Briefing: Shifting the Balance of Care

Aberdeen City Health & Social Care Partnership is embarking on a transformative initiative to enhance the delivery of frailty and specialist rehabilitation services.

The main aim is to shift the balance of care from hospital settings to community-based support, enabling patients to receive care in their own homes whenever possible.

This approach is in line with both local and national strategies aimed at improving patient-centred care and reducing the strain on hospital services. It forms part of the wider NHS Grampian approach to improving the flow within the unscheduled care system. Investment from the Scottish Government has been approved to support this work.

Key elements of the initiative include a phased reduction in bed capacity at Rosewell House, with a complete withdrawal from the building by March 2026. A programme of work called Discharge Without Delay is being implemented to ensure timely and effective patient care transitions through key projects such as

• Discharge to Assess – a programme for people leaving hospital to their own home who require a short-term period of rehabilitation and assessment rather than this happening in hospital. This supports people regaining independence in their home.
• Frailty at the Front Door – a geriatrician and therapists will be available in ED to assess and offer intervention where required at the earliest opportunity to prevent lengthy delays waiting for a specialist review.
• Community Rehabilitation – work is ongoing in community hospital settings to ensure that people are able to move to the right place at the right time, therefore preventing prolonged waits in hospital to move to the next stage in the patient journey.
• Planned Date of Discharge – this means within 48 hours of admission, there will be a planned date of discharge for the person and realistic goals will be set to ensure that the planned date of discharge is met.
• Integrated Discharge Hub – this is to support streamlining of referrals/discharges of patients who may need further support in community hospitals or in their own home. The hub will have key members of staff to work collectively to support movement throughout the hospital.

In addition to this, a number of inpatient rehabilitation beds will be relocated from Rosewell House within ACHSCP to ensure care is available for those patients unable to be supported within the community.

This community-focused approach is expected to reduce hospital stays, prevent hospital-induced harm, and improve overall patient outcomes. The initiative also addresses challenges such as staffing issues and financial pressures, ensuring a sustainable and efficient healthcare system for the future.

Further updates will be provided as the Discharge Without Delay Programme progresses.

Julie Warrender, ACHSCP Chief Nurse