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Complex discharges

Definition

For patients requiring specific support on discharge, proactive and systematic planning is essential (Winfield and Burns [54]). A complex discharge may be considered when:

a large package of care involving various agencies is required
the patient's needs have changed since admission, with different services requiring co‐ordination
the family and/or carer require intensive input into discharge planning considerations (e.g. psychological interventions)
the patient is entitled to NHS Continuing Healthcare and requires a package of care on discharge
the patient requires repatriation
there is dispute among the family about where the patient should be discharged to or what their care needs are
the patient is homeless.

Related theory

Patients who have specific social or specialized care needs, who have funding issues or who require a change of residence may have a complex discharge need (Lees‐Deutsch et al. [23]) and may require referral to the hospital's discharge team. Hospital trusts may have different titles for staff within the discharge team, but essentially their role is to co‐ordinate plans among all involved by liaising with the multidisciplinary team both within the hospital and in the community. In this way they act as ‘knowledge brokers’ to facilitate sharing and co‐ordination (Waring et al. [52]).

If a patient has dementia or a learning disability, the approach to their discharge needs to be carefully planned and tailored to meet their specific additional needs (Poole et al. [43]). If, for example, the patient has been assessed as lacking capacity to make a decision under the Mental Capacity Act ([27]) about where they should live, then a ‘best interest’ decision must be made, ensuring that family and carers are involved. Where the patient is assessed as lacking capacity and has no relatives or friends and so is ‘un‐befriended’ (as defined by the Mental Capacity Act [27]), a referral should be made to a local independent mental capacity advocacy service to ensure the patient gets the required support (Mental Capacity Act [27]). Where there is a concern that a person has a degree of cognitive impairment, it can easily be assumed that they cannot return home or that they need care. These assumptions should be challenged and decisions made on the basis of a needs assessment, which should include a mental capacity assessment. The assessment should evidence that the principles of the Mental Capacity Act ([27]) have been applied and that any decisions have been made in the person's best interests. For more detailed information on the principles of capacity and safeguarding, see Chapter c05: Communication, psychological wellbeing and safeguarding.

Evidence‐based approaches

NICE ([37]) recommend several key principles of care and support that should be considered for more complex patients during the transition from a healthcare facility to home:

Person‐centred care: see everyone as an individual, involve families and carers, and identify those at risk.
Communication and information sharing: provide appropriate information in the right format at the right time and ensure discussions take place with all involved.
Discharge co‐ordinator: a dedicated individual who works with the multidisciplinary team and involves carers and families in discussions about the care being proposed.
Develop a discharge plan: this should include details about the person's condition, medicines and practicalities of daily living, and should detail which services and sources of support are involved.
Plan for care following discharge: ensure follow‐up arrangements are made and communicated effectively.
Readmission risk: ensure those at risk of readmission are referred to appropriate community‐based health and social care teams prior to discharge.

For patients who may have additional needs on discharge, it is worth exploring what support services may be available and identifying what services were in place prior to admission. For example, if the person has a learning disability, they may have a learning disability nurse in the community. If so, involving the nurse in the patient's discharge will ensure a safer transition for the patient by enabling access to a professional who has knowledge and expertise in the field of learning disabilities but also in the needs of the patient.

Principles of care

A comprehensive assessment is initially required to ascertain a patient's discharge needs. Joined‐up inter‐professional care and good carer partnerships can then be established to facilitate safe and seamless transfer of care of the patient from the hospital back to the community (Teodorczuk et al. [49]) (Table 3.1).

