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Passing the Baton : A Practical Guide to Effective Discharge Planning

June 2008

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Passing the Baton

“Responsibility to deliver the right care using knowledge and understanding of the patient’s needs.”

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Passing the Baton

Addresses weakness in:-

– Knowledge

– Skill

– Confidence

of front line staff in managing the discharge of patients from hospital.

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Passing the Baton

Accepts

• Significant amount of resources used caring for patients in hospital beds who ideally could and should have been discharged to a more appropriate setting for their needs.

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Discharge processes increasing complex

• Requires greater involvement and leadership of key specialist staff, e.g. Discharge Liaison Nurse.

• The reasons:-

– Faster pace of ward or A & E environment.

– More performance pressure upon stays.

– Increasingly complex needs of patients.

– Increasing challenge of translating health and social care policy into practice.

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Getting it Wrong :Where does it leave the patient?

Affects

– The rights of others

– The patient

– Carers, and

Undermines

– Their confidence in the ability of the NHS to deliver.

Resulting in

– Conflict, further delay and cost.

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Is this the Future?

• Test cases in the High Court.

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Where does it go wrong?

“A key element in effective discharge planning is recognising the difference between simple and complex discharge processes early in the patient’s “journey”.

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Mental Health Strategy/Strategy for Older People in Wales

• Fundamental concept of citizenship and further engagement in the community.

• Non-hospital settings to be the default location for care with only appropriate or necessary transfers into other care settings and timely discharge.

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National Service Frameworks

• Stress the importance of normal daily life as a contributor to good health and well being.

• NSF for older people – good standard for intermediate care, involving an integrated system and actions which promote effective rehabilitation and a return to independence.

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Diagram of high level pathway

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Key Principles : Passing the Baton

• Communication

• Co-ordination

• Collaboration

• Consideration

• Creativity

• Integrity

Failure to secure principles, provides recognition of patient and carers’ rights

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Value of Manual?

• Secure understanding of process at all levels.

• Adoption should assist joined up thinking across all levels in the NHS and elsewhere.

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Timeliness of Manual?

• National Assembly for Wales : Audit Committee

“Tackling delayed transfer of care across the whole system.”

• University of Glamorgan

“Independent Review of Delayed Transfer of Care.”

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Continuing Health Care & Delayed DischargeWhat are we talking about?

“…. we are talking about individuals not statistics, in the hospital or social services setting. We are talking about individuals who want to maintain some dignity in their lives, who do not want to be stuck in a hospital and who want more appropriate care settings ....” [Edwina Hart April 22nd 2008].

“…. we must not shuffle them about and we need to look at some long-term solutions for the individuals concerned….”

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Continuing Health Care & Delayed DischargeThe new …..?

• Report of Plenary – Consideration of Independent Review into Delayed Discharges. April 22nd.

• Process and Policy Guidance.

“….Considerably more effort is needed by local government and the National Health Service to manage the problem.

…. Social Services and the NHS are not planning and managing services effectively, resulting in patients being delayed in inappropriate setting, because the required services are not available to them.” [Edwina Hart].

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Continuing Health Care & Delayed DischargeCont/d…. The new ….?

“Partnerships between the NHS and social services are often immature, failing to address problems from the patient’s perspective. Partnerships are too often subject to the whims of individuals, rather than recognising the imperative for work targets for patients. Some organisations are still working in their own silos, following their own narrow interests, rather than being truly citizen-centred. Pooled funds and other flexibilities have been made available since 1999. The social services and the NHS have made limited use of the provisions in developing joined-up solutions.” [Edwina Hart].

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Continuing Health Care & Delayed DischargeBeginning

“Within the NHS effective discharge planning is patchy. Inadequate progress has been made in this basic activity, despite much guidance and support. Weakness in this area leads to confusion, delay and disputes at patient level.”

“Inadequate discharge planning must be addressed. NHS staff and social workers need to make sure that every discharge is handled with the interests of the patient at heart. Arrangements must be made for essential services to be in place that enable a patient to return home or to a community settling quickly. Planning should begin at or before admission and not when the patient is deemed to be medically fit to go home….”

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Continuing Health Care & Delayed Discharge Current Emphasis

Independent Review: University of Glamorgan.

• Complex series of 46 recommendations identified.

– Need for better information and support.

– Proactive and timely management of patient’s progress.

– Regular monitoring of patients’ and carers’ perception of the quality of care.

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Continuing Health Care & Delayed Discharge Independent Review – Some issues

• Sensitivity

….patient faces having to leave behind the home and way of life with which they are familiar, moving to circumstances which are largely unknown.

….relatives are living through this transition too.

….at the same time they are having to come to terms with the fact that their relative is entering a changed …. and possibly final ….phase of their life and that their capacities may be greatly reduced.

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Continuing Health Care & Delayed Discharge Independent Review – Some issues

• Guilt

– ….relatives may feel guilty that, this, change somehow reflects their own ‘failure’ to support their …. adequately ….

• Delay

– Expose patients to unnecessary danger.

– Prolong periods of uncertainty about future.

– Improve burden on families.

– Reduce long-term chance of recovering independent and full health.

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Continuing Health Care & Delayed Discharge Independent Review – Some issues

Significant Issues

• Are patients and relatives given enough information?

• Are patients’ families involved enough in making decisions?

• Should independent help (advocacy) be available?

• Does discharge planning start too late?

• Are we recognising cultural differences?

• Does personal financial responsibility for continuing care result in delayed transfers?

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Continuing Health Care & Delayed Discharge Independent Review – Some issues

Cont/d….. Significant Issues

• Do patients really have a choice?

• Should “holding” wards be used?

• Do patients’ experiences vary?

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Continuing Health Care & Delayed Discharge

How to Respond to ….?

• Growing levels of dissatisfaction by patients and families:-

– About the assessment of need

– About the effect this can have on who pays.

How to Respond to ….?

• Need to re-examine decision making process.

• Increasing resort to litigation.

Cont/d….

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Continuing Health Care & Delayed Discharge

How to Respond to ….?

• Need

– Clear policy and procedures relating to discharge and advice of future accommodation.

– Explicit guidelines.

– Clear pathway.

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• CASE STUDY

Continuing Health Care & Delayed Discharge

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• CASE STUDY – Key Stages

Continuing Health Care & Delayed Discharge

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• Acknowledge that no one wants to end up ‘in dispute’.

• Remember the person at the centre.

• Communicate, communicate, communicate.

• Understand and adhere to agreed discharge policies and processes.

• Don’t prejudge outcomes.

• Manage expectations from the beginning.

• Document and communicate individual and national decisions.

Continuing Health Care & Delayed DischargeEssentials? [NLIAH Guidance]

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Passing the Baton :Managing Expectation

“Not everyone wants to go out to Bingo, day care, luncheon clubs or special interest groups.”

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Managing Expectation

• Individuals and families need to understand how and when discharge arrangements are going to take place so that they can be involved in planning.

• Staff need to involve the professionals across the MDT so that they take sufficient time to assess the patient and make appropriate arrangements.

• Information which outlines care options needs to be comprehensive, accessible and up to date.

• Staff and patients need to have information about eligibility criteria, referral protocols and capacity in order to be able to access alternative care options.

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Managing Expectations : Reduce risk of legal challenge?

“It got to the point where every day I would dread going into the ward. It was particularly bad on the days when the Consultant did his ward round. I always felt that they were cross with me, that they felt I should be doing more to get mum out of hospital. But what could I do?.......”

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Questions & Answers