community nurse elderly womanGuidance has been released by the UK Government for effective hospital discharges into community settings that will help health and social care professionals, and those involved in providing and installing assistive equipment into people’s homes, provide efficient, timely and person-centred care.

The Department of Health and Social Care’s (DHSC) new guidance is for NHS organisations, including commissioning bodies, and local authorities in England about hospital discharge and community support.

Effective since 1 April 2022, the guidance details how the health and social care sectors can work together to effectively plan and deliver hospital discharge and recovery services from acute and community hospital settings that are affordable within existing budgets.

There is a large focus on ensuring a local approach when planning hospital discharges. The push is to enable as many people can recover and rehabilitate at home in a timely manner, wherever possible, before their long-term health and care needs and options are assessed and agreed.

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Discharging people permanently into care homes for the first time should only occur in “exceptional circumstances”.

This ‘home first’ approach helps reduce the risk of infections and falls and free up vital hospital space, especially in light of NHS England recently reporting that, between December 2021 and March 2022, it experienced its busiest winter ever with record 999 volumes and ambulance call-outs for life-threatening conditions.

NHS bodies and councils are consistently urged to join up thinking and processes throughout the document, including through pooling budgets to speed up discharges.

The guidance importantly details that all local discharge and community support processes should be person-centred, take into account the views of the individual and any unpaid carers, and maximised the individual’s independence.

When local authorities and NHS organisations are making local funding arrangements, they should include clear information for self-funders of adult social care, so they can make informed choices about any onward care needs that do not fall under locally funded eligible costs, DHSC underlines.

Surrey County Council (SCC) and South Warwickshire Foundation Trust are used as examples of organisations that have successfully agreed funding for best outcomes locally.

DHSC stresses that discharges should start to be planned when a patient is admitted to hospital. This will enable the person and their family or carers to ask questions, explore choices and receive timely information to make informed choices about the discharge pathway that best meets the person’s needs.

Multidisciplinary teams are advised to work together to plan post-discharge care, long-term needs assessments and, where appropriate, end of life care.

The guidance also states that information should be given to patients, and anyone else who is involved with their care needs, about available community support and housing options post-discharge, including information about housing adaptations.

Furthermore, for people who have medical conditions which make them “frail” or less mobile, the guidance says that provision of assistive technologies should be included in discharge planning and procedures to help mitigate risks at home.

The guidance further reinforces the crucial need to free up hospital bed space: “If a person’s preferred placement or package is not available once they are clinically ready for discharge, they should be offered a suitable alternative while they await availability of their preferred choice. People do not have the right to remain in a hospital bed if they do not need acute care, including to wait for their preferred option to become available.”

Health and social care commissioners should consider how capacity across the system is being used to support people in their own homes and consider how resources can be best used to support this.

To make timely, appropriate, and joint-up discharges possible, the guidance says that ensuring organisations have clear roles when working together is important.

The guidance reads: “Senior level support from NHS providers and local authorities should provide strategic leadership and oversight of the discharge process to monitor and eliminate the causes of unnecessary discharge delays, and ensure that the agreed hospital discharge procedures are being followed consistently.

“NHS bodies, local authorities and other relevant partners should develop local protocols. These should set out each organisation’s role and how responsibilities should be exercised to ensure appropriate discussions and planning concerning a person’s short and long-term care options happen at the appropriate time in their recovery.

“To ensure hospital discharge processes are effective, NHS bodies and local authorities should also ensure local recovery, rehabilitation and reablement services are commissioned effectively and sustainably, and meet the needs of their local population in the short and long term that are affordable within existing budgets available to NHS commissioners and local authorities.”

Read the full hospital discharge guidance here.

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