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Target audience: Integrated Care Systems, Care Transfer Hubs, Multidisciplinary teams involved in the discharge process; and Voluntary, Community, Faith and Social Enterprise (VCFSE) partners (for example, admiral nurses).
Setting out the challenge
At any one time 25 per cent of hospital beds are occupied by people living with dementia (NHS England 2024) who often experience longer hospital stays and delays to discharge that result in reduced independence. Research into factors that contribute to delays in transfers of care for people with dementia (NHS London Clinical Networks, 2018), highlighted:
- difficulty with identifying rehabilitation potential in an acute environment
- lack of access to a person’s prior history hampering decision-making and personalised planning
- lack of joint working and poor communication and relationships between health and social care services
- difficulties in finding community service provision that meets the person’s needs
- lack of care partner involvement, where earlier participation could result in different outcomes.
These challenges are echoed for people with delirium, where research indicates people also experience higher rates of admission into high-dependency or intensive care units and an increased incidence of hospital-acquired complications such as infections and pressure injuries (Journal of Clinical Medicine, 2023).
Discharge pathways definitions (DHSC)
Pathway 0
Simple discharge home (to usual place of residence or temporary accommodation) co-ordinated by the ward without involvement of the care transfer hub, with:
- no new or additional health and/or social care and support
- self-management with signposting to services in the community
- voluntary sector support
- re-start of pre-existing home care package at the same level that remained active and on pause during the person’s hospital stay
- returning to original care home placement with care at the same level as prior to the person’s hospital stay.
Pathway 1
Discharge home (to usual place of residence or temporary accommodation) with health and/or social care and support co-ordinated by the care transfer hub, including:
- home-based intermediate care on a time-limited, short-term basis for rehabilitation, reablement and recovery at home
- re-start of home care package at the same level as a pre-existing package that lapsed
- returning to original care home placement with time-limited, short-term intermediate care
- long-term care and support at home following a period of intermediate care in the community.
Pathway 2
Discharge co-ordinated through the care transfer hub to a community bedded setting with dedicated health and/or social care and support, including bed-based intermediate care on a time-limited, short-term basis for rehabilitation, reablement and recovery in a community bedded setting (bed in care home, community hospital or other bed-based rehabilitation facility).
Pathway 3
In rare circumstances, for those with the highest level of complex needs, discharge to a care home placement co-ordinated through the care transfer hub, including:
- care home placement for assessment of long-term or ongoing needs and facilitation of patient choice in relation to the permanent placement
- long-term care and support in a care home following a period of intermediate care in the community.
Voices from stakeholders
80 per cent of the delays in our hospital are people waiting for long term care as their dementia has advanced and it’s become a battle for funding. Our most vulnerable patients then decondition further."
Discharge to assess needs to be individualised for this cohort, not a one size fits all approach which leads to being stuck in the hospital."
We have an obligation to try the person back home after a hospital stay before making long term decisions."
Outcomes
F1. Discharge planning is a standard that starts from admission, engages the person and their care partner, and focusses on getting the person home with the right support
F1.1. Develop processes/ protocols that fosters close working between ward staff and care transfer hub (CTH) multidisciplinary teams (or equivalent) to enable earlier discharge planning.
- There should be a shared understanding of processes, and planning for discharge between the teams, that maximise the person and their care partners involvement at the earliest moment possible (and include a review of available care plans). This reduces miscommunication, and enables consistent messaging and expectations, in line with the person’s wishes.
- Where there is a change in a person’s state that suggests a new functional baseline (i.e. better or worse than previously), this should be discussed with the person and their care partner. There should be a discussion between the ward team and the relevant members of the care transfer hub to agree together any change in expectations in relations to the patient’s goals and their plan for discharge.
F2. Teams that support discharge have the knowledge to respond to the needs of the person, maximising opportunities for rehabilitation and independence
F2.1. Emphasise a Home First approach (i.e. use Pathway 1) for people with dementia that maximises opportunities for independence and actively manages risk across organisations to reach a reasonable balance between safety (at all times) and independence.
Care transfer hub multidisciplinary teams could:
- Put in place a protocol to review transfer of care decisions to ensure they maximise the ability for the person to go to their usual place of residence. This requires a nuanced approach to discharge, as familiar faces and places impact the outcomes for people with dementia.
- Adopt the ethos that no long-term care decisions (including lack of rehabilitation potential) being made until the person with dementia or delirium is back in their usual place of residence.
- Have knowledge of the community interventions available for dementia and delirium, that best suit the pathway they will be leaving on, including adaptations at home where appropriate.
- Understand the value of a person-centred, therapeutic approach to discharge as an opportunity to regenerate hope, optimism and recovery for the person. This should, where applicable, also consider the role, ability and expectations of the care partner, to minimise the likelihood of carer breakdown.
- Be able to draw upon further mental health input where required to facilitate a safe transfer of care, including support from the liaison psychiatry team.
- Act as a conduit for seamless care, as the person transitions out of the hospital environment, and be able to coordinate the appropriate intervention in the community. This will require close working relationships with intermediate care and social care providers (as part of the wider multidisciplinary team).
- Maximise VCFSE organisations that have expertise in dementia care and can offer support to the person and their care partner in the transition back to their usual place of residence.
- Ensure good communication back to primary care and community mental health teams (or dementia specialist teams if applicable) to prevent any fragmentation in care, and facilitate any required post discharge support.