By C N S Christina Gaisey

1. By C N S Christina Gaisey Discharge planning

2. Admission to hospital Review pt at the acute trust where possible. Discharge planning should commence on admission

3. Standard for discharge • The trust is committed as an organisation to ensuring that every patient depending on their individual needs, will have a safe ,effective and timely discharge. • There is a joint discharge policy between the London boroughs of Barking and Dagenham and Havering Hospital NHS trust which states :

4. Expected standard • “After discharge from hospital some people need additional care from community health services, social services General Practice or the Voluntary Sector. • Their needs and the needs of their carers must be considered before discharge. • It is recognised that there are 3 mainstream of discharge. • Straightforward , Intermediate, and Complex

5. Planning • Discharge planning should commence on admission. • Project discharge dates should be set. • Discharge should be avoided on a Friday for those patients dependent on packages of care. • At least 48hrs notice should be given for commencement of packages of care. • TTAs should be written at least 24hrs in advance / one month supply. • If ambulance transport is required, this should be requested 24hrs prior to discharge • A discharge checklist should be completed to ensure all appropriate areas for an individual patient have been considered relating to discharge issues.

6. Referral to community • Patient identified by multi-disciplinary team for referral • Projected discharge dates should be set. • Option for early discharge discussed with patients and family by key worker.

7. Identified pt for referral • Medically stable as determined by the stroke team. • Able to transfer with assistance • Home environment assessed by referring service and is appropriate for discharge. • Section 2&5 has been completed and sent to social services as per hospital discharge process. • Patient is registered with NHS Barking Havering or Redbridge GP • Rehab and care needs can be met at home by clinicenta /social services care packages/ community hospitals.

8. Referral forms • Facilitator completes referral form and passes to appropriate borough/Trust/GP address • Information given to patient /cares on discharge. • Ensure discharge planning is not too late • There must be documentation evidence of discharge planning and discharge check list should be completed

9. Risk assessment • A home assessment will be undertaken by ASU/MDT of the home • The ASU/MDT regarding whether the patient requires a home visit or not. • ASU OT are responsible for arranging the practicalities of the home visit . • If a pre-discharge home visit is not appropriate the ASU OT will discuss with the patient the suitability of their home environment. • Where these issues relate to the home environment • If the patients home is safe for early discharge that rehab and care needs can be met at home by the social worker care package. • Decision agreed jointly between ASU team and the clinicenta

10. Home visit / pt assessment • When there are issues relating home enviroment (eg rails or equipment essential for discharge.

11. Pre discharge from secondary care • Referrer and community agree early discharge time and date with pt/ family /carer • Key worker co-ordinates necessary home alterations & order ADL/mobility equipment • ASU& community confirms date of discharge and with patient /carer. • All discharge arrangement completed by staff (TTO mobility equipment ,transport) • Staff notify GP of pt on going care discharge pt then discharged. • Therapy ONEL updates detailed centered goals achievement during inpatient stay

12. Discharge from secondary care • Full assessment needs within 24 hrs of discharge and assess to admit. • Rehab plan with collaborative goals agreed. • Assessment done by the rehab team ONEL form reviewed and is accepted transferred to the community. • Assessment and plan recorded notes CT ambulance ready. • Family informed of transferred

13. Daily update • To review and update pts discharge plan . • PDD is set for all appropriate pt • Tasks are set for all patients action today and identify specific person responsible for action. • Remaining duration of each task is identified. • Delay reasons are recorded in the delay history is documented every 2 days. • More than 75% nursing and therapy staff up-dating jonah every shift. • Jonah is used as part of the weekly /regular multi disciplinary meeting. • Ward manager produces weekly QFI discharge jonah reports for discussion with matron and staff. • To escalate issues for reslution.

14. Escalation Jonah process • Level 1 daily discharge meeting ward level. • Level 2 Matrons. • Level 3 Daily bed meetings • Level 4 2x weekly top delays meetings. • Level5 Monthly cross buffer meeting

15. Flow chart for discharge planning /24 hrs prior ADMISSION Change of needs actual or potential Ref OT/PT/SS/Dis nurse Document ref to members mdap Complex needs identified Ref to discharge co-ordinator Deemed safe for discharge Restart care package inform s/s/ sw/ relatives document whom spoken to and when Complex discharge path Dr complete TTA ,complete dis checklist/plan date/sign Arrange transport check key

16. Flow chart for complex discharge Assessment Complex change of needs Identified/relatives concerned Social work allocation MDAP report if required Ward ref to OT/PT/SS/and discharge co -ordinator RH/NH Hm as per mdap Facilitator D/C to assess Adv & ref in conjunc therapist Agreed d/c date discharge Relatives informed Health case management, Nursing hm/RHStroke rehab Arrange transport Discharge

17. Check list for day of discharge Patient aware Relatives aware S/S aware TTA written Medi given to pt/relative Care pack restarted TTA avaliable Any aids required Inf where to get rep pres TTA checked Against drug chart Referral to D/N if needed OPD app explained D/N letter given to pt Is trans needed D/N ref faxed over Trans req for OPD app Ambulance booked If necessary Dressing given for 3 days

18. Flow chart for self discharge Patients self discharging before deemed medicaly fit Patient informs nursing staff they wish to leave hospital Staff discuss reasons for self discharge Try to resolve issues Involve family/ carers ,other members multidisciplinary team Situation not resolved Patient remain in hospital Contact medical staff Contact D/N S/W GP Dis/facilitator/cord

19. Discharged home…

20. Happy discharging • Any questions ? ? ?