Abstract Introduction Frail older adults are often discharged from hospital with complex needs into community care services. Without senior clinical oversight, many experience fragmented care, delayed reviews, inappropriate care planning, and avoidable readmissions. This project evaluated the impact of introducing clinical leadership into a care provider pathway designed to deliver short-term, post-discharge domiciliary care. Methods Over 11 weeks, 51 patients were supported, 43 of whom were on the care provider pathway. Using the Plan-Do-Study-Act (PDSA) framework, the project identified inefficiencies and tested solutions. Interventions included senior clinician-led home visits, MDT support, care plan reviews, and collaboration with community therapy and social care teams. Data was collected on care package changes, hospital length of stay, and therapy involvement. Results Key issues included: lack of formal policy for the pathway, no senior clinical oversight, unregistered care staff making key decisions, and poor end-of-life planning. Outcomes from clinical leadership interventions included: 12% of patients had reduced care packages prior to discharge; 24% had reduced care needs once home. Estimated 476 care hours released per week. Approximate cost saving of £7000 per week. Senior clinician home visits proved the most impactful, enabling timely assessments, realistic care decisions, reduced dependence on social care, and improved patient experience. MDT engagement and end-of-life care planning also improved significantly. Conclusions Introducing senior clinical leadership to the care provider pathway significantly improved patient flow, care quality, and resource use. A 12-month Band 7/8 leadership role is recommended, jointly funded by acute, community, and social care partners, to oversee and define this pathway. This approach offers a sustainable model to manage complex discharges for frail patients while reducing system strain and supporting better outcomes.
S Densem (Sun,) studied this question.