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Discharge from hospital is a positive step for the patient, but moving from twenty-four-hour care on the ward to the community can be challenging. Careful assessment, planning and communication can ensure care continuity and help the patient recover and adjust to life at home in safety and comfort.

Meeting the needs of the patient as they transition from hospital to community care requires meticulous preparation and co-ordination. NICE says:

‘Planning for a patient’s discharge from hospital is a key aspect of effective care. Many patients who are discharged from hospital will have ongoing care needs that must be met in the community. This ongoing care comes in many forms, including the use of specialised equipment at home such as a hospital-type bed, daily support from carers to complete the activities of daily living, or regular visits from district nurses to administer medication.’

The NHS Institute for Innovation and Improvement has described the ten steps that should be followed for effective discharge planning. They’re not prescriptive, it’s always important to respond to a patient’s individual needs. However, they can provide a useful guideline, so that delays can be avoided and there is less risk of patients bouncing back into hospital care.

Early planning

Perfect discharge planning should start on the day of admission, or before admission if an individual is having an elective procedure. Rushed or poorly planned discharges may lead to problems at home, falls and readmissions.

Screening tools, risk assessment and examination of existing care pathways can be used to identify care needs and anticipate potential problems. It’s important to gather detailed and accurate patient information from the family, GP, primary healthcare team and any home carers.

Identify the patient’s needs

Understand whether the patient has simple or complex health needs. By identifying the likely patient pathway before, or soon after, admission you can help avoid problems and delays.

A simple discharge can be managed by the ward, the multidisciplinary team, the individual and the family. Discharges in which there are funding issues, a change of residence to a nursing home or sheltered accommodation, or significant health and social care needs are complex and will require more planning.

Patients who require end-of-life care, NHS intermediate care or NHS continuing healthcare should be identified so that the right pathways can be instituted and their needs met.

Develop a clinical management plan

A management plan should be developed during the first 24 hours after admission. An outline plan will usually have been made by the junior medical or surgical staff admitting the patient. This should be reviewed on the next ward round, so that the plan engages the whole multidisciplinary team. All aspects of care that will be needed prior to discharge should be identified.

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Discharge co-ordination

Any discharge or transfer requires careful coordination. Wards, hospitals and clinical areas may have different systems and staff responsibilities. Some use nurses, while others employ clerical staff or dedicated discharge coordinators. Whoever oversees the process should ensure effective assessment, multidisciplinary team working and communication with respect to the discharge.

Set a predicted date of discharge

An expected discharge date should ideally be set within 48 hours of admission. This can be very difficult to implement and will need to be amended according to the patient’s health, progress and any developing care needs. However, an estimated discharge date can be useful for planning. It can help predict hospital capacity, assess the progress of the clinical plan and allow patients to understand expectations.

Review daily

The clinical management plan should be reviewed on a daily basis to monitor progress. The National Leadership and Innovation Agency for Healthcare recommend the RAP strategy. Review; Action; Progress. It’s essential to update the plan together with the patient and the multidisciplinary team in response to their health, wellbeing and function.

Involve patients and carers

The patient and those that love or care for them should be involved throughout the discharge planning process. This helps them understand any challenges and manages their expectations. Care support requirements and options should be discussed and support services in intermediate care, dementia care, end-of-life care and NHS continuing care pathways given careful consideration where appropriate.

The patient’s involvement in their discharge and their right to choose the care they prefer are core principles. Depending on the individual, their home circumstances and their care needs, a number of meetings may be necessary between the patient, family, the multidisciplinary team, and any social care providers.

Seven days a week

Discharges are often complex, so plan for them to take place over seven days. Problems don’t stop on a Friday at 5pm. Supportive services such as OT or physiotherapy, transport, community nursing or intermediate care need to be engaged and available at weekends too. The Nursing Times learning unit on discharge planning said:

‘Only with the support of seven-day working from hospital and community services will continuity over seven days of the week be possible.’

Check the list

Complete a discharge checklist 48 hours before the planned time of transfer. There may be a number of individuals and agencies involved, so there is an enormous amount to consider and coordinate. A checklist will help ensure that essential aspects of planning are not forgotten.

Make discharge decisions every day

Discharge decisions should be made and planned seven days a week. Depending on unit policy this may be nurse-led, may involve the MDT or may be done by senior clinical decision-makers, like consultants.

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The right care

Each individual patient will have different needs and preferences about how and where they would like to live. The right care for each individual depends on their health, their function, their personal wishes, any family carers and the funding available.

Patients that are entitled to intermediate care can receive a package of up to six weeks of temporary care to help with rehabilitation after discharge. This care can be received in a care home or in their own home. A team of professionals tailored to the individual’s needs will provide the support. This can include trained carers, physiotherapists, occupational therapists, dieticians and others. This service is free of charge without means testing.

Patients with private funding and those who receive direct payments, following a care assessment, may choose to use private care providers. A nursing home or sheltered residential facility may offer support for a period of rehabilitation, allowing them to regain strength and mobility. Alternatively, many may prefer to recuperate in their own home. Home care can help facilitate this. Care is adaptable. Carers can provide reassurance and a helping hand, or can be employed around-the-clock, assisting with all activities of daily living and supporting complex health needs such as incontinence, dementia and tube-feeding.

At hometouch, we can source home carers with the experience and expertise to provide post-discharge support and adjust to the individual’s changing needs. The patient has the control to employ a professional caregiver of their choice, with the reassurance that they have undergone all the necessary checks and had their references followed up. We also manage paperwork, contracts and arrange care cover in case of illness or annual leave.

Carers work on a self-employed basis, managing their own taxes and insurance, this means that carers get a fair living wage but also ensures that rates are affordable.

Discharge planning is complicated, particularly in those who are frail, elderly or have complex care needs. But effective discharge planning can ensure that that the patient leaves the hospital in a timely fashion, has continuity of care and remains safe and healthy, without the need for readmission.

Dr Jane Gilbert

Jane has over 20 years’ experience as a health writer and TV presenter. Jane writes on a wide variety of clinical and care topics – from explaining the latest studies and research to unpacking conditions and discussing treatment options. Jane holds a MBBS degree from Imperial College, London and spent seven years working in the NHS.

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