.