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Draft guidance on social care for patients after discharge

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Hospital and community nurses will be expected to work more closely together to avoid vulnerable patients falling between gaps in care services, under draft guidance issued by the National Institute for Health and Care Excellence.

The draft document, which has been released for consultation, focuses on the needs of adults with social care needs as they move between hospital and home and aims to tackle unnecessary suffering caused by a lack of co-ordination in services.

“Carefully planning the complicated moves between social care and hospital… improves outcomes and potentially reduced costs significantly for the NHS and social care providers”

Gillian Leng

It stresses the need for careful planning by hospital and community teams from the moment a patient is admitted to hospital – or even earlier – to ensure all the right services are in place to support that person when they leave.

It also emphasises the need to work with the patient, their family and carers, involving them in all key decisions, to ensure they spend no longer in hospital than necessary.

Professor Gillian Leng, deputy chief executive and director for health and social care at NICE said careful planning using a “person-centred” approach was a “win-win” for all concerned.

“Focusing on the needs and wishes of people in decisions about their care benefits everyone – the person, their carers, social workers, social and primary care providers and hospital staff,” she said.

“Carefully planning the complicated moves between social care and hospital, which can involve lots of different health, social care and other services, improves outcomes and potentially reduced costs significantly for the NHS and social care providers,” she added.

The proposals state one health or social care practitioner, which may often be a nurse, should be responsible for co-ordinating someone’s discharge from hospital.

Hospitals should either create a designated discharge co-ordinator role or make a member of the relevant hospital or community multi-disciplinary teams responsible.

“The discharge coordinator should be a central point of contact for health and social care practitioners, the person and their family, particularly during discharge planning,” says the guidance. “They should be involved in all decisions about discharge planning.”

Staff training is a vital element in improving services, says the document, which says trusts and councils must ensure staff are trained in the discharge process in areas such as medicines management, how to work with colleagues in other teams, and assessing people’s home environment.

The guidance makes it clear community health and social care teams – such as community nursing teams – must maintain contact with patients once they have left hospital.

“This could include regular phone calls and home visits. It also involves making sure the person knows how to contact them when they need to,” says the draft guidance.

It states an “appropriately skilled practitioner” should follow up people with palliative care needs within 24 hours after their transfer from hospital.

Meanwhile, a community-based nurse or GP should phone or visit people at risk of readmission 24 to 72 hours after discharge.

Amid concerns over a lack of community services, the guidance stresses the importance of ensuring the right mix of support actually exists.

It says local health commissioners, hospital trusts and councils need to offer a co-ordinated range of services that could include “re-ablement” services to help people re-learn everyday skills they have lost, intermediate care services to ease the transition between hospital and home, and support for carers.

Health and social care organisations have until 6 August to comment on the recommendations with final guidance expected to be published later this year.

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Readers' comments (1)

  • Social Services seem to have taken over this role and have changed the guidelines so that very few people come under NHS care.This started with the PCTs and has been endorsed and encouraged by the CCGs.
    Means testing has also been applied denying the public "Free" healthcare

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