Our service is established to reduce delays and optimally manage all three pathways of discharge to assess.
It is now mandatory to have a model of discharge to assess in place: the principle being once a patient is medically optimised, they should not remain in hospital because they are waiting for an assessment. The individual should move to a setting best suited to their needs; assessments are planned and undertaken there.
There are three established discharge to assess (D2A) pathways:
- Home based D2A: individual returns to their own home with care and support, as needed and usually reablement
- Bed based D2A: patient transfers to a bed in community hospital/care home/nurse led step down ward where assessments are planned. In some models, there is reablement
- Continuing healthcare pathway: spot purchase of nursing home bed, checklist and Decision Support Tool
Person-centred care co-ordination
Person-centred care co-ordination is essential in discharge to assess. An individual will move across different care settings and home and many different services and professionals will be involved in their pathway. Our database, CHSTrack was created specifically for discharge to assess, giving visibility of all patients and every activity which needs to take place in order for the patient to move along the pathway.
This is critical, together with the focused management we provide, otherwise patients can easily become ‘stuck’ in D2A. We manage all processes to ensure there are no lengthy delays in assessments taking place, or in other required activities such as enablement being undertaken.