VOL: 96, ISSUE: 41, PAGE NO: 37
Wendy Stewart, RGN, DipGerontology, is clinical practice development nurse, Stockport NHS TrustThe focus on effective discharge-planning has intensified in recent years following the implementation of the NHS and Community Care Act (DoH, 1990) and the introduction of NHS Responsibilities for Meeting Continuing Health Care Needs (DoH, 1995).
The focus on effective discharge-planning has intensified in recent years following the implementation of the NHS and Community Care Act (DoH, 1990) and the introduction of NHS Responsibilities for Meeting Continuing Health Care Needs (DoH, 1995).
The growing trend for a shorter length of inpatient stay alongside a reduction in the number of inpatient hospital beds has resulted in a emphasis on ensuring that discharge is not delayed and that inappropriate re-admissions do not occur as a result of flaws in the discharge process.
In order to facilitate safe and effective discharge-planning and achieve seamless care, all staff need a clear understanding of the roles and responsibilities of multidisciplinary team members.
Learning from a pilot project
In 1997 a pilot project was undertaken on an acute medical ward to generate a baseline description of the current discharge-planning process and highlight areas for improvement.
The main benefit of this project was that the multidisciplinary team members were able to exchange views about discharge problems, many of which were resolved, such as:
- A review of the referral systems to the multidisciplinary team;
- Standardised times for the completion of multidisciplinary team assessments;
- Increased efficiency in casenote retrieval system.
However, there was scope for further improvements and a need for a whole-systems approach to discharge-planning.
We obtained funding from the Manchester East Education Consortium for a project on the development of discharge skills. A steering group comprising senior staff from various disciplines - nursing, occupational therapy, social services, clinical audit, training and development and a representative from the Community Health Council - was formed. The steering group's remit was to ensure that the aims and objectives were met within the agreed timescale.
A project to develop discharge skills
The aim of the project was to improve the process of discharge planning, utilising the knowledge and skills gained by staff in the 1997 project. The training was to be multidisciplinary in focus, involving all clinical and social services staff groups. In reality, the group comprised mainly nursing staff, an occupational therapist, a physiotherapist, a district nurse liaison officer, two social services staff and a pharmacy technician. Although medical staff and the speech and language therapists expressed an interest, they weren't able to commit themselves to the project for the length of time needed.
Members of the group adopted the role of discharge link worker for their area, taking on responsibility for disseminating information related to discharge-planning issues.
A training programme was developed which included a number of elements (see box).
The facilitators of the workshops were the project leader (head occupational therapist), project coordinator (a ward manager seconded to the project for 16 hours a week) and the trust's professional development specialist. 'Specialist' speakers such as the bed manager, social services service manager, transport manager and head of pharmacy were used as and when necessary. The legal aspects of documentation were addressed by the trust's lawyer.
Additionally, a user/carer survey into perceptions of discharge-planning was undertaken and the results disseminated across the trust.
Evaluation of the project
Staff completed an evaluation form giving feedback about the project and its impact on their work. The majority felt it had met their expectations and was relevant to their area of work. They were also able to identify changes in practice that they would like to see happen in their area.
However, some staff still had difficulty in perceiving their role in the discharge-planning process, particularly those that worked in smaller units. Many felt that one of the major benefits of the project was gaining an understanding of the role that others played in the discharge-planning process. This would enable them to understand the difficulties encountered by others on a daily basis.
A number of staff particularly valued the opportunity to discuss and share common problems with other people.
Some participants would have preferred to have more time for discussion and information-exchange at the workshops. Many stated they would have preferred the training to take place over a shorter time-scale.
The facilitators needed more time to plan workshops and to visit link workers in their areas than had been envisaged or included in the original bid to the education consortium. Also, in order to help the link workers implement changes in the workplace, the secondment of the project coordinator should have been for two years, not one.
Results of the project
All participants agreed that the project had been valuable and innovative, particularly as it provided a multidisciplinary perspective and used a whole-systems approach to discharge-planning.
As a result of the user/carer survey and other issues raised, all link workers have devised action plans aimed at addressing these. Ward managers and the project coordinator are monitoring these action plans and assisting where required.
A clinical practice development nurse has been appointed to examine strategic issues related to discharge-planning and to address issues raised from the project. This role is not that of a discharge coordinator, as discharge planning is an integral part of the patient's hospital experience and all staff involved in patient care should take a holistic view of the discharge-planning process.n