Effective Discharge Planning and Practice: Speaker News and Updates
On 1st December 2015 NICE released a national guideline on the Transition between inpatient hospital settings and community or care home settings for adults with social care needs. The guideline calls for continuity of care for people being transferred from hospital...Hospitals should ensure that any pressure to make beds available does not result in unplanned and uncoordinated discharges…In addition, hospital and community teams should work together to tackle factors that could prevent a safe and timely transfer of care from hospital.
This conference focused on delivering effective discharge planning and practice, and meeting the recommendations from the November 2015 NICE Guideline on Transition between inpatient hospital settings and community or care home settings for adults with social care needs.
Through national updates, extended sessions and practical case studies the conference looked out how to improve process and flow and reduce delayed transfers of care through 'discharge to assess", nurse led discharge, developing the role of the discharge coordinator, rapid discharge pathways and working in partnership across organisations.
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 & Consultant Physician in Acute Medicine, Salford Royal NHS Foundation Trust opened the day with a presentation on ‘Meeting the New NICE Guidelines on transition between inpatient hospital settings and community or care home settings for adults with social care needs’ and discussed:
- improving discharge planning and practice
- implementing the NICE recommendations
- delivering a person-centred care approach to discharge practice
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 & Consultant Physician in Acute Medicine, Salford Royal NHS Foundation Trust Full Presentation Click Here
In his presentation Olivier stated:
"Discharge problems can be resolved if family members work with nurses to make sure the patient is happy with the discharge process"
"Older people is a large area so if we can get it right for them we can help to improve other areas"
"Salford- evolutions what the service you vision? Lots of little projects that can be built into a service to help the guidelines evolve into different areas"
"Transition between inpatient hospital settings and community or care home settings for adults with social care needs (both ways) NOT JUST ....... Delayed transfers of care. But using the guideline to improve one should help the other…?"
“What’s most difficult to tackle but would make most difference? Improving understanding of person-centred care and support, Ensuring health and social care practitioners communicate effectively and Changing how community and hospital based staff work together to ensure coordinated person-centred support”
"Communication - discharge summary- opportunity missed on this document about the plan of the discharge and input of the patient"
"The future - QUESTION how can you move to the position to where you want to be?"
Dr Olivier Gaillemin Biography:
Olivier Gaillemin trained as a Geriatrician in the Northwest Deanery and was appointed as Consultant Physician in Acute Medicine at University Hospital South Manchester in 2008. Here he developed a multidisciplinary "Integrated Assessment Team" to try and meet the needs of older people accessing urgent medical care. Evaluations of this service were positive.
In 2012, he moved to Salford Royal Hospital, attracted by the possibilities created in an environment where CCG, city council and hospital had commenced vertical integration laying the foundations for horizontal integration of services on the ground.
He was an active member of the Salford Integrated Care Program for Older People, co-ordinating tests of change and service development. Alongside community and hospital based geriatricians, he has established a frailty unit embedded within the Emergency Assessment Unit, delivering early CGA and disseminating learning and good practice across the EAU. Evaluation of this work was published in Clinical Medicine February 2016.
He was a member of the guideline development group for NICE Guideline 27 (Transitions between inpatient hospital setting and home for adults with social care needs.) published December 2015 and currently sits as a specialist member of the relevant NICE Quality Standards Assurance Committee.
