Achieving the best possible outcome for every individual under our care is what drives us at SweetTree, and this commitment sits at the heart of our SweetTree-assisted Discharge Planning Partnerships. Through our work with hospitals, care homes, and other acute medical settings, we are proud to help teams successfully overcome all challenges inherent in the discharge process.
With a deep understanding of the intricacies, we call on our decades of care experience and the specialist knowledge of our team to facilitate a smooth and seamless transition, placing the individual’s needs at its core.
“Our hospital has developed a good working relationship with SweetTree, which has helped support our efforts to provide consistent and coordinated care for patients, particularly around discharge planning. SweetTree has been helpful in making the discharge process smoother by offering timely support in the community. Their involvement has contributed to better communication between teams and made it easier for patients to transition from hospital to home.
This partnership has also made it possible to reduce some delays in discharge, which benefits both patients and hospital staff. Having a reliable organisation like SweetTree involved helps us feel more confident that patients are getting the right level of care once they leave the hospital”.
– Enrico James C. Yap, Charge Nurse, The Wellington Hospital
The challenge of achieving a smooth transition
For individuals requiring specialist care and support, such as following a brain injury, one important juncture in their care pathway is making the transition between environments.
For example, moving from an acute hospital setting to their home or a supported living facility.
These transitions will often involve multiple stakeholders, all with varying aims and responsibilities, but with one common goal – ensuring the best interests of the patient are upheld, adequate support is put in place, and that the whole process runs smoothly.
With so many moving parts, the process risks becoming disjointed, with continuity of care also being a challenge.
For the individual patient, any uncertainty around their transition can leave them feeling unsure about what to expect in their new environment, adding a level of stress at a time when they are adjusting to a life-changing event.
In addition, without appropriate support in place and the continuation of their rehabilitation from day one, there is the potential for a reduction in the gains they have made during their inpatient stay.
It also risks noncompliance with required medicine or exercise regimes, which may impact on recovery and comfort – a problem estimated to cost the NHS anywhere between £300M-£800M annually.
Through our SweetTree Discharge Planning Partnerships, we can mitigate these issues, while freeing up the limited resources of individual care settings and preventing last-minute disruptions.
Our primary focus is on enhancing patient outcomes through a seamless, integrated transition process that benefits both patients and care providers.
Through the strong relationships we are building with key partners, the benefits of the model are already being clearly demonstrated.
“When I liaised with SweetTree, they were helpful, coming into the hospital and meeting with the patient and team at short notice to help plan a suitable discharge support plan that everyone was happy with” – Dr Anna Batho, Critical Care Psychologist, Homerton University Hospital
A ‘day one’ discharge strategy
By working closely with all members of a patient’s multi-disciplinary team (MDT), the individual and their families, including the clinical team, case managers, OTs and social services, our specialist team at SweetTree will coordinate the community-based support needed for a positive outcome.
This ensures everything runs smoothly, while taking pressure off limited care setting resources, with the right support implemented early on and strong communication between stakeholders being maintained.
The approach not only results in a smooth transition for the individual, with their welfare and care needs being central to the process, but supports positive, long term patient outcomes.
By acting as an extension of the MDT, we help to maintain and improve upon rehabilitation gains already made in the inpatient setting.
The specialist care and support provided by our team at SweetTree is goal-centred, delivered by specially trained carers and designed to enable each individual to thrive in their new environment, with ongoing monitoring highlighting where further intervention or support may be required.
Where individual patients, or the MDT, have existing relationships with carers or care providers, SweetTree will liaise with these parties as part of the planning process and manage any handovers.
There is no restriction on external involvement, with the discharge planning focused on creating the structure that works best for the partner organisation and individual.
Timeline
- A relationship is formed between SweetTree and the professional team
- Patient is admitted to the hospital
- The case manager alerts SweetTree, and the discharge planning process begins (Referrals may also come from family members, a CHC, or local authority)
- SweetTree undertakes an assessment and liaises closely with the MDT
- SweetTree’s specially trained carers begin visiting patient around 3-4 weeks before they are due to be discharged to build continuity and familiarity. They will shadow MDT professionals during these sessions with the client, meaning they are able to continue working on this in the community.
- Patient is discharged with a care plan and support in place
- SweetTree team continues to support the patient and to update their care plans over the course of the next 3 months, liaising closed with the MDT and communicating the individual’s process, along with any concerns.
- Where required, the SweetTree team continues to support the patient’s integration after the 3 months
“Your service was fantastic in investing the time to ‘handover’ and spend time with the patient and her family to help ensure the smooth transition into the community as well. Your team was respectful and professional, with a can-do attitude, which in the context of this complex case was really appreciated.” – Nicole Walmsley, Specialist OT, Neurological Hospital Queens Square.