Table 3.1 Procedure for the assessment process for complex discharges

1 Nurse conducts a comprehensive assessment on admission
Identify whether the patient has simple or complex needs.
Refer to relevant members of the hospital multidisciplinary team.	For example, occupational therapist, physiotherapist, social services or discharge co‐ordinator
Liaise with current community services to ascertain current support (if any).	For example, district nurse or community palliative care team.
2 Multidisciplinary team discuss the case at the ward multidisciplinary meeting
Appoint a discharge co‐ordinator.	To act as discharge planning lead for all social services and NHS Continuing Healthcare referrals. To act as a point of contact for discharge concerns. To plan and prepare the family meeting or case conference and to arrange a chairperson and minute‐taker for the meeting. To meet the patient, their carers and their family. To work in conjunction with multidisciplinary team. To liaise with the patient's named nurse.
Formulate a discharge plan.	Formulate a discharge plan based on the patient's assessed needs. Agree assessments required by the multidisciplinary team. Agree home visits required (e.g. occupational therapist home visit and functional report).
Set a provisional discharge date.	Agree a provisional discharge date and time frames. This will only be an approximate date, depending on care needs, equipment, etc. It should be reviewed regularly with the multidisciplinary team. Discharges should not be arranged for a Friday or a weekend, when skeleton social and care services are in place.
3 Discharge co‐ordinator arranges family meeting or case conference
Invite the patient, their family, their carers and all appropriate healthcare professionals, including community staff where possible.	Discuss the patient's needs and the services and equipment required, and agree preferred and appropriate place of discharge. If the patient is not returning to their own neighbourhood, a GP will be required to take the patient on as a temporary resident so this must be arranged. Agree all relevant Social Services and NHS Continuing Healthcare referrals required. Discuss any specific and special issues (e.g. infection status, IV therapy, need for syringe driver) to establish an appropriate plan. Notify community services.
4 Ward staff or discharge team make referrals to appropriate community services
Refer to community health services.	To include district nurses, community palliative care team, community physiotherapists etc. Ascertain whether the district nurse is able to undertake any necessary clinical procedures in accordance with their local trust policy (e.g. on care of skin‐tunnelled catheters) and make alternative arrangements if not. Arrange for night sitters via the district nurse if required.
Refer to Social Services.	The Social Services Assessment Notification (see Figure 3.7 for an example) must be sent at the earliest opportunity and no later than 72 hours prior to discharge.
Request equipment from community nurse after discussion with patient and family.	For example, hoist, hospital bed, pressure‐relieving mattress or cushion, commode or nebulizer. Additionally: Ascertain the type of accommodation the patient lives in so that the equipment ordered will fit appropriately. It is important to specify where the patient will be cared for – for example, ground or first floor.
Request home oxygen if required.	Medical team to complete Home Oxygen Ordering Form (HOOF) and Initial Home Oxygen Risk Mitigation Form (IHORM) for oxygen cylinders and concentrators at home. Fax or email to relevant oxygen supplier.
5 Ward staff or discharge team confirms the discharge date and finalizes the community arrangements
Confirm provisional discharge date.	The provisional date is agreed with the patient and their family and/or informal carer(s). The actual date will then depend on when the following community services can be arranged: social services package of care district nurse re‐ablement service nursing home or residential home placement hospice bed rapid response equipment and home oxygen.
Confirm equipment agreed and delivery date.	Ensure the family is informed of the delivery date and knows to contact the ward to confirm receipt of the equipment in the patient's home.
Confirm start date for care and fax or email details.	For example, Social Services, community nurse or community palliative care. Community care referral forms need to be faxed or emailed to district nurses at least 48 hours prior to discharge. The Social Services Discharge Notification (see Figure 3.8 for an example) must be sent at least 48 hours prior to discharge. In some situations, family members are able to bridge the gap before a package of care starts to enable the patient to be discharged sooner. This action should be talked through with the patient and the family to ensure they are able to provide the care needed and that they will not be putting themselves or the patient at risk. Confirm the agreed discharge date with the patient and their family.
6 Ward staff or discharge team co‐ordinates the hospital discharge processes
Arrange transport and assess need for escort and/or oxygen during transport.	Assess specific needs for transport – i.e. specify whether the patient needs a walker, chair or stretcher, and/or oxygen or an escort. Arrange for a do not resuscitate (DNR) form if required for ambulance crew.
Arrange discharge medication.	Determine whether the patient will self‐medicate and requires a self‐medication chart or dosette box. Confirm the name of the person who will provide the prompt or give the medication to the patient at home. Ensure take‐home medication is prescribed and given to the patient or carer with explanations. Ensure nutrition supplements, dressings and medical appliances are prescribed, ordered and given to the patient or carer with explanations. If the patient has hospital equipment (e.g. a syringe driver) ensure it is clearly marked for return to the hospital with written instructions for the patient, carer or district nurse.
Make arrangements for suitable access and provision for patient on arrival home.	Check access issues (e.g. front door keys and steps) and ensure heating has been organized and food will be provided.
Ensure patient has follow‐up arrangements made.	Next inpatient or outpatient appointment.
7 Confirm arrangements 24 hours prior to discharge
Telephone community services and confirm any special needs of the patient.	For example, infection status update or confirmation of hospital equipment required by patient.
8 After discharge, ward nurse or discharge co‐ordinator makes a follow‐up phone call to the patient (as agreed)