Assessment - Hospital discharge

What are the outcomes we want to achieve?

In Hospital

• No long-term decisions are made immediately following hospital admissions
• The person along with their family and/ or carer are involved in all discussions and decisions about their hospital discharge arrangements and ongoing care and support
• They know who is the lead professional is coordinating the hospital discharge and how to contact them while in hospital
• All professionals involved are working in partnership and have spoken together with the person to plan how to best meet their needs

Options

• The person, their family and/ or carer understand the options available and have been given time to consider these
• Where appropriate the person has the option of being discharged to a more supportive environment such as an NHS funded or LA funded interim bed to give them a little more time to make a decision about long-term care and support
• The person understands the local offer of services available to help them regain their independence

Discharge

• All parties have agreed the discharge plan and developed a short-term support plan
• The agreed care and supports are in place when the person returns home
• The person is able to be discharged from hospital when it is safe to do so

What tools and resources do we need to do a good job? What are the steps we have to go through?

Information

• The person's medical records, clinical management plan and previous assessments if relevant
• A range of information and advice about the range of care and support options available locally, how the system works, how to access them and how to raise concerns
• Specific information and advice on the reablement offer available and the benefits of this approach
• A range of information to enable people to self-manage their own conditions

Assessment

• Copies of assessment, support planning and financial assessment forms and continuing healthcare checklist
• Modular short-term assessment and support plan, that:
  • Clearly identifies short-term care and support needs
  • Clearly identified potential for reablement
  • Identifies the person's circle of support and how it can be utilised and strengthened
  • Enables agreement on:
    • Short term targets and outcomes
    • Risks
    • Risk enablement plans
• If likely to need ongoing support following reablement
  • Eligible needs
  • Eligible unmet needs
  • Risk assessment
  • Proper application of the Mental Capacity Act at each step if the person may lack capacity to make decisions about their own care and support

Resources

• All resources and information in preferred format
• Lead contact for the individual
• Independent advocacy and interpreter where relevant
• Mobile equipment/ technology
• Integrated care record/ system
• Information sharing protocol
• Clear roles and responsibilities
• Appropriately funded interim beds including step-down and discharge to assess

What are the products we will have at the end of this process?

• A smooth, timely and safe transition from hospital to home
• Level of discharge and transfer planning needs identified
• Agreed discharge date and post discharge initial review date shared with person and family/ carer
• Completed integrated assessment of care and support needs in hospital
• Short-term plan, goals and timescales agreed by all parties
• Record of interaction and decision making

When does this process start and end and within what timescales should this process be completed?

• Start planning for discharge or transfer before or on day of admission
• Expected date of discharge appropriate to anticipated clinical pathway

Who needs to be involved and what is their role? Who is taking the lead?

• Person
• Family, carer or other who the person chooses to be involved
• Independent advocate or chosen representative
• Interpreter
• Care coordinator/ Social worker
• Discharge coordinators
• Relevant professionals in hospital, e.g. OT, nurse, consultant
• GP
• Voluntary sector e.g. discharge home support