Effective Discharge Planning and Practice
News and updates from today's conference chaired by Liz Deutsch Consultant Nurse (Acute Medicine) Heart of England NHS Foundation Trust, Liz is currently undertaking an NIHR funded PhD Research Fellowship in Discharge Practice and Risk Assessment.
The conference opened with an update on Meeting the New NICE Guidelines on Transition between inpatient hospital settings and community or care home settings for adults with social care needs by Dr Olivier Gaillemin Member, Guideline Development Group, Transition between inpatient hospital settings and community or care home settings for adults with social care needs, NICE, and Consultant Physician in Acute Medicine, Salford Royal NHS Foundation Trust.
In his presentation Dr Gaillemin said; "services are struggling, penalties imposed and targets being missed...it's incumbent on us to change the way we manage our services to improve patient care." He said; "the NICE guideline was timely, or maybe is should have happended some time ago....it's important to remember the guideline applies to all parts of transfer...if we can get it right on the way in it surely effects what happens on the way out." Dr Gaillemin went on to say that's impossible to just replicate good discharge practice from service to service; all have different factors and needs to consider, the solution will be different everywhere. Dr Gaillemin said quality improvement methodolgy is the way forward for improving discharge planning and practice which needs to focus on a bundle of things to make a difference including person-centred care and support, communication, and how community and hospital based staff work together. This requires regular training, trying different things, constant reevaluation.
NICE Guideline available here.
Conference chair Liz Deutsch followed with an extended session on Effective Discharge Planning for unplanned admissions to hospital.
Pre-Event abstract: Risk Objective Assessment for Discharge (ROAD).
My talk today will offer an introduction and early insight into the results from a 3-year programme of research underpinning the process for discharge planning in acute care. At this stage I have completed an extensive literature review, scoping review, discharge typologies and completed the data collection for the research study. This is portfolio research, funded by a Doctoral Fellowship from the National Institute for Healthcare Research. Prior to this I have led/published two nursing books exploring (at a very honest and pragmatic level) the topic of discharge planning from acute care.
Rationale for the development of new knowledge – why risk assessment?
Having undertaken a Systematic Review of the literature; a critical comparison and evaluation of national discharge planning Policy Guidance across the UK reveals a recent convergence of ideas supporting discharge of patients from hospital, most notably a ‘stepped’ or ‘staged’ approach . The aim is to assure parity to guide practitioners and organisations alike, through core areas of ‘the planning’.
Despite this, there is a dearth of literature in the UK concerning a standardised approach to assessment of patient issues/ risks appertaining to a discharge plan – most notably upon admission, hence this area would greatly benefit from further research. We are, it would seem focussed upon triage, capacity, time and speedy transfers, sometimes to the detriment of relevant risk assessment.
What does the literature say?
Assessment of problems/risks is well explored in the literature from USA, Australia (Victoria), Canada and more recently, Hong Kong. This has been promulgated by Medicare penalties for readmissions at 30 days and the need to provide evidence of risks in a plan, at the point of admission to Hospital. Paradoxically, although risk assessments are developed which could aid discharge planning their implementation in practice, remains very poor. It is crucial that lessons learnt from the USA and Hong Kong are understood in order not to replicate the issues they have encountered, pre-dominantly, the non-conformity of staff to complete simple risk questions on the patients admission to hospital and the lack of robust evaluation of the research, over time.
A word of caution!
Once developed, risk assessments must not be regarded as the panacea for all bed reduce the time lags between referrals, provide transparency of assessment for assessors and improve the quality of the discharge experience for patients.
Ready to Go? (2010) Planning the discharge and transfer of patients from hospital and intermediate care. Department of Health, London.
Scottish Intercollegiate Guidelines Network (SIGN) 2012, SIGN 128, The SIGN Discharge document. www.sign.ac.uk
Integrated Care Guidance (2014): A practical guide to discharge and transfer from hospital, Health Service executive, National Integrated Advisory Group, www.hse.ie
Passing the Baton (2009) A practical guide to effective discharge planning, National Leadership & Innovation Agency for Healthcare, www.nhs.wales.uk
Liz Deutsch full presentation.
Changing the way discharge planning works: Operational Planning to achieve NICE 27 by Suzanne Nicholls Clinical Director Therapies and Ann Edgar – Head Nurse, Medicine, and Karen Lewis Physiotherapist, Heart of England NHS Foundation Trust.
In 2014 the Heart of England NHS Foundation Trust, in partnership with Birmingham and Solihull Local Authorities, were awarded the Health Service Journal award for secondary care redesign, in recognition of their development of the Supported Integrated Discharge service.
The SID model aims to reduce the acute hospital stay for patients aged 65 and over, by reducing some of the causes of delay, such as social care assessment and proactively ‘pulling’ medically stable patients out of the hospital environment. Through multi agency partnership SID therapists and nurses became ‘trusted assessors’ for patients with complex discharge needs and following identification by the ward team patients receive prompt health and social care assessment from the SID team. Working with the council’s re-ablement service whenever possible patients are discharged home to receive personal care, therapy and nursing care via a multi-skilled team. If patients are more dependent, SID will access care home beds and deliver care and rehab there until the patient can return home, with suitable support.
The SID acute therapy team provides up to two weeks of rehabilitation to patients, handing over to community teams if ongoing therapy is needed. Simultaneously the local authorities provide a six-week reablement programme to meet personal care needs and further support return to independent living.
Patients now go home earlier – on average at 10 to 14 days – and stays over this period have reduced by 13 per cent. The local authorities benefit from reduced demand for re-ablement packages and more efficient use of social worker time.
Supported Integrated Discharge is all about improving the quality of people’s lives and getting them home from hospital quicker. SID facilitates hospital flow and bridges the gap between primary care and community services through partnership working and role development.
This service is a successful example of how staff in different organisations can work together for the benefit of patients. By challenging existing processes and systems, it has enabled us to provide continuity of care, which is centred on the individual patient’s needs.
Suzanne Nicholls and Karen Lewis full presentation.
Future events of interest:
Masterclass: Nurse Led Discharge
Friday 10 February 2017
De Vere, West One, London
19 October 2016