What is Hospital Discharge?
Hospital discharge is a critical phase in a person’s life, signifying the transition from hospital care to continued recovery at home or in an alternative care setting. This occurs when a person no longer needs inpatient care. Hospital discharge undertakes a comprehensive evaluation of the person’s support needs to ensure a smooth and safe discharge. It involves coordinating various aspects, including medication management, follow-up care arrangements, and providing resources for ongoing health and social support. Furthermore, effective communication between the person, their family, and the healthcare team is vital to managing a successful transition, ensuring that the person’s needs are met post-discharge.
The discharge process extends beyond the physical act of leaving the hospital and consists of detailed planning and preparation to support the person’s recovery journey. Moreover, the involvement of community health services and local care providers plays a crucial role in providing additional care and support. By understanding the intricacies of hospital discharge and actively participating in the planning process, people and their families can contribute to a seamless transition, promoting better health outcomes and minimising the risk of complications.
Discharge Planning
Every hospital follows its own discharge policy, which includes a discharge assessment to determine if the person needs additional care, whether short-term support (intermediate care or reablement care) or long-term support. This assessment helps create a care plan that outlines the treatment, ensuring the person is discharged safely, and the support they will receive when they leave the hospital is effective. It also includes who will provide the ongoing care and how it will be monitored.
Hospital discharge planning should be a collaborative effort involving the care recipient, family and a multidisciplinary team, including a therapy team, social workers, support workers and nurse-led care, contributing to the process. This collaborative approach ensures that the discharge plan is tailored to the person’s needs, human rights, including aspects such as medication reconciliation, follow-up care arrangements, and the provision of necessary resources for ongoing support in better managing everyday tasks.
Leaf Complex Care focuses on the Transforming Care Agenda, to assist people in transitioning to their own homes, near their families, and within their local communities.
We collaborate with commissioners, case managers, and other care professionals to reduce delayed hospital discharges and help people achieve stability in their homes, whether alongside another provider or through our provider organisations.
Community Transition Support
Community Transition Services (CTS) are designed to support people who require complex care in transitioning from hospitals into their own homes, home-like environments, and supported living accommodations. The CTS aim to promote improved quality of life and ensure a smooth and successful transition into the community.
The key components of the Community Transition Support include:
Purposefully planned transition process
Holistic and specialist support
Person-centred approach and proactive care after hospital discharge
Multidisciplinary approach working across hospital and community settings
Family support
Community-based integrated services (social work, nursing, occupational therapy, and reablement services)
Ongoing support and monitoring
Finding personalised support that focuses on a person’s strengths during their most challenging moments can be a complex journey. Acknowledging these challenges and the potential risk of hospital readmissions, the Community Transition Services enables people to rejoin their local community, ensuring a smooth transition.
Experience trust, consistency, and reliability, supporting people to comfortably transition to the next chapter of their lives. Get safe and smooth transition support, with Nurseline Healthcare, one of our family organisations.
When Discharge is Unsafe
Unsafe patient discharge is a significant issue that can lead to negative outcomes and prolonged hospital stays. This often stems from inadequate discharge planning and a need for coordination among healthcare services.
Key factors contributing to unsafe discharge include:
The absence of a comprehensive home care plan
Premature discharge
Insufficient mental capacity assessment
Exclusion of family members in post-discharge care decisions
Unnecessary hospitalisation due to the unavailability of post-discharge care
Delays in hospital discharge are a widespread issue, often occurring when a person is ready to be discharged medically, but there are delays in ongoing care post-discharge. This can lead to unnecessary distress to the person and prolonged hospital stays. It is, therefore, important to plan for after-hospital care as early as possible to implement strategies to smooth the way towards discharge.
Our white paper study explored the personal experiences of people detained in a hospital. The numbers indicate that 66.7% found this environment unsupportive, 22.2% felt neutral, and only 11.1 % reported a positive experience. Delays in hospital discharge are emotionally and physically stressful for care recipients and their families who can’t wait to bring their loved ones home.
We further explored the distance people travelled to visit their family members in a hospital. Based on the results, 50% of the families had to travel at least 50 miles to see their loved one, in contrast to 37.5 % travelling within 100 miles and 12.5% within 300 miles.
Arranging home care and community support services when people transition is profound and affects people’s overall well-being for the better.
⇒ Learn more about Why Delayed Hospital Discharge is a Harm Event.
The Importance of a Smooth Transition
Leaving the hospital and returning home is the moment a person desires the most. A smooth transition is essential to ensure effective care and ongoing support. This involves coordinating efforts across care teams to develop a comprehensive support plan tailored to the person’s needs. Social services, respite care, and live-in care options may be necessary components of this plan to facilitate person-centred care in one’s own environment.
