hospital discharge pathways · • build awareness of acute and community re each others’ roles...
TRANSCRIPT
Hospital Discharge Pathways
Philip Rankin – BSUH Doctor and Clinical Lead BSUH Discharge Hub
Learning Objectives 1. National best practice 2. National hospital discharge requirements during the Covid19 pandemic 3. Challenges to effective discharge planning and common concerns of staff 4. Which pathway is your patient on? Hospital discharge pathways 0, 1, 2 and 3 5. Roles and responsibilities enabling discharge 6. Using the new referral forms and processes, screening tools, discharge planner
and ward documentation
7. Discharge hubs and integrated discharge teams 8. Continuous improvement relating to discharge and championing best practice 9. Voluntary and community sector discharge support 10. Common concerns patients and carers have relating to discharge and the tools
available to support communication of discharge to patients and ongoing care providers
11. Education 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, 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.
• 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 #Last1000Days
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:
• 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. 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) 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!
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, 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)
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 [email protected]
Coastal and Central West Sussex SCFT Responsive Services using West Sussex joint health and ASC referral form
[email protected] And [email protected]
East Sussex JCR using HSCC form [email protected]
Pathway 2 - Beds
B&H beds, SCFT HWLH (East) - complete the SCFT IPR beds referral form [email protected]
SCFT Coastal West Sussex Health Beds and and SCFT Central Health Beds Complete the West Sussex joint health and ASC referral form
[email protected] and [email protected]
East Sussex (Eastbourne Hastings, Rother) Health Beds. Complete the HSCC form [email protected]
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
East Sussex – complete the SCFT IPR beds referral form (as East Sussex ASC have
agreed it has the information they need)
West Sussex – complete the joint West Sussex joint health and ASC referral form
[email protected] and [email protected]
CHC
B&H – contact the discharge hub for details of CHC staff available
Email details about your patient / query to: [email protected]
[email protected] and [email protected];
East Sussex – collate patient details and history and send email Email patient details to [email protected]
West Sussex – complete the West Sussex joint health and ASC referral form Email all of [email protected] and [email protected] and [email protected]
Homeless – focus on B&H residents but can support with links to all areas. Involve early
in all admissions – before MRFD.
Phone 07884195417 and / or email [email protected], or Katie Carter [email protected]
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 e.g. 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. Twice daily review.
Complete pre-morbid functional screen within 24 hours of admission and determine likely pathway
number – 0,1,2 or 3
Ward informs Integrated Discharge Team (IDT)
IDT liaise with ongoing provider. Ward gets TTO, discharge letter,
transport ready
Medically Ready For Discharge (MRFD) (Medical decision made)
Ward decide by time of MRFD if safe for discharge home, or needs discharge to another place of care
Ward liaise with ongoing provider. Ward gets TTO,
discharge letter, transport ready
Follow up after discharge
Best practice for wards to also give their contact details and include in discharge letter. Discharge hub can also support with queries over first 48 hours after discharge
Hub provides oversight & co-ordination of all BSUH
pathway 1,2 & 3 discharges
- Unblocks escalated issues
IDT directly supports discharge out of hospital
- Provides education and guidance
- Specialises in complex discharge (pathway 3)
What is it?
Discharge Co-Ordinators and Flow Coordinators
Community Trust Managers and Nurses
Doctors and Adult Social Care
Continuing Health Care and CCG
Therapists – Community & Acute
Voluntary and Community Sector
Administration, Quality Improvement and Safety
BSUH Discharge Hub & Integrated Discharge Teams (IDT)
- Tell us about MRFD patients early
- Organise TTOs and transport needs
- Check if patient has keys or needs them
- Involve NOK throughout recording their details
- Escalate any unresolved issues promptly to us
- Continuously feedback improvements
- - Promote independence from arrival
- Become a champion for:
Who are we?
How to get in touch? How can wards help with discharge?
BSUH Discharge Hub:
RSCH Trust Headquarters, Level 7 Office [email protected]
Extensions: 63496 / 65071 / 65226 / 67907
RSCH IDT: [email protected]
Extensions: 67885, 63221, 63635
Barry building wards DISCO: 65228
Other wards DISCO: 65227
PRH IDT: [email protected]
Extensions: 68275, 68276 Bleeps 6106 / 6107
Download a copy for your staff room here
Discharge Planning from the Front Door
• Screening and collateral at point of first contact: • This is the best time to get accurate history from the
paramedic, carer or relative accompanying the patient about the baseline condition of the patient and the home circumstances.
• PRH – SCFT HRDT providing ongoing support to ED and CDU • RSCH – IDT Front Door L5 in development building on
existing HRDT • Early identification and documentation of pathway and
plan
Screening document and vision
Started from the front door, cutting down duplication, standardising information, in future for onward referral
Community Cards can be used by all members of the multidisciplinary team
They summarise key resources to best link up acute and
community care for patients, support high quality discharges, system flow, and offer alternatives to admission or emergency
attendance.
Printed copies coming to wards and download from Microguide
Additional resources to complete
• Video 2 – Case Studies with Veena Lalsing
• Review rest of Iris education page: https://iris.bsuh.nhs.uk/course/view.php?id=654
• Updated Medway training (coming soon)
• Explore Microguide: click here
• Submit your ideas on Padlet about what each staff member can do to best support discharge: https://padlet.com/melanie_armstrong4/o4ge8zg2dre7
• Speak to us at the Hub / IDT staff [email protected]
Thank you!