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Executive Summary

• The discharge of older people with high levels of dependency and complex health and social care needs requires careful planning, should be timely and to an appropriate location.
• For frail patients with complex needs it may be more useful to regard the process as a transfer of care.
• Methods of joint working between health and social care agencies vary across the 4 countries of the United Kingdom.
• Person centred multidisciplinary assessment and discharge planning should take place at the earliest opportunity and ideally from admission.
• The effects of the Community Care (Delayed Discharges) Act 2003 and “Payment by Results” on discharge and readmission processes in England are currently being evaluated.
• A multilayered approach to assessment and rehabilitation co-ordinated by the multidisciplinary team is recommended, with review at formal MDT meetings.
• Input from the private sector and voluntary agencies are an increasingly important component of care packages.

1. Introduction

1.1 Older people discharged from hospital and living in the community have higher levels of dependency and more complex health and social care needs than other patient groups. For frail patients with complex needs it may be more useful to regard the process as a “transfer of care” to community agencies.

1.2 This process requires careful planning and should be timely, to an appropriate location and with adequate resources available to support the discharge.[1]

1.3 Methods of working between Health and Social Services differ across the United Kingdom.

2. Principles

2.1 The British Geriatrics Society is committed to providing for older people appropriate interventions consistent with patient/client choice, the assessed needs of carers and the highest quality health and social care.

2.2 Person centered multi-disciplinary assessment should be carried out at the earliest opportunity. The discharge planning process should begin at the point of hospital admission. However, it should be noted that admission may be avoided if timely assessment and interventions can be obtained in the community. The appointment of community matrons, the single assessment process and the implementation of case management may impact on this aspect of planning.

2.3 Some older people require significant stays in hospital on order to achieve optimal health status and potential. Others may benefit from ongoing community rehabilitation in residential units or at home.

2.4 Older people who do not require community support can be discharged by ward staff without the need for referral to social services but may be given a contact number for the Social Services Department to self refer in case they need help in the future. For others who already have a package of care, and whose care needs have not altered, ward staff should need only to inform the provider that the care package needs to recommence. For others a re-assessment of their needs will be required and a timely referral for therapy assessments and social services input should be made so that assessment and planning for discharge can begin as soon as possible.

2.5 Older people with complex needs require assessment from a range of health and social care professionals coordinated through a multidisciplinary meeting. It is important that care plans emphasise promotion of independence.

2.6 Transfer of older people straight from an acute hospital bed to a care home bed without comprehensive geriatric assessment is not encouraged. The opportunity of assessment and rehabilitation in a short term residential environment or at home with enhanced community support (e.g. by supported discharge team) should be offered.

2.7 Decisions to fund a nursing home placement should take into account local eligibility criteria agreed by the Primary Care organisation and local Social Services department as part of joint continuing care arrangements.

2.8 Each unit should have clinical governance processes in place to audit the discharge process. , eg analysis of reason for return to hospital sector within two weeks,return to home rates,institutionalisation rates from hospital

3. Practical Aspects of Discharge Planning

3.1 Local arrangements
Discharge arrangements are dependent upon the interface between social services, health authorities, NHS trusts and primary care groups/trusts. Input from the private sector and voluntary agencies are increasingly important in constructing care packages.

3.2 Patient and carer involvement
Patients need to be involved early in the assessment process and care plans should offer them real choice. Carers who provide a substantial amount of care on a regular basis are entitled by law to receive if required an assessment of their ability to continue caring.

3.3 Referral
A multi-layered approach to assessment is recommended. The first step is screening by a member of the health team who possesses appropriate skills and knowledge of local eligibility criteria and the available services. The multi-disciplinary team will distinguish between patients with simple needs (e.g. requiring only a single domiciliary service such as home care) and those with complex needs who require a full care assessment.

3.4 Where discharges are straightforward, timely discharge may be enhanced by a variety of techniques including the following [2]:

• Developing a treatment plan and estimated date of discharge within 24 hours if arrival.
• Nurse initiated discharge processes
• Daily ward rounds by senior staff (SpR, Staff Grade, Associate Specialist or Consultant).
• 7 day per week discharges where possible

3.5 Accident and Emergency Departments and Medical Admissions units should have access to a discharge planning team ideally coordinated by either a discharge liaison nurse, or social worker so that they can refer and discharge appropriately. Arrangements for dealing with patients "out of hours" should be in place.

3.6 Care planning
Social Service departments are required to work with patients, their carers and relevant hospital and community staff to construct appropriate care plans and hospital discharge arrangements. All assessed patients should receive a care plan before discharge. The medical needs of the patient will continue to be the responsibility of the general practitioner and it is important that he/she is provided with adequate information at discharge.

• Role of the Consultant in geriatric medicine

The professional responsibility for discharge arrangements remains with the individual members of the multi-disciplinary team often but not always under the leadership of the Consultant in geriatric medicine. Not all older people will be under the care of geriatricians yet it is desirable that in all hospital departments those patients with complex needs should still have a full assessment by multi-disciplinary teams. Communication must occur with the General Practitioners and community or intermediate care services in a clear and timely way, ideally in advance.

3.8 The Discharge Coordinator
Recently Discharge Coordinator posts have been developed in many NHS Trusts. They have a pivotal role in liaising with members of the multidisciplinary team and can improve communication between these individuals. They can also interface directly with the patient and their spouse, family or other caregiver.

4. Conclusion

The discharge or transfer of care of an Older Adult from the hospital to the community is one of the most satisfying aspects of Geriatric Medicine. The complex health and social needs of this group requires the experience and skills of a large number of professionals from a range of different organisations. Without careful coordination this process can disintegrate to the detriment of the patient and their family. The needs of frail older people with cognitive impairment to EMI care homes are considered in a parallel document.

References:

• Discharge from Hospital Pathway, Process and Practice (2003), Health and Social Care Joint Unit and Change Agent Team, Department of Health, London.
• Achieving timely simple discharge from hospital: A toolkit for the multi-disciplinary team (2004), Department of Health London.