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Discharge Pathway v4

Perth & Kinross Discharge Pathway 2012
by

mark dickson

on 13 November 2012

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Transcript of Discharge Pathway v4

First time using this Pathway? P&K Discharge Pathway Patient receives Anticipatory Care / Preventative Care Primary and Community Care staff
consider options for prevention of admission Telehealth
COPD / CHD Nurse and Physiotherapist
Anticipatory / Advanced care plans
Community Rehab Team (CRT), Mental Health Teams, DN, Intermediate Care, GP, Assessment Clinic for the Elderly (ACE)
Case Management
Virtual Ward HEALTH CARE Telecare
Day Services
Case Management
Equipment Adaptions SOCIAL CARE The patient is referred to a P&K Hospital via Out of Hours, A&E, GP or Elective Inital Assessment
Initial Documentation
Initial Referrals HEALTH CARE Estimated Date of Discharge (EDD) set and reviewed on a daily / weekly basis
Medical management plan commenced and reviewed on an ongoing basis
Contact with family / carers ongoing
Referrals to other appropriate professionals.
Weekly Multidisciplinary Team meetings HEALTH CARE Attend weekly Multidisciplinary Team meetings
Hospital Discharge Team Social Workers activate referral when received / medically fit, then screen and allocate SOCIAL CARE Referrals to CRT, Community Nursing, WRVS, Community Alarm, Supporting People
Health Equipment ordered
Meet or contact family to plan / finalise discharge HEALTH CARE Documentation
Hospital Discharge Team Social Work (HDT SW) Assessment initiated
HDT SW meet family regarding care arrangements
Referral if appropriate for Reablement, Homecare, Community Alarm and meals
HDT SW assessment completed within 2 days
Reablement screening once daily SOCIAL CARE Discharge Planning begins Patient becomes a Delayed Discharge The day before discharge:-
ambulance booked, medications ordered and confirmation of discharge date provided to Community Nurse if required HEALTH CARE Patients with Community based Social Workers have their asssessment intitiated, and all Social Work processes carried out SOCIAL CARE To work through the
Pathways in sequence,
use the arrows at the bottom right of the screen.

To freely explore the Pathways, click and drag with the mouse to move around, and use the mouse scroll wheel to zoom in and out. Current Pathway Future Pathway PATIENT DISCHARGED "HOME" All services in place. Telecare
COPD / CHD Nurse and Physiotherapist
Anticipatory / Advanced care plans
CRT, MHT, DN, Intermediate Care, GP, ACE
Care Management
Virtual Ward HEALTH CARE Telecare
Day Services
Step up
Single point of contact / Rapid response
Case Management
Equipment and adaptations SOCIAL CARE Ward 4 conduct assessment, decide admission is appropriate, and: PRI ward 4 triage and "fast track OT" in A&E
Psychiatry of Old Age Dementia Liaison Team
Geriatrician Model
GP / Step down admissions to Community Hospitals HEALTH CARE SOCIAL CARE • Discharge training for SW staff supported by Practice Development Facilitator • Discharge training for Health Care staff supported by Practice Development Facilitator Within 48 hrs of receipt of referral of complex patients:-
Screening, allocation and commencement of assessment.
Consider patients for potential step-down or interim placement.
Ensure choice policy is followed. SOCIAL CARE Restart Care at Home packages and make referral to HDT SW (PRI) or Access Team (Community Hospitals) as appropriate
Ongoing assessment, documentation, referrals and review of goals set and planned date of discharge (PDD)
Direct access to Reablement as appropriate
Consideration of equipment / adaptation requirements For Non-Complex clients (Direct Access), reablement accepts client onto requested service(s)
Reablement services guaranteed to be in place within 48 hours of receipt of request
Restart Care at Home packages, and HDT / Access team liaise with Care at Home team leader and ward staff
For complex clients, ongoing assessment, documentation, referral and reviews of goals set and planned date of discharge.
Request all services for commencement on planned date of discharge Ward 4 conduct assessment and decide admission is not appropriate OR SOCIAL CARE Other support requirements:
Regular attendance at board rounds / MDT meetings
Regular contact maintained with family and carers.
Consideration of equipment or adaptation requirements. SOCIAL CARE Other support requirements
Throughout care, treatment and rehab, ongoing MDT referral / assessment
On completion of assessment, healthcare staff request any other services required
Ongoing identification of potential discharge issues
Ongoing MDT meetings and contact with family and carers HEALTH CARE HEALTH CARE Order medication
Transport for discharge
Finalise discharge date for all relevant Community based services
Finalise arrangement with family / carers HEALTH CARE PATIENT DISCHARGED "HOME" All services in place. Click here! To work through the Pathways in sequence, use the arrows at the bottom right of the screen. To freely explore the Pathways, click and drag with the mouse to move around, and use the mouse scroll wheel to zoom in and out. A S P I R A T I O N S Active discharge planning will be central to Hospital based care. RAG budget will be sufficient to fund people for care home placements I M P R O V E M E N T S • Increase the amount of social care equipment • Increased Reablement capacity (Immediate Discharge Service) for all hospital discharges • Review of hospital to home services being undertaken. • Immediate transfer to interim placement for people awaiting completion of social care arrangements / housing issues. Discharge Planning begins Day 0
Patient Admitted to Admission Ward Days 0-21
Patient receives ongoing care and rehabilitation in pre discharge ward area 7 Days before Discharge DAY 21
Patient clinically fit for discharge DAY 23 - 51
Patient delayed in their discharge Patient receives Anticipatory Care / Preventative Care Primary and Community Care staff
consider options for prevention of admission Decision to Admit Decision not to Admit Specific care, treatment and rehabilitation in pre-discharge ward Patient clinically fit to leave hospital following MDT decision which includes SW input I M P R O V E M E N T S I M P R O V E M E N T S • Introduction of daily 'board rounds' and functional screening tool • Implementation of SBAR tool to monitor potential and actual delayed discharges • Introduction of telephone referral processes for social work support for inpatients • Review and streamlining of all social work processes which impact on discharge • Named social worker for all P&K hospital wards • Increased social work assessment capacity through employment of four new social workers • Development and implementation of patient/carer leaflets outlining P&K councils discharge options • All SW referrals will be allocated to a hospital social worker except existing adult protection and guardianship cases • Introduction of reablement training for HCA's in community hospitals • Introduction of direct access to reablement by hospital OT staff. • Increased community rehabilitation and support for direct access • Increased health equipment e.g beds, hoists available to ensure timeous discharge • Plan that CRT OT's take on key worker roles for clients being discharged from hospital with reablement to home where they are actively involved with that patient • Development of 'step-down' model for people requiring further slow stream rehab on discharge. • Links developed with housing to progress housing issues • Twice daily screening of reablement requests • Introduction of direct access to reablement by hospital OT staff to reduce duplication of assessment and allow social workers to focus on complex clients • Purchase of 3 four-wheel drive vehicles to ensure patients are discharged in adverse weather Active discharge planning 7 days per week All appropriate healthcare staff will have direct access to reablement There will be a dedicated Social Worker for every ward area in Perth & Kinross Access to equipment 7 days per week 'Home' is the default position for all discharges No patients will be admitted to residential care directly from hospital All patients will be discharged within 24 hours of being clinically fit I M P R O V E M E N T S
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