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By Rachael Hardbattle, CHS Healthcare Manager Midlands and North, responsible for 10 different hospital discharge schemes

“Discharge planning is a key part of the operational management of beds,” the NHS Institute for Innovation and Improvement has stated. It is a process common to all NHS hospitals, yet is subject to enormous variation. Many would argue this variation reflects the fact that much of the process is out of control of the hospital and commissioning groups; that delays are due to the myriad of community care services and the challenges of working with older people who have complex needs. Can anything be done to better plan thus gain greater control over the discharge process? What would a perfect hospital discharge look like?

1. Start discharge planning as early as possible (on or before admission)

• Discharge planning usually works well if the patient is a planned admission with simple discharge needs e.g. admitted for a planned orthopaedic procedure. Patient and surgeon are highly motivated to minimise time spent in hospital and needs are straightforward
• There are inevitably greater challenges when patients have complex discharge needs. This means it is essential that discharge planning begins as early as possible
• A ‘red flag’ system can be used for any patient admitted to hospital likely to have complex discharge needs. The red flag triggers additional focus on the discharge process. For example, in one CHS Healthcare scheme, we receive a referral for every patient admitted to hospital from a care home. Care home patients are at high risk of a delayed discharge, not only because of their complex needs, but also due to poor co-ordination with their care home resulting in delays. Our staff liaise with the care home from the point of admission to quickly establish whether the home will be able to care for the patient after discharge. If return is not feasible, we establish this from the onset and work with the family to start the process of finding another home. If return is feasible, we ensure the necessary assessments are carried out by the care home staff in a timely way
• The red flag principle could be applied more broadly than patients admitted from care homes – for example, patients with multiple emergency readmissions and patients with dementia.
• The principle is that discharge planning must take place from the moment of admission and in conjunction with medical treatment. If discharge planning only begins after the patient is judged to be fit for discharge, because of the complexity of the process, a delay in transfer of care (DTOC) will be inevitable.

Key message: putting additional resource into early discharge planning is a valuable investment as it will yield substantial reductions in the costs of DTOC.

2. Identify and focus on the bottlenecks

The top two reasons for delayed transfers of care (DTOC) are: waiting for an assessment to take place or waiting for other non-acute NHS care (data from NHS England statistics for 2012/3). How can these be addressed?

• We now directly employ nurses to carry out continuing healthcare checklist assessments. Our key performance indicator for this service is assessment undertaken within 48 hours of the referral being made. Our nurses work during evenings and weekends, which is critical to meeting KPI.
• We also provide a focus on other necessary arrangements for discharge, such as medication (TTOs), transport home and equipment in the home to allow for return to independent living. These practical arrangements can cause delays if not well managed
• Step-down/discharge to assess care and reablement is well established and widely used as a strategy to address DTOC from acute beds. However, focus and resource is required to ensure this strategy works well. Without this, patients end up spending far longer in step-down than planned, lacking the additional services they need, at a cost to the NHS. In effect, the delays are not addressed; they are displaced from acute to community care.
• We can help home of choice patients; patients who are in hospital but need long term care and therefore must choose a care home. This cohort are at the greatest risk of long length of stay – choosing a care home can be an overwhelming and difficult process. Our service to support patients and families choosing a care home typically reduces DTOC among this cohort from 16 days to 5-6 days.

Key message: waiting for assessments and waiting for additional services causes delays in both acute discharge and the ‘next step’ discharge to assess beds. Home of choice patients are particularly susceptible to delays

3. The perfect discharge to assess and reablement

A recently commissioned CHS Healthcare scheme provides a good model of step-down and reablement for best outcomes.

• Once the hospital patient is referred for a CHC checklist, this is undertaken within 48 hours
• If the patient is checklist positive, they are transferred to a discharge to assess bed with intensive rehabilitation therapies. This will vary according to their needs, but can include physiotherapy and occupational therapy
• As soon as the agreed period of rehabilitation has been completed, a second CHC checklist is undertaken and if needed, a Diagnostic Decision Support Tool (DDST)
• Crucially, there are no delays in any of the steps required in this process because we take ownership of ensuring the patient has the services they need and assessments take place when required
• Thus patients predicted to go into long term care have been able to benefit from the intensive therapy and return to their homes with a package of support.
• Assessments are carried out within agreed timescales, intensive therapies are provided and discharge to assess beds are only occupied for a time-limited period

Focus is key – although we cannot control the resources of, for example, the community physiotherapy service or mental health team, by ensuring referrals are made and processed at the earliest possible stage and communication is always timely, we can positively impact upon the process.

Key message: with discharge planning (whether from an acute or discharge to assess bed), ownership is vital – we take responsibility for meeting key performance indicators and working with community services so they “buy into” the same aims and objectives.