Hospital Discharge Pathways Philip Rankin – BSUH Doctor and Clinical Lead BSUH Discharge Hub Learning Objectives

1. National best practice 2. National hospital discharge requirements during the Covid19 pandemic 3. Challenges to effective discharge planning and common concerns of staff 4. Which pathway is your patient on? Hospital discharge pathways 0, 1, 2 and 3 5. Roles and responsibilities enabling discharge 6. Using the new referral forms and processes, screening tools, discharge planner and ward documentation

7. Discharge hubs and integrated discharge teams 8. Continuous improvement relating to discharge and championing best practice 9. Voluntary and community sector discharge support 10. Common concerns patients and carers have relating to discharge and the tools available to support communication of discharge to patients and ongoing care providers 11. Education materials and professional development

Discharge Planning

• The critical, quality link between hospital and the community providing continuity of care, based on individual needs of the patient

• Multidisciplinary, integrated and whole system

• An ongoing process, not an isolated event

• Involves patients and carers as partners

• Discharge is as important as admission and starts from day one

• Discharge planning can even begin before arrival – advance care planning

More information on ReSPECT here Discharge Planning

• Independence - More people maintaining independence and returning to usual place of residence

• Staff - Improved staff satisfaction where staff can make decisions on the right information, work collaboratively in an efficient system with a wide range of colleagues, feel that their expertise is used, can develop new skills and roles.

• Patient - Improved patient experience – feeling empowered, experience seamless service, understand what is happening and agree to it

• Carers - Carers feel valued, they understand what is happening, they have a role in decision making and feel confident.

• Strengths -Takes a strengths based approach – what’s strong rather than what’s wrong

Joyful reunion as dog welcomes owner, 96, back from hospital Supporting Flow

Doing the Right Thing - Valuing Patient Time #EndPJParalysis #Last1000Days

Key Questions for Us to Know and Communicate

Discharge to Assess – Purpose and Principles

• Home as default • Home is more than own home • Assessment in place best for person • Continuity of coordination and clear, simple onward processes • System approach • Build awareness of acute and community re each others’ roles It works - DToC reduced by 25% in 3 months in Medway, Sheffield had 37% increase in patients discharged on day of admission or next day

• NHS England, quick guide to Discharging to Assess • NHS England, quick guide to better use of care at home • Liz Sargeant, Emergency Care Improvement Programme, Developing a Home First Mindset • Health Education England, Care Navigation: a competency framework • Housing LIN, Hospital to home resource pack Report link here BSUH – Key Themes for Improvement

The following themes were identified across BSUH during the Reset Week: • Need simplified discharge pathways which everyone agrees and understands • EDD’s, board rounds and Medway use – Needs consistent approach & standard working • Pharmacy – Inconsistent availability & cover across all divisions & at weekends • Discharge planning at point of admission • Roles & responsibilities – Wards & Integrated Discharge Team (Every ward to know discharge support available to them, and the role the ward play themselves) • Risk of over-assessment or inpatient input when community alternative available • Internal central point of coordination required Click here for link to read more

From 19 March, all systems must use a modified discharge to assess (D2A) model to discharge all patients who have been confirmed by a consultant as no longer meeting the criteria for acute care.

Once a decision has been made that someone should be discharged, they should be transferred to a discharge lounge or suitable designated area within one hour and discharged from hospital within a further two hours. Discharge home today should be the default pathway

Written communication and setting Click for RSCH files here and here, and expectations – for all patients PRH here Best practice board rounds

X 2 / day Improving patient & staff experience of discharge planning Making the most of the new patient discharge handbook.

1 For patients (and staff): For all staff: Please give handbook to The purple discharge planner patients as soon as possible in should be the central , regularly to their admission (latest updated, accurate MDT record within 24 hours) and discuss of discharge planning and sits with them how to use it and alongside the more patient- keep safe and accessible. focused discharge handbook

Full version here

2 For patients (and staff) Please support patients & carers (with MDT support) write key updates about their discharge and enable them to be part of shared decision making and have a reliable record for their own purposes

Improving patient & staff experience of discharge planning Making the most of the new patient discharge handbook.

