Multi-agency Integrated Discharge Team

The Multi-agency Integrated Discharge Team (MAIDT) brings together dedicated health and social care professionals and members of the voluntary sector who work to ensure patients with complex needs can be discharged from our hospitals on the correct pathway in a safe and timely way.

Some 80 per cent of discharges at Bradford Teaching Hospitals Foundation Trust are simple to complete and are carried out by ward staff. However, a further 20 per cent are more complex and are referred to the MAIDT.

If ward staff wish to include the MAIDT in a discharge, they must complete a referral form and request support.

The MAIDT was established to bring about a number of step changes in the way we care for our patients when they are ready to leave us, including:

• A single referral process
• System change
• Co-ordinated discharge plans
• Joint assessment process
• Effective discharge
• Better overall outcomes for patients

The team’s key stakeholders include Bradford Teaching Hospitals NHS Foundation Trust (BTHFT), Bradford District Care NHS Foundation Trust (BDCFT), City of Bradford Metropolitan District Council (CBMDC) and the voluntary and community sector (VCS), primarily Home from Hospital.

MAIDT supports the above organisations’ commitment to working with common objectives and shared principles which aim to deliver better co-ordination of services for people being discharged from our hospitals.

The MAIDT aims to practice person-centred care planning and support for eligible adults with complex needs. We are committed to home-first discharge wherever possible. The key principles of this service are:

• To maximise wellbeing
• Maximise choice and control
• Maximise independence, function and self-care
• To help people receive the right care at the first time of asking
• To maximise opportunities to enable safe discharge from hospital by working with the individual and, with their consent, their families to understand their needs prior and post hospital admission

A person is defined as requiring a complex discharge if:

• A change in an existing home care package is required
• There has been a change of circumstances which requires multidisciplinary team (MDT) planning
• There is a safeguarding issue
• There are complex social circumstances
• There is a need for intensive community nursing input
• The person may require input from more than one agency

Patients who require referral must be informed give their consent before their record can be shared.

• Joint (health and social care) triage of referrals and support for ward-based assessments as required of individuals and goal planning
• The lead MAIDT team member will devise a multi-agency discharge plan which will support the person and their carers to allow for a safe and effective discharge and prevent hospital re-admission due to poor discharge planning
• The lead MAIDT team member will ensure referral to appropriate community-based services for patients who require individual complex packages of care, including community complex care teams.
• The MAIDT work with carers and families to establish their ability to engage with their discharge and the support they need.

Multi-agency Integrated Discharge Team
Bradford Royal Infirmary
Bradford Teaching Hospitals NHS Foundation Trust
Duckworth Lane
Bradford
BD9 6RJ

Telephone: For appointment queries please call 01274 274274.

Bradford Enablement Support Team (BEST Plus)
Time limited

• Patients with rehabilitation potential who are motivated to engage in therapy
• Patients must be independent or require minimal assistance
• Patients who have been assessed by an occupational therapist and have functional goals

Bradford Enablement Support Team (BEST)
Time limited then goes to a private provider

• Patients who are struggling to manage independently and do not have the ability to engage or benefit from rehab on this admission
• Patients who have the support of others such as family or friends to manage independently at home prior to admission, but the support cannot continue due to the strain on the carer
• Patients who require social rehabilitation

 Community hospital

• Patients who are medically fit and able to transfer with help from no more than two members of staff
• Patients must have rehabilitation potential and be motivated to engage in therapy
• Patients who are not yet at their previous level of mobility/function and who would benefit from increased therapy input to reduce their dependency and return home
• Care for end of life patients

Social rehabilitation (local authority care homes)

• Patients who require ongoing low level inpatient rehabilitation
• Patients who may be experiencing loss of confidence
• Patients who require maximum assistance of one other person with transfers, mobility and functional tasks

Assessment beds (local authority care homes)

• Medically-fit patients who cannot be discharged home from an acute bed safely without further assessment

Home from Hospital

• Six weeks low-level social care/support
• Promotion of self-care/choice/control
• Support to patient, carers and families
• Integrated working – NHS/social care/voluntary organisations
• Works well alongside other services
• Simple discharge referrals from the ward direct to Home from Hospital eg shopping assistance with finances

 Homeless Pathway (Bevan)

• Patients who have no home to be discharged to due to housing needs
• A referral to the homeless team who will assess the patient for appropriate accommodation

Non-Weight Bearing Pathway

• Patients who have a new fracture or are unable to weight bear but are not required to remain in an acute bed
• Patients who require rehab once their weight-bearing status changes

 Fast-track discharges

• Patients who have limited life are discharged home with fast-track funding to their own home or a care home usually on the same day of referral
• Assessed for care home and palliative care

 Patients requiring long-term care

• Patients who have needs who can no longer be supported at home
• Patients are assessed by the Continuing Health Framework for appropriate funding to meet the needs of the patient on discharge

Our talented and compassionate staff care for a diverse population, which is what makes Bradford such a special place to work. Choosing the right people is key to our success. If you think you’ve got what it takes, please contact us by email at careers@bthft.nhs.uk to discover more about our latest opportunities.