Pathfinder team (Northern services)

The Pathfinder Team is a fully integrated discharge team of health professionals, who work to prevent unnecessary admission to hospital and make sure patients are safely discharged to the most appropriate care setting.

Every professional within our team has a wide range of skills, allowing us to carry out comprehensive holistic assessments, support decisions, and put interventions in place where needed. 

We follow up with every patient referred to us via the Emergency Department, Medical Assessment Unit or ward areas with a telephone call, or where necessary, a home visit, to make sure your transfer of care is seamless. We will also make any referrals needed to appropriate Health and Social Care teams.

When might I need your services?

Our service works to avoid hospital admissions where appropriate by providing timely assessments in the emergency department and considering what support is needed for the individual to manage within their home environment. 

You may need our services if you have been in hospital for less than 48 hours and have been a patient on the Medical Assessment Unit or on Alex Ward. Our team would assess your ongoing care needs and help arrange support. 

Pathfinder are responsible for the assessment and timely, safe transfer to care homes suitable for the patient’s needs, for all patients requiring Nursing Home placement. This includes those assessed as End of Life requiring transfer to a nursing home bed.

When you are discharged from hospital

The Pathfinder team will provide your assessment and complete any necessary paperwork needed to make sure you are safely transferred to a care setting that best meets your needs, whether this is to your own home, residential or nursing care home accommodation. 

We also help with assessments and discharge planning if you, your relative, or the person you care for are being cared for by our End of Life service. We facilitate rapid discharge, coordinate ongoing care and liaise with any community teams who may support. 

What happens when I have complex discharge needs?

We work within a multi-disciplinary team to assess and plan ongoing support for those with complex discharge needs, liaising with acute, community, and support services to offer a coordinated approach.

We work collaboratively with health and social care colleagues to identify delays and improve your journey with us. We act as a link between acute and community teams, including the Northern Single Point of Access.

Last updated: March 31, 2023.

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