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 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 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 [email protected]