Occupational Therapist (Care Transfer Hub)

Occupational Therapy Role in Care Transfer Hub

Within the Care Transfer Hub, the Occupational Therapy skillset takes a lead in supporting patient discharges that have a complexity around function or cognition or where there is lack of clarity around which pathway is the best fit for a patient leaving the hospital.

The Therapist problem solves where there are challenges around discharge in 4 main areas that require a holistic approach and knowledge of overcoming functional or cognitive issues while supporting reablement and maximizing independence.

• Assisting in discharge planning where there are complex moving and handling needs. Particularly where patients have specific equipment requirements to support reablement at home. For example, bariatric patients where knowledge of equipment and function is needed to support optimal independence. This patient group may include identifying those who fit the criteria for proportionate care.
• Overseeing discharges where cognitive impairment requires problem solving to facilitate pathway 1 back home. For example, when delirium and or dementia presents and re orientation at home is likely to improve function.
• Where pathway 3 is not suitable but concerns remain from family and MDT. An understanding and support of ongoing needs and risks is required. Managing discharges where functional challenges could be overcome to facilitate pathway 1. This can then be explained to patient family and carers to gain understanding and offer reassurance and support.
• Early identification of patients with pre-existing complex challenges at home. Including those with previous extensive community involvement. They may have multiple health and or social needs. Where a sound understanding of the previous function and communication with community services is needed. Using clinical reasoning and problem solving to implement early discharge planning.