1 For patients (and staff): For all staff: Please give handbook to patients The purple discharge planner should as soon as possible in to their be the central , regularly admission (latest within 24 hours) updated, accurate MDT record of and discuss with them how to use discharge planning and sits alongside it and keep safe and accessible. the more patient-focused discharge handbook

Planning discharge from day 1 Going home day 3 Checklists on page X and page X (going home day) please encourage and support patients and colleagues to consider items on the checklist

Key principles to think about with colleagues, carers and patients

S—Senior Review A—All to have EDD F—Flow of patients E—Early discharge 45% before midday R—Review—MDT Discharge Checklists

Planning discharge from day 1 Going home day 3 Checklists on page 4 and page 6 (going home day) please encourage and support patients and colleagues to consider items on the checklist

Look out for new BSUH discharge planner coming soon! Which hospital discharge pathway is your patient on? Ward led

Print a copy for your clinical area here Further discharge pathway information Pathways are determined by discharge destination and level of patient need Largest majority of discharges Pathway 0 – Simple discharge Restart of existing package of care with no change Discharge home / usual place of residence May include routine community nursing Discharge back to care home Discharge home with family or unpaid carer Restart packages of care May require access to settle @ home services including Meals on Wheels

Pathway 1 – Support to recover at home Discharge to Assess pathway (Responsive Services / JCR) Patient returns to usual place of residence with New care package required or existing care package increase interim support Temporary reablement to maximise independence Nursing / therapy assessment / intervention, eg new equipment or new community wound care

Pathway 2 – Rehab/reablement in a bedded Short-term rehabilitation to maximise potential setting Bedded assessment for health and/or care needs in order to return home Patient transferred to non-acute bed for period Bedded assessment for health and/or care needs in order for a new of rehab/reablement home/usual place of residence to be determined Specialist rehabilitation Patient transferred to non-acute setting for a period of assessment of ongoing needs As examples, SCFT community rehab bed, D2A bed, dementia assessment beds, Sussex Rehab Centre, delirium pathway, non-weight bearing needs

Pathway 3 - Complex New long term care home placement (nursing or residential) Majority of patients are no longer able Complex Continuing Healthcare needs to return home and require a long term Examples of this pathway may be: placement (include health, social care Complex End of Life Care or self-funding placements) Complex mental health needs Life changing event Complex housing and homelessness needs A small number may return home with Live in or more than QDS POC with multi-professional input significant support

Referrals (not sure or any issues requiring escalation – contact us at the hub) All forms available via this link here on Microguide

Pathway Service and Referral Form / Information Required Send it to / contact details Pathway 1 – [email protected] B&H SCFT Responsive Services using streamlined RS referral form Home / Usual Residence Coastal and Central West Sussex SCFT Responsive Services using West Sussex joint [email protected] health and ASC referral form And [email protected] East Sussex JCR using HSCC form [email protected]

Pathway 2 - [email protected] B&H beds, SCFT HWLH (East) - complete the SCFT IPR beds referral form Beds

[email protected] and SCFT Coastal West Sussex Health Beds and and SCFT Central Health Beds [email protected] Complete the West Sussex joint health and ASC referral form

[email protected] East Sussex (Eastbourne Hastings, Rother) Health Beds. Complete the HSCC form

Pathway 3 - Adult social care for placement or other complex care requiring ASC input B&H HospitalRSDuty@brighton-hove.gov.uk Complex B&H – contact the discharge hub for details of social workers available East Sussex – complete the SCFT IPR beds referral form (as East Sussex ASC have ESx [email protected] agreed it has the information they need) [email protected] and West Sussex – complete the joint West Sussex joint health and ASC referral form [email protected]

CHC Email details about your patient / query to: [email protected] B&H – contact the discharge hub for details of CHC staff available [email protected] and [email protected];

East Sussex – collate patient details and history and send email Email patient details to [email protected]

Email all of [email protected] and West Sussex – complete the West Sussex joint health and ASC referral form [email protected] and [email protected]

Homeless – focus on B&H residents but can support with links to all areas. Involve early Phone 07884195417 and / or email [email protected], or Katie Carter in all admissions – before MRFD. [email protected] How Many Patients On Each Pathway?

