Background to learning:
The pandemic has led to the NHS making changes to the way it delivers a number of services to patients. This has been to enable people to receive the care they need in an environment that meets their requirements, while reducing the risk of spreading of COVID-19.
At STSFT it was recognised there was a need to adapt discharge planning processes to help avoid delays for patients leaving hospital. A new model was created, establishing a new Integrated Discharge Team (IDT) and the development of a new discharge process to support safe and timely discharge of people medically fit.
Learning and advice to be shared
The IDT includes senior nurses specialised in discharge assessment, trusted assessors, social workers and discharge liaison officers to ensure a comprehensive offer to patients and ward staff. The IDT operates every day from 8:00am to 8:00pm with a named nurse coordinator supporting the discharge of patients by liaising with the relevant services, such as rehabilitation services, homeless services, district nurses and social services. Streamlined referrals to community services during the pandemic have also supported staff to avoid unnecessary delays.
The IDT also rapidly introduced a new ‘RED 2 GREEN’ Days model and integrated discharge pathway to support discharge decision-making and to make sure patients support needs are identified. This huge effort, embedded at ward level during the pandemic, also supports upcoming seasonal pressures, ensuring optimum patient flow across the hospitals, enabling improved patient experience and discharge as soon as patients are medically fit.
At the CNO National Shared Decision-Making Council, members discussed discharge planning and shared their experiences of discharge processes during the pandemic. A common theme was noted of the beneficial support that dedicated discharge teams brought to complex discharge planning. Here, communication across disciplines both internal and external to the hospital was thought to be key in maintaining strong working relationships.
The council noted helpful colour coding of wards to identify infection control status and other approaches such as the use of traffic light systems and using digital technology to actively manage discharge processes. The council also highlighted collaborative approaches with non-NHS sectors including local hotels to support the discharge of homeless patients – ensuring their safety and wellbeing, while care and support was put in place.
Would it be beneficial to retain these changes?
Coordinated approaches to discharge planning support organisations to provide seamless care from admission through to discharge. Utilising an MDT approach ensures services are ‘wrapped-around’ the patient, offering a safe and timely discharge which is inclusive in its decision-making approach.
The transparency of a coordinated IDT and its’ processes supports patients, carers and relatives to feel reassured that the support given is in accordance with individual patients’ needs prior to discharge and they are involved at each step. It also helps early identification of individual patients who will need additional support packages or have complex discharge circumstances.
A person’s holistic needs must be identified early when admitted to hospital, including how they will be safely discharged and during the pandemic this continues to be paramount. Through systems working effectively together, we can continue to ensure people can access the right care, in the right place and at the right time as well as support our staff across the system during the COVID-19 response. Discharge to assess models offer nursing and midwifery colleagues the means to support this for all adults across England.
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