Discharge planning

Discharge Liaison Nurse’s Patient Flow Team Janet DaviesChristine Jones-Williams

Challenges

Balancing capacity with demand

Ensuring safe Effective discharge

Prevent readmissions

Avoid complaints

Discharge Planning - Getting It Right

Pre admission (planned admissions) On admission Assessment (identifying risks to

discharge ) Making appropriate referrals to MDT Involve Patient/ Carer Predicted discharge (based on

clinical knowledge & data )

The patient can only be Discharged or Transferred when

A clinical decision has been made that the patient is ready for discharge / transfer

The MDT decision has been made that the patient is ready for discharge/ transfer

Patient, Family , Carers have sufficient help & support if required (arranged prior to discharge)

Nursing Home / Residential Home able to meet identified needs.

Appropriate funding for above has been arranged

Assessment

Is the Patient homeless? Refer immediately to Social Services

Have the Patients needs changed since admission?

What help are they likely to require on discharge ?

Will they require equipment?

Assessment continued

Has the patient reached their full potential ?

Will the patient benefit from further rehab/ assessment in a community hospital ?

Is the patient likely to require care home placement? If so what kind?

Who will pay?

How is the decision made ?

MDT/patient /family/carer decision based on the needs of the patient identified during the assessment process (Unified assessment from Sept 06)

Medical,Nursing Specialist nursing Speech &Language Physiotherapy/ Occupational Therapy Social Worker

Care Homes

Residential

Residential EMI

General Nursing

EMI Nursing

Specialist Nursing i.e. ABI unit, Younger adult etc

Types of Funding

Self funding

Local authority funded

Self Funding with NHS contribution to Nursing Care (£110 per week)

Continuing health Care (fully funded by the Local Health Board)

Placement

As a general rule people should not be discharged directly from an acute episode of hospital care to a permanent placement in a care home

Further rehabilitation may take place at hospital, at home or in an intermediate care setting i.e. Community Hospital

Definition of Nursing Care

Any services provided by a Registered Nurse and involving:

The provision of care or The planning, supervision or

delegation of the provision of care

NHS Funded Nursing Care in Care homes in Wales What it means for you December 2003 WAG

Continuing NHS Health Care

A Package of health care that is arranged , provided and funded solely by the NHS.

It can be provided in hospital, people’s own home or in Care homes providing nursing care

the Local Health Boards take into account the nature, complexity, unpredictability or intensity of a persons medical, nursing or clinical needs in deciding whether or not this is appropriate to meet the persons needs

Continuing Health Care Assessment

All Patients have the right to have their ongoing needs assessed against the criteria for fully funded NHS Continuing Health Care (CHC)

Documentary evidence of this assessment is essential

Failure to do so could result in the Trust being held financially responsible

Resources available to help you with discharge planning

Discharge policy Single Point of Access Discharge liaison Team Community Services i.e. District Nurses Intermediate care teams Voluntary Services

Discharge liaison Nurse referral guidance

Patients with complex discharge requirements i.e.

P.E.G./ NG feed/tracheotomy Grade 3-4 pressure ulcers learning Disabilities Patients requiring ‘Health’ funding for

specialist/ rehab/ nursing home placement complex family dynamics Reassessments of patients admitted from

care home settings