A well-planned transition considers the evolution of the treatment plan and adjusts the level of care accordingly as the recovery process progresses. And the lack of an adequate care continuum can disrupt the hard-earned progress made during the hospital stay. Therefore, it is crucial to have open communication between the person, their care providers, and their loved ones.
Continuity of Care
Following a hospital discharge, receiving continuity of care at home ensures a smooth recovery and helps prevent complications. The ongoing support encourages people to feel informed and empowered, which ultimately improves their overall quality of life. In addition, continuity of care highlights the importance of personalised and person-centred care that takes into account one’s health and social needs, personal preferences, and lifestyle.
This approach promotes comfort by allowing people to recover in their own homes. It also supports family members who often take the role of care assistants, providing them with necessary respite and support. Effective coordination and comprehensive care planning are essential to minimise rehospitalisation risks and ensure that people receive the right care and support they need during their recovery process.
Readmission Avoidance
In the UK, avoiding readmissions for people requiring complex care is a significant priority. Research indicates that reducing hospital stays and delivering care and support at home, when safe and appropriate, is beneficial for care recipients and more cost-effective. The Discharge to Assess (D2A) model has been successful in reducing hospital stays and ensuring timely discharges, which aligns with the strategic aim of providing more localised care.
According to NHS England and NHS Improvement (NHSEI), there was a 28% decrease in care recipients staying over 21 days in hospitals between winter 2020/21 and winter 2021/22, demonstrating the effectiveness of these strategies. Commissioners are essential in making sure people are discharged at the right time, to the right place, and with the necessary support, thus enhancing the efficiency of health and social care systems.
Community Care Services
Community care services are designed to support people in maintaining their independence and quality of life within their own homes and communities. These services are essential for helping people, particularly older adults and people with disabilities, to live with dignity and avoid social isolation. The primary aim of community care is to enable people to remain in their own homes, providing a range of services such as home care, adaptations to the home, and various recreational and educational activities.
Home Care Services
Tailored care at home provides essential support to people within a comfortable environment and can help ensure their daily social living needs are met. Home care offers numerous benefits, including personalised attention, a familiar environment, independence, autonomy, flexible care, and family involvement. The demand for home care has grown significantly, with the number of domiciliary care roles surpassing those in care homes. This shift highlights the increasing preference for home-based care solutions. Providing care in the comfort of a person’s home allows them to maintain familiar surroundings, routines, and connections with their community, which can reduce stress and anxiety.
Through our survey, 75% of care recipients who were in hospital care experienced stress, anxiety and signs of depression, while 45% had traumatic experiences. And still, only 20% of people received bespoke support at home.
Change needs to happen, and everyone should be able to express how they feel. Home is the place people have the most significant connection with and often where they want to receive their care.
White Paper Publication 2023
Download the White Paper Publication and stay up to date with the current state of the UK health and social care sector.
Personalised Care Plans
Tailored support begins with recognising a person’s needs and preferences, customising care plans to address specific challenges and promoting independence and quality of life. These personalised care plans take into account the unique circumstances and challenges people face, significantly improving their well-being. Developing personalised plans involves collaboration between the person receiving care, their family, and care professionals, ensuring that the care plan is comprehensive, holistic, and aligned with the person’s social needs and aspirations.
Download our case studies here.
Person-Centred Approach
The person-centred care ensures that people are actively involved in their own care decisions, allowing them to make informed choices about their well-being. Central to person-centred care is establishing trust-based relationships between care recipients and care providers committed to the person’s long-term well-being.
Please watch what families say about their loved one’s experience with Leaf Complex Care and the positive outcomes they achieved.
Care After Hospital Discharge with Leaf Complex Care
Leaf Complex Care offers comprehensive services designed to meet people’s unique needs. Reablement support is a key component of after-hospital care, helping people re-learn essential skills needed for daily life and activities. The therapy team, a core part of our support, consists of multidisciplinary in-house Positive Behaviour Support (PBS) specialists, Occupational therapists, and Speech and Language therapists. Person-centred care is at the heart of the therapy team’s approach, using the PERMA and Capable Environments models to enhance well-being.
Rapid Response and Crisis Support
Our Rapid Response team works closely with hospital teams, care recipients, their families, and other stakeholders to coordinate and deliver personalised care plans. This service can significantly speed up the discharge process by providing immediate, high-quality care at home. The crisis support service also helps people experiencing challenging times transition smoothly back home after unnecessary hospitalisations.
Our Rapid Response team ensures people get the right care in place within 4-6 hours of the initial call, depending on the location provided.
By providing the right support, the right care and the right culture, we encourage people to live life on their own terms.
Offices: Bristol, South East, Birmingham and Somerset