Sarah Mitchell Director Towards Excellence in Adult Social Care (TEASC) LGA continued the morning with an extended session on ‘Helping people home: Working together to reduced delayed transfer of care’ and discussed:
- improving joint working on discharge between primary care, hospitals, GPs, community services and adult social services
- models of care for discharge to assess, and assess to admit
- improving patient flows within the hospital, smoothing transitions between modes of care
- giving people the training and tools to remain independent after discharge
- the impact on delayed discharge
Sarah Mitchell Director Towards Excellence in Adult Social Care (TEASC) LGA Full Presentation Click Here
In her presentation Sarah stated:
“Ensuring people do not stay in hospital for longer than they need to is an important issue – maintaining patient flow, having access to responsive health and care services and supporting families are essential. We learnt valuable lessons from the Health and Care system across the Country last winter about what works well and we have built those into a High Impact Change model. This model has been endorsed in a joint meeting between local government leaders and Secretaries of State for Health and for Communities and Local Government in October. We know there is no simple solution to creating an effective system of health and social care, but local government , the NHS and Department of Health are committed to working together to identifying what can be done to improve our current ways of working.”
"Financially is very stressful and placing a huge pressures and delays on recruiting- context it is as hard as it has every been"
"Work with the ECIST who fund and the LGA assist- huge effort into this to make people to move"
"Delayed discharge meeting - NHS and local government held meetings last year and strong opinions were announced on how to improve delayed discharge"
Delays will be reduce with 8 changes - on the journey to have these in place the delays will reduce"
"The 8 changes which are outlined have been developed through last year’s Helping People Home Team’s work (a joint DH, DCLG, NHS England, ADASS and LGA programme)."
Change 1: Early Discharge Planning. In elective care, planning should begin before admission. In emergency/unscheduled care, robust systems need to be in place to develop plans for management and discharge, and to allow an expected dates of discharge to be set within 48 hours.
Change 2 : Systems to Monitor Patient Flow. Robust Patient flow models for health and social care, including electronic patient flow systems, enable teams to identify and manage problems (for example, if capacity is not available to meet demand), and to plan services around the individual.
Change 3 : Multi-Disciplinary/Multi-Agency Discharge Teams, including the voluntary and community sector. Co-ordinated discharge planning based on joint assessment processes and protocols, and on shared and agreed responsibilities, promotes effective discharge and good outcomes for patients
Change 4 : Home First/Discharge to Access. Providing short-term care and reablement in people’s homes or using ‘step-down’ beds to bridge the gap between hospital and home means that people no longer need wait unnecessarily for assessments in hospital. In turn, this reduces delayed discharges and improves patient flow.
Change 5 : Seven-Day Service. Successful, joint 24/7 working improves the flow of people through the system and across the interface between health and social care, and means that services are more responsive to people’s needs.
Change 6 : Trusted Assessors. Using trusted assessors to carry out a holistic assessment of need avoids duplication and speeds up response times so that people can be discharged in a safe and timely way.
Change 7 : Focus on Choice. Early engagement with patients, families and carers is vital. A robust protocol, underpinned by a fair and transparent escalation process, is essential so that people can consider their options, the voluntary sector can be a real help to patients in considering their choices and reaching decisions about their future care.
Change 8 : Enhancing Health in Care Homes. Offering people joined-up, co-ordinated health and care services, for example by aligning community nurse teams and GP practices with care homes, can help reduce unnecessary admissions to hospital as well as improve hospital discharge.
"Principles of working together needs to happen and make sure everyone is valued and come to the team as an equal from all areas"
"7 day service - Major cause is Friday nights and the lack of nursing cover over the weekends- more assertive for 24/7 care"
"Focus on choice - communications on information about process whether there its home cares, caring homes etc- looking at choices with patient and family"
Sarah Mitchell Biography:
Sarah Mitchell has over 30 years experience in social care and health having worked in Local Government, the NHS and the DH. A background in nursing, child protection work and adult social care, she was also an SSI Inspector working on policy and in the regions whilst at the DH.
Sarah has been a Director of Adult Social Care and She currently works for the Local Government Association leading a national sector led improvement programme - Towards Excellence in Adult Social Care (TEASC) helping to implement the recent Care Act changes and a new risk awareness tool for local systems.
The conference continued with presentation from expert speakers.
Future events of interest:
Masterclass: Nurse Led Discharge
Wednesday 21 September 2016
Hallam Conference Centre, London
4 May 2016