December 2015 – New Guidelines on Leaving Hospital

The guidance also aims to improve peoples experience of admission to, and discharge from, hospital by better coordination of health and social care services.

The guideline includes recommendations on:

 

Person-centred care and communication and information sharing before admission into hospital including developing a care plan and explaining what type of care the person might receive

 

Admission to hospital including the establishment of a hospital based multi-disciplinary team during hospital stay including recording medicines and assessments and regularly reviewing and updating the persons progress towards discharge

 

Discharge from hospital including the role of the discharge coordinator 

 

Training and development for people involved in the hospital discharge process

 

The guidance is for commissioners of hospital, care home and home care services who should ensure that any service specifications take into account the recommendations in this guideline.

 

Health and social care practitioners, including care home managers and out‑of‑hours GPs, responsible for transferring people into hospital should ensure that the admitting team is given all available relevant information. This may include:

 

Advance care plans

Behavioural issues (triggers to certain behaviours)

Communication needs

Communication passport

Current medicines

Housing status

Named carers and next of kin

Other profiles containing important information about the persons needs and wishes

Preferred places of care

 

For an emergency admission, A&E should ensure that all available, relevant information is given to the admitting team when a person is transferred for an inpatient assessment or to an admissions ward. The admitting team should provide the person and their family, carer or advocate with an opportunity to discuss their care as well as provide the following information:

 

Reason for admission

How long they might need to be in hospital

Care options and treatment they can expect

When they can expect to see the doctors

The name of the person who will be their main contact (this is not necessarily the discharge coordinator)

Possible options for getting home when they are discharged from hospital care and treatment after discharge

 

As soon as the person is admitted to hospital, relevant staff should be identified to form the hospital‑based multidisciplinary team that will support them. The composition of the team should reflect the persons needs and circumstances.

It is also recommended that care for older people with complex needs be provided in a specialist, geriatrician‑led unit or on a specialist geriatrician‑led ward.

 

Hospitals should also make a single health or social care practitioner responsible for coordinating the persons discharge from hospital. The discharge coordinator should arrange follow‑up care. They should identify practitioners (from primary health, community health, social care, housing and the voluntary sector) and family members who will provide support when the person is discharged and record their details in the discharge plan.

If the discharge plan involves support from family or carers, the hospital‑based multidisciplinary team should take account of their:

 

Willingness and ability to provide support

Circumstances, needs and aspirations

Relationship with the person

Need for respite

 

The guideline also focuses on the range of local community health, social care and voluntary sector services available to support people when they are discharged from hospital including:

 

Reablement (to help people re‑learn some of the skills for daily living that they may have lost)

Other intermediate care services

Practical support for carers

Suitable temporary accommodation and support for homeless people.

 

Commissioners will also be required to develop local protocols so that out‑of‑hours providers have access to information about the persons preferences for end‑of‑life care.

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