MARY BREENADPHN SEPT 2015

Community Discharge Co-ordinator

Background

A collaborative initiative within PCCC and UHL group.

A response to acute hospital demandsTo enhance communication between the

acute hospital and primary careTo place patients and their families at the

centre of discharge planning.A recommendation in Code of Practice for

integrated Discharge Planning (HSE 2008 revised 2014)

Objective

Early identification of patients who will require co-ordination of services to facilitate discharge

to home.Includes assessment of need, liaison with community services and MDT, the patient always being at the centre of the process.

What is effective Discharge Planning

Strong partnership between primary care and acute hospital network.

Knowledge of available healthcare servicesClear understanding of respective rolesRequires a whole systems approachHolistic common assessment Two way communicationCommitment from management at all levels

of the organisation.

How it works in practice

Referrals from the hub each morningReferrals from medical teamsMDT referralsSelf/family referralLiaison with Primary care team members to

ascertain home supports prior to admissionDiscussion with MDT at ward levelMeet with patient, family, carerConvene pre discharge meeting and plan

directed date of discharge

Initiate home care supports based on assessed needs of patient.

Patient discharged safely for follow up with appropriate service

ChallengesA process not an eventDischarge plan should start ideally on pre

admission or as soon as possible after admission.Well defined discharge policies and guidelines

available to all staff.Managing impediments to good discharge

practice (IFPC, Family dynamics, poor communication)

Integrated Discharge Planning is everyone’s responsibility/change in mindset

Dependent on availability of a range of community services to meet ongoing care needs.

Challenges

Education and training/ joint approachICTMultiplicity of referral documents per clientSAT role out

Benefits

Reassured/Well informed patient and familyValuable resources used to maximum effectThe right plan for the right patientReduced likelihood of re-admissionLess stress for staff and better working

environment .Positive feedback from families.Positive feedback from acute and primary

care staff

Conclusion

Old Irish Proverb

“Ní neart gur cur le chéile”(There is strength in unity)