Detailed patient assessments
Our assessments typically involve a visit from 1–2 of our skilled assessors, with multiple assessments being carried out for more complex cases.
They cover every facet of an individual’s needs, supporting the creation of a care journey that is tailored to requirements, while also supported by data-driven insights.
This evaluation includes the following, which will help shape a comprehensive discharge and support plan:
Person-Centred Assessment
Daily Routine
Cognitive Needs
Behavioural Needs
Mental Health
Environmental Assessment
Environmental Risk
Fire Safety
Carer Accessibility
Equipment
Communication, Comprehension & Sensory
Activities of daily living
Social, Employment & Education
Moving and Positioning
Skin Integrity Assessment
Medication
GP Outreach
Medication management
eMARs
Client Documentation
Drafting & Review
Electronic daily records
Service Logistics
Recruitment and coordination
Technology Insights
Technology Planning & Installation
Data Observation and Assessment
Home Care Specific Insights
Geography/Travel/Recruitment
“A central aim for people after a life-changing injury is getting home, but this is more complex than it may sound. Having someone who has witnessed and understands your journey and can be a consistent anchor the overwhelmingness of change is really important. Consistency and continuity of rehabilitation progress is optimised when there is a professional who can bridge between the skills you developed in one setting and generalise and maintaining these into the next setting. By having a support worker with a person in the rehab unit where the interventions are delivered really helps this process.”
– Dr Sonja Soeterik, Consultant Clinical Psychologist (Neuropsychology & Rehabilitation) Clinical Director at Neurolink Psychology
Example scenario
Aiding a smooth transition from hospital to home
When Gary*, a 45-year-old salesman from Putney, was involved in a severe car crash that resulted in a traumatic brain injury, his world changed in an instant.
The accident left him with significant cognitive and physical impairments, requiring extensive rehabilitation and support to regain his independence.
After spending several months in hospital, John was ready to be discharged. But making the transition from hospital to his home and back to being an active member of the local community posed a significant challenge for him and his family.
Thanks to a partnership between SweetTree and the hospital, the company’s specialist team was able to collaborate closely with the hospital’s multidisciplinary team to create a comprehensive discharge plan that ensured continuity of care and the strongest possible outcome for John.
The planning for his transition began soon after he first entered the hospital.
Following a detailed assessment, SweetTree’s team began to work with John in person around four weeks before he was due to be discharged.
In this time, they were able to develop a relationship with him and became familiar with his medical needs, daily routines, and personal preferences.
Upon discharge, SweetTree then provided one-to-one support for John, helping him adjust to his new environment, assisting with his medication routine, supporting him to complete his physical exercises and daily activities, all while ensuring that he felt comfortable and supported.
For the next few months, SweetTree’s structured and supportive approach helped John settle into his home smoothly, supporting him with adjustments to his care plan as needed.
This allowed John to stabilise and regain his independence, while also giving his family peace of mind.
By partnering with SweetTree, John’s healthcare providers ensured a seamless transition from hospital to home, reducing stress and anxiety for both John and his family.
SweetTree’s discharge planning model proved to be an invaluable resource, offering a structured and reliable process that facilitated John’s recovery, reduced the risk of noncompliance with medical regimes, and helped improve his overall quality of life.
SweetTree’s Brain Injury and Neurological Conditions Service
We understand that life after a brain injury, or the diagnosis of a long-term neurological condition, can feel challenging and confusing.
Our highly skilled team works hard to improve the quality of life of our clients to support each individual to reach their full potential.
Our fundamental focus is high-quality care, supporting wellbeing, growth, and development. We make this vision a reality by employing the best people and by adopting a team approach to the provision of our services.
Ways we provide support include:
• Acting as an extension of the MDT, maintaining and improving upon rehabilitation gains already made in the inpatient setting
• Providing trained support staff – skilled in rehabilitation
• Implementing independent living trials in the community
• Promoting independence and championing capacitous decision making
• Relearning skills such as budgeting, managing appointments and correspondence
• Behaviour management such as emotional needs and Neurobehavioural needs
• Activities of personal care and daily living
• Smooth transitioning from acute hospital settings to the community
• Helping clients to increase their socialisation and build meaningful relationships
• Enhance a client’s ability to participate in employment and vocational positions
• Collaborating with clients, their families, and friends to support and enable them to reach their full potential
Find out more
Health and care professionals who would like to find out more about SweetTree, our specialist team, and discharge partnerships can get in touch via our contact form.