Discharge planning

Discharge Liaison Nurses

Patient Flow Team
Janet Davies
Christine Jones-Williams

Challenges

Balancing capacity with demand

Ensuring safe Effective discharge

Prevent readmissions

Avoid complaints

Discharge Planning - Getting It

Right

Pre admission (planned admissions)

On admission
Assessment (identifying risks to
discharge )
Making appropriate referrals to MDT
Involve Patient/ Carer
Predicted discharge (based on
clinical knowledge & data )

The patient can only be

Discharged or Transferred when

A clinical decision has been made that the

patient is ready for discharge / transfer
The MDT decision has been made that the
patient is ready for discharge/ transfer
Patient, Family , Carers have sufficient help &
support if required (arranged prior to discharge)
Nursing Home / Residential Home able to meet
identified needs.
Appropriate funding for above has been
arranged

Assessment

Is the Patient homeless? Refer

immediately to Social Services
Have the Patients needs changed
since admission?
What help are they likely to require
on discharge ?
Will they require equipment?

Assessment continued

Has the patient reached their full

potential ?
Will the patient benefit from further
rehab/ assessment in a community
hospital ?
Is the patient likely to require care
home placement? If so what kind?
Who will pay?

How is the decision made ?

MDT/patient /family/carer decision based

on the needs of the patient identified
during the assessment process (Unified
assessment from Sept 06)
Medical,Nursing
Specialist nursing
Speech &Language
Physiotherapy/ Occupational Therapy
Social Worker

Care Homes

Residential

Residential EMI

General Nursing

EMI Nursing

Specialist Nursing i.e. ABI unit, Younger

adult etc

Types of Funding

Self funding

Local authority funded

Self Funding with NHS contribution to

Nursing Care (110 per week)

Continuing health Care (fully funded by

the Local Health Board)

Placement

As a general rule people should not

be discharged directly from an acute
episode of hospital care to a
permanent placement in a care
home
Further rehabilitation may take place
at hospital, at home or in an
intermediate care setting i.e.
Community Hospital

Definition of Nursing Care

Any services provided by a

Registered Nurse and involving:
The provision of care or
The planning, supervision or
delegation of the provision of care

NHS Funded Nursing Care in Care homes in Wales

What it means for you December 2003 WAG

Continuing NHS Health Care

A Package of health care that is arranged ,

provided and funded solely by the NHS.
It can be provided in hospital, peoples own
home or in Care homes providing nursing
care
the Local Health Boards take into account
the nature, complexity, unpredictability or
intensity of a persons medical, nursing or
clinical needs in deciding whether or not this
is appropriate to meet the persons needs

Continuing Health Care Assessment

All Patients have the right to have

their ongoing needs assessed against
the criteria for fully funded NHS
Continuing Health Care (CHC)
Documentary evidence of this
assessment is essential
Failure to do so could result in the
Trust being held financially
responsible

Resources available to help you

with discharge planning

Discharge policy
Single Point of Access
Discharge liaison Team
Community Services i.e.
District Nurses
Intermediate care teams
Voluntary Services

Patients with complex discharge

requirements i.e.
P.E.G./ NG feed/tracheotomy
Grade 3-4 pressure ulcers
learning Disabilities
Discharge
liaison
Nurse referral
Patients requiring
Health funding for
specialist/ rehab/ nursing home placement
guidance
complex family dynamics
Reassessments of patients admitted from
care home settings