Hospital discharge:

Supporting families making care choices

Supporting families making care choices

Our service is proven to reduce delays to hospital discharge by providing high-quality support for families who need to make care choices.

Many of the patients who remain in hospital for a long time after being medically optimised for discharge do so because a care choice must take place. Often, discharge is delayed because the patient’s family struggles to find and choose a care home. There are multiple barriers: there may be difficulty finding a care home that has capacity, or one that can meet complex needs; family members can feel overwhelmed or disagree. All affect the process of decision-making and thereby delay hospital discharge.

Our service addresses the multiple causes of choice delays to hospital discharge.

This is how it works:

  • Our team receives referrals for patients medically optimised for discharge who need to move from hospital to 24-hour care
  • Our team contacts patient’s next of kin on the same day as the referral
  • Our team provides an evening and weekend working service which means no time is lost
  • By providing families with a shortlist of suitable care homes with capacity who meet their needs, we support them to focus on relevant providers
  • Care home is chosen within two days of referral
  • We work closely with care home providers to ensure they carry out their own hospital-based assessment as promptly as possible
  • Transfer from hospital to care home takes place within a total of five days of referral

Quality of reporting

By focusing on every aspect of the process, quickly addressing any delays and constantly seeking improvements, we achieve huge improvements in speed of discharge. The quality of our reporting is widely valued; enabling us to achieve optimal process management and providing key business intelligence to commissioners.Evaluation of our service is overwhelmingly positive: families value the tailored support provided at a very difficult time. Consistently, more than 95 per cent of service users say our support was ‘excellent’ or ‘good’.

We often work with people funding their own care; recognised as a group in need of support at greater risk of choice delays. We often work with families of individuals with Fast Track end-of-life funding, where sensitivity and speed of process are both essential. Our hospital discharge family support service can be commissioned for all patients, or for specific funder types.

Care co-ordination for discharge home

Our service is proven to reduce delays to hospital discharge by co-ordinating care and support required for a patient to return to their own home.

The principle is widely established that following hospital treatment, people should be supported to go home, if this is safe and in their best interests. However, the critical shortage in capacity can cause significant hospital discharge delays; patients remain in acute care awaiting the organisation of care and support in their own home.

Our service focuses on arranging packages of care and support as quickly as possible by reducing all potential causes of delay and through close relationships with local care providers. We are in contact with local providers every week, building positive links which enable our teams to find capacity where resources are under pressure and to organise care for individuals with high, complex needs.

This is how it works:

  • Once a referral is made, we contact patient and/or next of kin on the same day
  • Our service model includes evening and weekend working, so no time is lost
  • Package of care and support is arranged within 48 hours of referral (often less) and discharge from hospital within five days of initial referral (often less)

Our service is proven to reduce delays to hospital discharge and in doing so, improve patient flow and experience. The quality of our reporting is highly valued: we have visibility of every patient, optimal process management and our commissioners recognise the business intelligence our reporting provides.

All models of discharge to assess

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.

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