Placing in the correct pathway ensures we: Minimise patient's acute hospital length of stay Maximise independence through enablement Support care at home or closer to home Make no decision about long term care in an acute setting Real-time use of Medway

Updating Medway with patient pathway and EDD will support all discharge to happen quicker with greater clarity and reporting on what the patient is waiting for

Pathway codes and reasons go live 15th June PRH 22nd June RSCH – shop floor support available and speak with IDT.

Live bed state will also tell us how many pathway 0,1,2 and 3 patients on each ward to enable escalation and getting right support Arrival to Discharge Simplified Process

Admission: Letter given to patient upon admission Clear clinical plan & EDD. Twice daily review.

Complete pre-morbid functional screen within 24 hours of admission and determine likely pathway number – 0,1,2 or 3

Medically Ready For Discharge (MRFD) (Medical decision made) Ward decide by time of MRFD if safe for discharge home, or needs discharge to another place of care

HOME / Usual Residence ANOTHER PLACE OF CARE Pathway 0 or 1 Pathway 2 and 3 (Pathway 3 e.g. complex live in care in small number cases) Ward informs Integrated Within I hour: Discharge Team (IDT) Moved to discharge lounge

Ward liaise with ongoing IDT liaise with ongoing provider. Within 2 hours: provider. Ward gets TTO, Ward gets TTO, discharge letter, Discharged from hospital discharge letter, transport ready transport ready Follow up after discharge

Best practice for wards to also give their contact details and include in discharge letter. Discharge hub can also support with queries over first 48 hours after discharge BSUH Discharge Hub & Integrated Discharge Teams (IDT)

What is it? Who are we?

Hub provides oversight & co-ordination of all BSUH Discharge Co-Ordinators and Flow Coordinators pathway 1,2 & 3 discharges Community Trust Managers and Nurses - Unblocks escalated issues Doctors and Adult Social Care Continuing Health Care and CCG IDT directly supports discharge out of hospital Therapists – Community & Acute - Provides education and guidance Voluntary and Community Sector - Specialises in complex discharge (pathway 3) Administration, Quality Improvement and Safety

How can wards help with discharge? How to get in touch?

- Tell us about MRFD patients early BSUH Discharge Hub: - Organise TTOs and transport needs RSCH Trust Headquarters, Level 7 Office - Check if patient has keys or needs them [email protected] - Involve NOK throughout recording their details Extensions: 63496 / 65071 / 65226 / 67907 - Escalate any unresolved issues promptly to us - Continuously feedback improvements RSCH IDT: - - Promote independence from arrival [email protected] - Become a champion for: Extensions: 67885, 63221, 63635 Barry building wards DISCO: 65228 Other wards DISCO: 65227 PRH IDT: [email protected] Extensions: 68275, 68276 Bleeps 6106 / 6107 Download a copy for your staff room here Discharge Planning from the Front Door

• Screening and collateral at point of first contact: • This is the best time to get accurate history from the paramedic, carer or relative accompanying the patient about the baseline condition of the patient and the home circumstances.

• PRH – SCFT HRDT providing ongoing support to ED and CDU • RSCH – IDT Front Door L5 in development building on existing HRDT

• Early identification and documentation of pathway and plan Screening document and vision

Started from the front door, cutting down duplication, standardising information, in future for onward referral Community Cards can be used by all members of the multidisciplinary team

They summarise key resources to best link up acute and community care for patients, support high quality discharges, system flow, and offer alternatives to admission or emergency attendance.

Printed copies coming to wards and download from Microguide

Additional resources to complete

• Video 2 – Case Studies with Veena Lalsing • Review rest of Iris education page: https://iris.bsuh.nhs.uk/course/view.php?id=654 • Updated Medway training (coming soon) • Explore Microguide: click here • Submit your ideas on Padlet about what each staff member can do to best support discharge: https://padlet.com/melanie_armstrong4/o4ge8zg2dre7 • Speak to us at the Hub / IDT staff [email protected]

Thank you!