Hospital Discharge Pathways

1 Hospital Discharge Pathways Philip Rankin BSUH Doctor and Clinical Lead BSUH Discharge Hub Learning Objectives best practice Hospital Discharge requirements during the Covid19 pandemic to effective Discharge planning and common concerns of staff pathway is your patient on? Hospital Discharge Pathways 0, 1, 2 and 3 and responsibilities enabling Discharge the new referral forms and processes, screening tools, Discharge planner and ward documentation hubs and integrated Discharge teams improvement relating to Discharge and championing best practice and community sector Discharge support concerns patients and carers have relating to Discharge and the tools available to support communication of Discharge to patients and ongoing care providers 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.

2 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.

3 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 #Last1000 Days 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.

4 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.

5 Discharge home today should be the default pathway Written communication and setting expectations for all patients Click for RSCH files here and here, and 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. For patients (and staff): Please give handbook to patients as soon as possible in to their admission (latest within 24 hours) and discuss with them how to use it and keep safe and accessible. For all staff: The purple Discharge planner should be the central , regularly updated, accurate MDT record of Discharge planning and sits alongside the more patient-focused Discharge handbook 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 Checklists on page X and page X (going home day) please encourage and support patients and colleagues to consider items on the checklist S Senior Review A All to have EDD F Flow of patients E Early Discharge 45% before midday R Review MDT Key principles to think about with colleagues, carers and patients Planning Discharge from day 1 Going home day 1 2 3 For patients (and staff)

6 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 2 For patients (and staff): Please give handbook to patients as soon as possible in to their admission (latest within 24 hours) and discuss with them how to use it and keep safe and accessible. For all staff: The purple Discharge planner should be the central , regularly updated, accurate MDT record of Discharge planning and sits alongside the more patient-focused Discharge handbook 1 Improving patient & staff experience of Discharge planning Making the most of the new patient Discharge handbook. Full version here Discharge Checklists Checklists on page 4 and page 6 (going home day) please encourage and support patients and colleagues to consider items on the checklist Planning Discharge from day 1 Going home day 3 Look out for new BSUH Discharge planner coming soon!

7 Which Hospital Discharge pathway is your patient on? Ward led Print a copy for your clinical area here Pathway 1 Support to recover at home Patient returns to usual place of residence with interim support Discharge to Assess pathway (Responsive Services / JCR) New care package required or existing care package increase Temporary reablement to maximise independence Nursing / therapy assessment / intervention, eg new equipment or new community wound care Further Discharge pathway information Pathways are determined by Discharge destination and level of patient need Largest majority of discharges Restart of existing package of care with no change May include routine community nursing Discharge home with family or unpaid carer May require access to settle @ home services including Meals on Wheels Pathway 0 Simple Discharge Discharge home / usual place of residence Discharge back to care home Restart packages of care Short-term rehabilitation to maximise potential Bedded assessment for health and/or care needs in order to return home Bedded assessment for health and/or care needs in order for a new home/usual place of residence to be determined Specialist rehabilitation As examples, SCFT community rehab bed, D2A bed.

8 Dementia assessment beds, Sussex Rehab Centre, delirium pathway, non-weight bearing needs New long term care home placement (nursing or residential) Complex Continuing Healthcare needs Examples of this pathway may be: Complex End of Life Care Complex mental health needs Complex housing and homelessness needs Live in or more than QDS POC with multi-professional input Pathway 3 - Complex Majority of patients are no longer able to return home and require a long term placement (include health, social care or self-funding placements) Life changing event A small number may return home with significant support Pathway 2 Rehab/reablement in a bedded setting Patient transferred to non-acute bed for period of rehab/reablement Patient transferred to non-acute setting for a period of assessment of ongoing needs Referrals (not sure or any issues requiring escalation contact us at the hub)

9 All forms available via this link here on Microguide Pathway Service and Referral Form / Information Required Send it to / contact details Pathway 1 Home / Usual Residence B&H SCFT Responsive Services using streamlined RS referral form Coastal and Central West Sussex SCFT Responsive Services using West Sussex joint health and ASC referral form And East Sussex JCR using HSCC form Pathway 2 - Beds B&H beds, SCFT HWLH (East) - complete the SCFT IPR beds referral form SCFT Coastal West Sussex Health Beds and and SCFT Central Health Beds Complete the West Sussex joint health and ASC referral form and East Sussex (Eastbourne Hastings, Rother) Health Beds. Complete the HSCC form Pathway 3 - Complex Adult social care for placement or other complex care requiring ASC input B&H contact the Discharge hub for details of social workers available B&H East Sussex complete the SCFT IPR beds referral form (as East Sussex ASC have agreed it has the information they need) ESx West Sussex complete the joint West Sussex joint health and ASC referral form and CHC B&H contact the Discharge hub for details of CHC staff available Email details about your patient / query to: and East Sussex collate patient details and history and send email Email patient details to West Sussex complete the West Sussex joint health and ASC referral form Email all of and and Homeless focus on B&H residents but can support with links to all areas.

10 Involve early in all admissions before MRFD. Phone 07884195417 and / or email or Katie Carter 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 Within I hour: Moved to Discharge lounge Within 2 hours: Discharged from Hospital HOME / Usual Residence Pathway 0 or 1 (Pathway 3 complex live in care in small number cases) ANOTHER PLACE OF CARE Pathway 2 and 3 Admission: Letter given to patient upon admission Clear clinical plan & EDD.