To ensure seamless arrangements for the discharge from hospital settings, it is important that a range of staff within the hospital (e.g. occupational therapists, physiotherapists, liaison nurses, and staff within multi-disciplinary discharge teams) can assess and order directly, equipment and relevant adaptations, for 'safe discharge', for their patients. It is important that these staff are supported to provide all aspects of the assessment role including follow-up and conclusion of the assessment following provision, and/or work jointly with other colleagues to fulfil these responsibilities.
Pathways for safe discharge must bridge the hospital to home gap through effective holistic joint multi-disciplinary and multi-agency working, with all relevant services e.g. community based health and social care services, Housing, technology, etc, to ensure each plan is discharge ready, the home environment is suitable, arrangements are subject to review, and the service user will be safe.
Potential rehousing needs should be identified at the earliest possible stage, ideally at admission, if not prior, to ensure a multi-agency approach which can work in partnership with the service user and their family, to identify and explore potential solutions which will support long term needs.
A hospital discharge guide Planning Discharge from Hospital, A guide to Providing Community Equipment on Discharge from Hospital, is based on arrangements tested and implemented in some existing services in Scotland. It has been developed to assist local services clarify roles and responsibilities for the provision of equipment, between the hospital and community settings, and support the implementation of clear and effective pathways.
- Ongoing needs, require to be taken forward by appropriate community services so these can be properly assessed in the context of the person's home environment, and wider rehabilitation needs, as part of their recovery plan. Therefore, although hospital based staff can access a wide range of equipment, they will only provide what is appropriate to support the service user to safely return to the community.
- In addition, it is essential that clear pathways are in place to allow hospital staff, to refer to relevant community staff for the assessment and ordering of equipment for more service users with more complex, ongoing needs, for example tissue viability. Ideally, this should ensure that one assessor will take on the provision of all relevant equipment for discharge to avoid duplication and multiple deliveries.
- It is important that hospital-based referrers avoid risk-averse behaviour, and over-prescription of equipment e.g. tissue viability, moving and handling etc, for all patients, and services agree provision of standard simple solutions, to ensure a safe discharge and allow for a review of needs and more specialist provision, if required, once the person is back in their home environment.
There will also be circumstances where joint working should prevail, and the expertise of the hospital based practitioner should be utilised alongside the skills of the community professional to meet the needs most effectively e.g. service users with spinal injuries, children with complex needs, or requirement for equipment for use within planned adaptations related to discharge.
Effective planning is crucial, and initiatives to improve discharge pathways by introducing a 'Planned day of Discharge' will be important in improving the processes. This provides a change in emphasis from Estimated Date of Discharge to Planned Date of Discharge, which should be an agreed date and plan for discharge that the multi-disciplinary team, as well as the patient, family and carers, are involved in. In terms of on-going care and support needs it is important that planning starts early and that all parties actively work towards the Planned Date of Discharge and not from the Date of Discharge.
Good Practice Example
In South Lanarkshire the introduction of Home First, Planned Date of Discharge, intermediate care, and discharge to assess/ rehabilitation has led to a 70% reduction in delays. The PDD initial tests of change were undertaken in high referring wards in Hairmyres, mainly care of the elderly. The focus was still on home first and enablement, but when care at home or long term care was required, social care would be part of the daily MDT, all working towards a planned discharge.
It is hoped that this approach will support the more effective provision of equipment, and also ensure the opportunity to clarify other wider needs related to the home environment e.g. need to discuss re-housing and/or the need for adaptations. In some areas, in-reach models have been explored as a way of supporting improved discharge pathways.
Good Practice Example
The Inverclyde in-reach Occupational Therapy Service started as a pilot project in 2015 utilising a Band 6 Occupational Therapist based in the community, with the aim of improving hospital and community links and to work with hospital based occupational therapist and physiotherapist colleagues, to plan and follow up on complex discharges, with a 'home first' approach.
This involved establishing good communication links within the hospital and community settings, working closely with the In-reach community nurse colleague, and other relevant rehabilitation and social care services. This post has now been integrated into the service provided by the Rehab and Enablement Service (RES) team.
The benefits have included the streamlining of the discharge process for complex cases, a more coordinated multi-disciplinary approach to planning and support for complex discharges with better communication and knowledge sharing, patients and their families feeling reassured due to improved continuity, and timely and effective service intervention.
- Integration Authorities (IAs) should utilise the hospital discharge equipment provision good practice guide, to support improvements in the provision of equipment for discharge.
- IAs should ensure that a range of staff within the hospital can assess and order directly, equipment and relevant adaptations, for 'safe discharge'.
- IAs should ensure that clear pathways are in place to allow hospital staff to refer to relevant community staff for the assessment and ordering of equipment and adaptations for more complex, ongoing needs.
- All services should avoid over-prescription for patients with standard needs, and agree simple solutions, to ensure a seamless, and safe discharge.
- Services should explore the opportunities to implement a Planned Date of Discharge approach, to improve forward planning for the provision of equipment and relevant adaptations for discharge.
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