The potential for recovery, rehabilitation and reablement will be fully considered before any decisions are made on long term care plans. The aim should always be to return home if possible and appropriate. Wherever possible, decisions about long term care should not be made in an acute hospital setting. Ideally, the patient should be discharged to a more appropriate non-acute setting such as a community hospital, or intermediate care facility for further rehabilitation and assessment.
The DwD programme was launched in 2021 and aims to improve the patient journey, from the initial point of a hospital stay, preventing any delays through early and effective planning. A key aim is to limit hospital stays to what is clinically and functionally essential, getting patients home at the earliest and, crucially, safest opportunity.
While the challenge is highly complex, ever shifting and dynamic, the foundations of DwD are based on simple patient-centred principles which aim to enhance discharge and prevent delay, through early and effective planning, limiting hospital stays to what is clinically and functionally essential, and getting patients home at the earliest, safest opportunity. These can be distilled down to three basic elements.
1. Prepare and plan for discharge with patients, from admission;
2. Prioritise and protect time to plan as an extended team;
3. Adopting a ‘Home First’ ethos.
A key element of Discharge without Delay programme is the setting of a Planned Date of Discharge (PDD). Discharge from hospital should take place in line with the agreed PDD. If the person is transferring to an intermediate care facility the PDD should be reassessed on admission and a new PDD established.
Moving into a care home is a major decision for a person and their family, so preparation and planning needs to commence as early as possible in the patient’s journey. This process is less likely to be successful when it is rushed, and can have a negative impact on the patient’s health and wellbeing. It may also result in the inappropriate use of health and social care services. Ideally, a hospital admission should not be the trigger point for this planning. The patient, family or proxy and, where appropriate, social work services and community health staff will have given thought to long term care needs as part of an Anticipatory Care Plan.
The application of the choice guidance at a local level should be embedded firmly in a local admission, transfer and discharge policy/protocol. Consistent, timely and appropriate communication by all professionals involved with the patient and family or proxy will help to address many of the difficulties and misunderstandings that can occur and will ensure the process of moving on takes place in an effective and efficient manner.
A person is not entitled to remain indefinitely in hospital once they are ready for discharge. Failing to make a choice of care home, or reluctance to co-operate with the discharge process should not prevent discharge taking place. The NHS and local authorities will take robust action to ensure that people are not inappropriately delayed in hospital if a placement more appropriate to their needs is available elsewhere. The previous Cabinet Secretary for Health and Wellbeing made it clear that a patient does not have a right to ‘choose’ to stay in hospital where this goes against best clinical practice.
Where the preferred choice(s) of care home is not immediately available the person will be required to make a temporary (interim) move to another home with a suitable vacancy to wait. The decision to discharge an individual will be based on clinical need and must not be influenced by a person’s choice of care home or resolution of financial issues.
Consideration of capacity and the principles and requirements of the Adults with Incapacity (Scotland) Act 2000, Human Rights, and Equality legislation must underpin the application of this guidance.
The issue of the patient’s capacity to make informed decisions about future care should be investigated as early as possible in the patient’s journey. This will help to avoid unnecessary delays in the patient’s discharge.
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