Integrated Transfer of Care Hub (Discharge)

Integrated Transfer of Care Hub

The Integrated Transfer of Care Hub (ITOC) is a multidisciplinary team made up of health and social care professionals, therapists, discharge coordinators and third sector agencies. The aim of the hub is to promote and support a safe and timely discharges from hospital.

About the service

When you no longer need to be in hospital, it is better to continue your recovery out of the acute setting.

Staying in hospital for longer than necessary may reduce your independence, result in losing muscle strength or expose you to infection.

From the day you are admitted to hospital, the staff involved in your care will work together with you and your relatives/carers to assess your needs in preparation for leaving hospital.

On the first day of your stay, you will receive an estimated date of discharge (EDD) which may change as your care progresses. During your admission should you or your relative/carer wish to discuss discharge planning please ask for the Discharge Coordinator.

If the ward think you need ongoing support, a referral will be sent to the Integrated Transfer of Care (ITOC) Hub to triage and process. Working closely with the wards multidisciplinary team and following national guidelines the ITOC team ensure everyone has a shared understanding of the best outcomes for the patient.

The teams top priority is to achieve safe and timely discharges whilst working closely with patients and their families using the home first approach.

If you need more care and support than when you first came into hospital and returning home is initially deemed unsafe, you may require a period of further assessment in a community bed which can best meet your needs at this time.

Let's help get you home

‘Let’s help get you home’ as soon as your medically fit is the latest campaign to help educate all patients across the Mid Yorkshire footprint. Created in partnership with Wakefield Council, Carers Wakefield and Age UK, the new discharge campaign shares the journey from assessment in accident and emergency to supported offered by third sector organisations.

The Trust is informing patients and families about who they will see, and what will happen at each stage of a hospital journey.

Lyndsey Scaife, Head of Discharge at Mid Yorkshire Teaching NHS Trust said:

We want patients to be involved in their discharge journey, so they feel well informed at each stage.

As a Trust, we feel it is important to reassure patients and about who we are, what we do and how we can help on the road to recovery.

By knowing this information, it may help to reduce anxiety following a potential long stay in hospital.

The video produced can be viewed below.

How you can help with your discharge

How to help with your discharge

When you no longer need hospital care, it is better to continue your recovery out of hospital. Staying in hospital for longer than necessary may reduce your independence, result in you losing muscle strength or expose you to infection.

It is very important that when in hospital care, you ask four questions every day to the team caring for you:

What is the matter with me?
What is going to happen to me today?
When am I going home?
What is needed to get me home?

This way you can keep on track of your care and make a plan to be supported whilst heading home. Leaving hospital when you are ready is not only best for you but will help us to care for someone else who is unwell.