Hospital Discharge Pathways€¦ · CHC B&H tracey.collier1@nhs.net– contact the discharge...

Hospital Discharge Pathways

Philip Rankin – BSUH Doctor and Clinical Lead BSUH Discharge Hub Veena Lalsing – BSUH Matron for Integrated Discharge

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. 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,

communication support tools with 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 • 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

Supporting Flow, Better Experience

Click here (12 sec video) Joyful reunion as dog welcomes owner, 96, back from hospital

Discharge to Assess – Purpose and Principles

• Home as default • Home is more than own home • Assessment in place best for

person • Community bed if home not safe • Trust, continuity of coordination and clear,

simple onward processes • 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

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

Report link here

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 and are medically ready for discharge. 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 and supporting MRFD and discharge decision-making

Discharge Planning from the Front Door • PRH – SCFT HRDT providing ongoing support to ED and CDU

• RSCH – IDT Front Door L5 in development building on existing HRDT

• Involve early where required

• Early identification and documentation of pathway and plan

Screening started from the front door, cutting down duplication, standardising information, in future for onward referral

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

3. Useful checklists in both

Ward led

Print a copy for your clinical area here Majority of discharges should be simple (0 and 1)

All suspected pathway 3 patients require discussion and confirmation with Matron/DLN/Clinical Site Team/IDT to enable: • Sense check / review of pathway • Early awareness by senior team of complex patients who are likely to have a

longer length of stay

Is your patient really pathway 3? Role of senior nursing

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 - vital

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

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 sc-tr.rsreferralhub@nhs.net

Coastal and Central West Sussex SCFT Responsive Services using West Sussex joint health and ASC referral form

AdultsandHealthPlacementTeam@westsussex.gov.uk And ASPRHN1HospitalDuty@westsussex.gov.uk

East Sussex JCR using HSCC form Esh-tr.hscc@nhs.net

Pathway 2 - Beds

B&H beds, SCFT HWLH (East) - complete the SCFT IPR beds referral form sc-tr.patientflowcentre@nhs.net

SCFT Coastal West Sussex Health Beds and and SCFT Central Health Beds (primary rehab need) Complete the West Sussex joint health and ASC referral form

sc-tr.patientflowcentre@nhs.net

West Sussex D2A and Interim Placement WSCC Beds (primary reablement / short term placement need – rather than rehab) – Complete the West Sussex joint health and ASC referral form

AdultsandHealthPlacementTeam@westsussex.gov.uk

East Sussex (Eastbourne Hastings, Rother) Health Beds. Complete the HSCC form Esh-tr.hscc@nhs.net

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

B&H HospitalRSDuty@brighton-hove.gov.uk

East Sussex – complete the SCFT IPR beds referral form (as East Sussex ASC have agreed it has the information they need)

ESx as-duty-sdw@eastsussex.gov.uk

West Sussex – complete the joint West Sussex joint health and ASC referral form

AdultsandHealthPlacementTeam@westsussex.gov.uk and ASPRHN1HospitalDuty@westsussex.gov.uk

CHC B&H – contact the discharge hub for details of CHC staff available

Email details about your patient / query to: cheri.gillam@nhs.net

tracey.collier1@nhs.net and bhccg.nhsfundedcareteam@nhs.net;

East Sussex – collate patient details and history and send email Email patient details to ASC.CHCDutyTeam@eastsussex.gov.uk

West Sussex – complete the West Sussex joint health and ASC referral form Email Wsxccg.chcduty@nhs.net

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 gregg.lock@nhs.net, or Katie Carter katie.carter1@nhs.net

Ward staff / flow coordinators as well as IDT can complete referral forms Crucial role of seniors supporting quality of referrals

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

- All pathway 0 and 1 should go via discharge lounge

- 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 bsuh.dischargegovernancecontrolcentre@nhs.net

Extensions: 63496 / 65071 / 65226 / 67907

RSCH IDT: bsuh.dischargegovernancecontrolcentre@nhs.net

Extensions: 67885, 63221, 63635

Barry building wards DISCO: 65228

Other wards DISCO: 65227

PRH IDT: Bsuh.prhdischargehub@nhs.net

Extensions: 68275, 68276 Bleeps 6106 / 6107

Copy relevant site email for P0, P1, P2 referrals you send

Download a copy for your staff room here

Key Messages

• Once MRFD – discharge home same day is default option (guidance within 3 hours)

• Discharge planning starts from day one (or before! – advance care planning) • Give patients discharge handbook, and government discharge letters within 24h of admission • Discharge to assess is the common model and language across Sussex • Know the pathways 0,1,2,3 and referral processes – championing and role modelling

• Please share the graphic widely and add pathway patient is on to handovers / narrative • Pathways 0,1,2 = ward led – IDT can always be contacted to advise and support • Maximise use of our discharge lounges – discharge from lounge as default for all pathway 0 and

1 patients when open. • Pathway 3 = IDT led (don’t wait until these patients are MRFD to inform IDT) • Rapidly escalate any discharge delays of your pathway 0,1 and 2 patients to the IDT / Discharge

Hub for support • Document all key progress notes relating to discharge in the discharge planner • Copy bsuh.dischargegovernancecontrolcentre@nhs.net in all referrals for discharge services for

RSCH patients and bsuh.prhdischargehub@nhs.net for all PRH patients • Update Medway in real time, EDD, pathway number, and what they are waiting for • Inform B&H patients they will be followed up by Healthwatch Wellbeing Check and provide all

patients with means to contact ward if any issues with discharge • Contact hub / IDT with queries early – phone, email, in person

• Facebook Workplace (if not patient specific)

Additional resources to complete

• Complete 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

• Ask any questions (not patient specific) on Workplace here

• Speak to us at the Hub / IDT staff bsuh.dischargegovernancecontrolcentre@nhs.net

Thank you!