DISCHARGE PLANNING

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DISCHARGE PLANNING

• North Glasgow Hospitals
• Nurse Induction Programme

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Discharge Groups
1. Simple !
2. Supported
3. Complex
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IDM Aims Objectives

• Provide a whole systems approach to discharge
  management for all patient groups within NHS
  Greater Glasgow Hospitals. The integrated
  structure ensuring smooth and seamless patient
  journeys, minimising gaps and delays and
  providing clarity of roles within the single team
  framework.
• Improving and monitoring performance across the
  raft of discharge activity.
• Providing appropriate admission avoidance, early
  and supported discharge services, particularly to
  older people.

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IDM Structure (North Glasgow)
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NHS GG Discharge Planning Agreement

• Effective discharge policy is vital to good
  patient care.
• Gains made by admission may be lost if discharge
  process is ineffectual.
• Needs of the individual are paramount and will
  respect individual choice.
• Effective communication between health
  professionals, Primary Secondary care is
  central to good planning.

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Business of Good Discharge Planning Getting It
Right for Older People

• There are 787,000 gt65yrs living in Scotland.
  Expected to rise to 1,200,000 between 2000 and
  2031.
• Acute admissions are rising in the oldest age
  groups.
• gt65yr patients are more likely to suffer from
  cancer, stroke, coronary heart disease,
  depression and dementia.
• Adding Life to Years
• January 2004

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Effective Discharge Planning
Key Principles
Documentation (e.g. Discharge Checklists EDD)
Communication
TEXT
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WHY DO WE PLAN DISCHARGES?

• Good practice i.e. S.I.G.N
• - Provides guidelines based on evidence.
• - Promotes good clinical practice.

The Immediate Discharge Document (65) Highlights
the importance of

• - Timeous accurate information on discharge.
• Aims to improve communication between Primary and
  Secondary and reduce clinical errors.
• UCC National Targets

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Risk Factors

• Frail / Elderly
• Cognitive Impairment
• Poor Functional Ability
• Sensory Impairment
• Multiple Pathology
• History of Falls
• Prolonged Hospital Stay
• Multiple Medications

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When do we plan discharge?

• On admission and in conjunction with the
  discharge checklist
• Gather information from patient regarding
• Home circumstances.
• Existing services, day centres etc.
• Layout of home.
• Pre-admission functional problems.
• Others involved in care.
• Liaise with Family, Carers, Primary Care Team and
  Social Work Services.

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How do we plan discharge

• Communicate at ward level with MDT Discharge
  needs identified Refer to other agencies in
  timeous manner.
• Consultant / Medical Staff
• Dietician
• Occupational Therapist
• Pharmacist
• Physiotherapist
• S.L.T.
• Social Work

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Continued /

• The Named Nurse/associate nurse is responsible
  for coordinating discharge and documenting on
  discharge plan as well as providing discharge
  information to patient/carer.
• MDT have duty to evaluate, document and
  communicate progress to the named/associate
  nurse.
• Discharge date should be set as soon as possible
  in conjunction with Patient, Carers, Medical
  Staff, Named Nurse, MDT, Social Worker.
• Referrals should be made to relevant people who
  may facilitate discharge.
• e.g. IRIS (early/supported discharge), Specialist
  Services/Nurses, Care Home Liaison Practitioner,
  Homeless Liaison OPHAT.

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Referrals to Social Work
1. Glasgow City
2. East Dunbartonshire
3. West Dunbartonshire
4. North Lanarkshire
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District Nursing Services

• 7 day supply of nursing equipment should be given
  on discharge e.g. dressings, catheter, equipment,
  continence aids.
• District Nurse should be contacted by telephone
  48 hours prior to discharge.
• Details of hospital stay and continuing care
  should be given.
• Letter containing details should be sent or given
  to patient for District Nurse.
• District Nurse should be contacted as early as
  possible where there is a need for nursing
  equipment e.g. commode, mattress.

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Medication
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Discharge prescription should be sent to Pharmacy
24hrs prior to discharge.
Patients own medication should be returned or
destroyed with their permission. (My medicines
roll out)
7 days supply of medication should be given.
N.B. If patient has dosette/requires dosette,
please discuss with pharmacy department to ensure
community pharmacy follow-up.
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TRANSPORT
Patients must arrange own transport home, unless
otherwise indicated by medical staff.

• If hospital transport required, order transport
  within 24 hours of discharge for patients living
  in Glasgow Area / 48 hours if outwith area.
• Consider functional ability and type of
  accommodation.
• One item of luggage and one piece of equipment
  only.
• Ensure access to house. (? Keys ? Clothes)
• Order transport for OutPatient appointments.

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Discharge Checklist
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Discharge Lounges

• Located at
• Western Infirmary Level 8 (TAS)
• Gartnavel General 8th Floor
• Glasgow Royal Infirmary Ground Floor, Centre
  Block
• Stobhill Hospital Day Hospital
• All discharges must transfer to discharge lounge.
• However if in doubt, discuss with discharge
  lounge
• staff.

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Why do discharges fail?
Poor Communication
Poor Planning
1. Patient, Carer, GP, DN Questionnaires
2. Audit Documentation
3. Address re-admissions within 48hrs
4. Address multiple re-admissions
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How to get advice
Discharge Planning Folders
Integrated Discharge Team
PATIENT CARERS
M.D.T.
Partnership Agencies