Discharge planning

1. Discharge planning Discharge Liaison Nurse’s Patient Flow Team Janet Davies Christine Jones-Williams

2. Challenges • Balancing capacity with demand • Ensuring safe Effective discharge • Prevent readmissions • Avoid complaints

3. Discharge Planning - Getting It Right • Pre admission (planned admissions) • On admission • Assessment (identifying risks to discharge ) • Making appropriate referrals to MDT • Involve Patient/ Carer • Predicted discharge (based on clinical knowledge & data )

4. The patient can only be Discharged or Transferred when • A clinical decision has been made that the patient is ready for discharge / transfer • The MDT decision has been made that the patient is ready for discharge/ transfer • Patient, Family , Carers have sufficient help & support if required (arranged prior to discharge) • Nursing Home / Residential Home able to meet identified needs. • Appropriate funding for above has been arranged

5. Assessment • Is the Patient homeless? Refer immediately to Social Services • Have the Patients needs changed since admission? • What help are they likely to require on discharge ? • Will they require equipment?

6. Assessment continued • Has the patient reached their full potential ? • Will the patient benefit from further rehab/ assessment in a community hospital ? • Is the patient likely to require care home placement? If so what kind? • Who will pay?

7. How is the decision made ? • MDT/patient /family/carer decision based on the needs of the patient identified during the assessment process (Unified assessment from Sept 06) • Medical,Nursing • Specialist nursing • Speech &Language • Physiotherapy/ Occupational Therapy • Social Worker

8. Care Homes • Residential • Residential EMI • General Nursing • EMI Nursing • Specialist Nursing i.e. ABI unit, Younger adult etc

9. Types of Funding • Self funding • Local authority funded • Self Funding with NHS contribution to Nursing Care (£110 per week) • Continuing health Care (fully funded by the Local Health Board)

10. Placement • As a general rule people should not be discharged directly from an acute episode of hospital care to a permanent placement in a care home • Further rehabilitation may take place at hospital, at home or in an intermediate care setting i.e. Community Hospital

11. Definition of Nursing Care • Any services provided by a Registered Nurse and involving: • The provision of care or • The planning, supervision or delegation of the provision of care NHS Funded Nursing Care in Care homes in Wales What it means for you December 2003 WAG

12. Continuing NHS Health Care • A Package of health care that is arranged , provided and funded solely by the NHS. • It can be provided in hospital, people’s own home or in Care homes providing nursing care • the Local Health Boards take into account the nature, complexity, unpredictability or intensity of a persons medical, nursing or clinical needs in deciding whether or not this is appropriate to meet the persons needs

13. Continuing Health Care Assessment • All Patients have the right to have their ongoing needs assessed against the criteria for fully funded NHS Continuing Health Care (CHC) • Documentary evidence of this assessment is essential • Failure to do so could result in the Trust being held financially responsible

14. Resources available to help you with discharge planning • Discharge policy • Single Point of Access • Discharge liaison Team • Community Services i.e. • District Nurses • Intermediate care teams • Voluntary Services

15. Discharge liaison Nurse referral guidance • Patients with complex discharge requirements i.e. • P.E.G./ NG feed/tracheotomy • Grade 3-4 pressure ulcers • learning Disabilities • Patients requiring ‘Health’ funding for specialist/ rehab/ nursing home placement • complex family dynamics • Reassessments of patients admitted from care home settings