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Each patient should have own 'discharge co-ordinator', says NICE

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A single health professional should be appointed to co-ordinate discharging each patient from hospital, according to the National Institute for Health and Care Excellence.

NICE has published guidance on ensuring adult patients receive the support needed from community services or nursing or care homes to be discharged in a “co-ordinated and timely way” – and also to help avoid repeated hospital stays.

The guidance, which focuses on tackling poor communication and lack of social care support, comes a week after nurse researchers highlighted these two issues as key problems preventing the timely discharge of hospital patients.

NICE suggested a “discharge coordinator” role could be specially created or responsibility handed to a member of the multi-disciplinary team looking after the particular patient due to be discharged.

The role should include being the “main point of contact” for the patient, their family and health and social care practitioners involved in their care. The co-ordinator should share updates on the person’s health, including medicines information to all appropriate practitioners.

In addition, they should work with both hospital- and community-based teams to agree a discharge plan, which should take into account the patient’s social and emotional wellbeing, as well as the “practicalities of daily life”.

NICE suggested a “discharge coordinator” role could be specially created or responsibility handed to a member of the multi-disciplinary team looking after the particular patient due to be discharged.

“One of our recommendations is for a single person to coordinate the process for each individual”

Gillian Leng

The plan should be given to the patient and all those involved with their care, including family members and carers.

The co-ordinator should also oversee the agreeing of a plan for ongoing treatment and support with the community-based multi-disciplinary team that will be providing care – ensuring any specialist equipment and support is in place before the person is discharged.

Meanwhile, all relevant staff should be trained in the hospital discharge process and this should be refreshed regularly, added NICE.

The institute highlighted that a “key focus” of the guideline was to encourage closer communication between health and social care teams in order to achieve a good transition between hospital and home.

The guidance recommended that a community-based nurse or GP call or visit people at risk of hospital readmission 24-to-72 hours after discharge.

In addition, a community-based multi-disciplinary team should maintain contact with the patient, for instance through regular phone calls and home visits. The person being cared for should also know how to contact the team.

It also recommended that practitioners responsible for initially transferring people to hospital, including care home managers, should share all appropriate information with the hospital when a patient with social care needs was admitted.

Hospitals should bring together a team of multi-disciplinary professionals “as soon as a person with social care needs is admitted” in order to look after them.

“We’re keen to encourage good collaboration between health and social care”

Tony Hunter

It also called on health and social care practitioners to record information about medicines, assessments and patient preferences using an electronic system, which was accessible to everyone providing care.

Professor Gillian Leng, deputy chief executive and director of health and social care for NICE, said: “We know that it can be challenging to co-ordinate a person’s discharge from hospital when they also have extra care needs.

“One of our recommendations is for a single person to co-ordinate the process for each individual, to streamline and simplify the process,” she said.

Professor Leng noted that a “smooth and timely transition from hospital back to their home environment” should help ease pressure on hospitals and avoid patients becoming readmitted because they are not getting the right community support.

NICE

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Gillian Leng

“Having a plan in place to ensure adequate health and social care services are available in the local community and are able to cope with any seasonal or other pressures is vital,” she said. “Practitioners should be talking to each other, sharing information and planning discharge from the time the person is admitted or earlier if possible.”

Tony Hunter, chief executive of the Social Care Institute for Excellence, said: “We’re keen to encourage good collaboration between health and social care and people’s experience of transition between hospital and home is a key indicator on how well integration is working.

“The guideline helps by providing a joint script and practical advice with clear and specific recommendations for health and social care staff working in hospitals and the community, often in testing circumstances,” he added.

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Readers' comments (1)

  • michael stone

    Despite any moans about 'even more paperwork', etc, this is probably necessary.

    Why - because only by attaching individual responsibility, as opposed to some sort of 'vague group/system responsibility' to the smooth-running of the discharge/community process, will problems get dealt with promptly (and with more determination: 'the buck stops with me' is a sharper motivator than 'the buck rests with the team').

    Although I say 'it is necessary', I am not assuming that it will work !

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