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NHS Lanarkshire Introduction of Discharge Hubs

NHS Lanarkshire Introduction of Discharge Hubs. Why Change?. Desire to improve discharge planning from admission, proactive approach to support complex cases 17 different discharge routes from hospital Scattergun approach to service referrals Improve quality of referrals and assessments

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NHS Lanarkshire Introduction of Discharge Hubs

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  1. NHS LanarkshireIntroduction of Discharge Hubs

  2. Why Change? • Desire to improve discharge planning from admission, proactive approach to support complex cases • 17 different discharge routes from hospital • Scattergun approach to service referrals • Improve quality of referrals and assessments • Delays to discharges • Inaccurate reporting of bed days delays • New delayed discharge targets

  3. Planning the Change • Reviewed Discharge Co-ordinators role • Lanarkshire has 3 DGH, two local authorities, phased approach to implementation • Initially worked closely with South Lanarkshire Council to develop pathway underpinned by clear roles and responsibilities

  4. Introduced the Integrated Discharge Facilitator Role • Dedicated to Discharge Planning • Developed an Induction programme ( 4 weeks) • Homecare Office • District Nursing Teams • Community rehabilitation service • Training on SWISS/ EDISON

  5. Ward Communication sessions • Only refer people who are clinically ready for discharge • Email to discharge hub, electronic referral form (desktop) • Hub Staff will attend ward and complete assessment paperwork • Discharge Hub Team will inform ward of outcome and confirm discharge date • Ward retains responsibility for prescription, transport and communication with family

  6. Ward Communication sessions -Do Not's • Do not contact and liaise with community SW direct • Do not send separate referrals to CARS and or SW • Do not refer people who are not Clinically Ready • Do not prescribe services • Do not inform patients and families of level of services that will be provided • Do not inform patients and families that assessment is for nursing home

  7. Script for Patients and Families “When you are clinically ready for discharge we recognise that you may need some support on discharge and we are referring you to the discharge hub who will undertake an assessment and discuss this with you”

  8. Families requesting transfer to Nursing Home “We recognise that you are concerned about the prospect of your mother/ father returning home. We will refer you to the discharge hub who will undertake an assessment and discuss with you how your mother/ father can best be supported”

  9. Yes Person is medically fit for discharge No Generic Referral form completed and emailed to Hub Ward staff identify ongoing support required for discharge (CARS, Re-ablement and/ or social work) Triage referral and allocate to services based on anticipated needs Supported Discharge Pathway Discharge to place of residence. Provide advice leaflet on how to contact community services Homecare manager CARS Social work Complex CCA Discharge Facilitators Assessment of support required to facilitate discharge Arrange services to support discharge base on person needs and underpinned by prioritisation framework

  10. Who is Involved in the Hub ? • 2 Integrated Discharge Facilitators (IDF) • Homecare Team Leader (NLC/ SLC) • SW Senior or SW (NLC/SLC) • Carers Liaison • Admin • Acute Care of Elderly Nurse • CARS Screener community rehab • Community Nursing, Care managers • Psychiatric Liaison

  11. Proactive Discharge Planning Activities • Supporting complex cases from point of admission • Education • Case conferences • Pre assessment – Planned Surgical • Linkage with Community Care Manager

  12. Challenges • Co location of Health and Social Work staff • Single Manager • Threat to specialist roles • IT Access – Data sharing • Database Development - stats

  13. Hairmyres Hub referral activity

  14. Benefits – 12 months on • Improved patient outcomes, Single point of contact holistic approach to discharge planning. • Improved communication – Acute / Community services. AHP Goal sharing. • Reduction in bed days lost to Delayed Discharge • Correct delayed discharge information • Hub valued by wards and departments • Job satisfaction levels increased for Discharge Co-ordinators

  15. Future plans • Seven Day working • Single Management Structure • Enhancement of database reports • Learning and sharing

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