Discharge to Assess: who’s who and what do they do?

Bethany Deverson

Senior Sister, Elgar Enablement Unit, Southmead Hospital

Our ward is for older people who are ready to leave hospital, but need additional care in place to make sure that happens safely.

Elgar Enablement Unit is a sub-acute enablement unit, where people are well enough to be discharged from hospital, but are waiting for plans to be put in place to support their move from hospital to the community. This could be for help with social care, complex health and social care funding, or awaiting a discharge to assess pathway.

The multidisciplinary team (nurses, physiotherapist, occupational therapists) carries out assessments and completes a transfer of care document (ToC Doc). This is then reviewed by the community hub, who advise on the most appropriate pathway to meet the patient’s care and support needs. Once a discharge support pathway is identified and confirmed by community teams, we communicate with the patient and family members about the next steps and what to expect on discharge.

Communication is everything – with colleagues, patients and next of kin. We present all the discharge support pathways to patients and their families, so they have as much information as possible. We use information leaflets provided by community service providers, to help keep messages consistent. If someone is able to be supported on pathway one, we always advocate a home-first approach.

My role involves being the interface with the community services. I’m regularly part of complex multidisciplinary meetings to plan for discharge. We also meet together as hospital and community colleagues to develop discharge plans with patients.

There’s a lot more to discharge planning than just how a person can function and carry out activities of daily living. There are many complex social and family needs to consider too. It’s here that we access voluntary services such as Red Cross and other partners to support patients at home following discharge.

It’s not just filling in forms and referrals. It’s keeping the patient at the centre of the care planning and considering available care options with patients and family members, and all working towards a safe discharge from hospital and a safe transition to the community setting. I feel confident when patients are discharged to a discharge to assess pathway, as I know community partners will continue care and support for the patient.

I make a point of ensuring patients and their families are updated, even if there’s no outcome or discharge date known. It’s important for families to know we’re still working on a plan to get their loved one back home or to a community setting.

We’re in a unique sub-acute setting, therefore our focus is enablement and things that enhance patients’ hospital experience. We try to de-hospitalise the environment so they can enjoy their time with us. We run activities like dance and music; we have dogs visit. We want to make a difference for patients at the end of their hospital stay.

The best thing about my job is when people leave with support in place and are looked after with a community set-up that will allow them to thrive and avoid being readmitted. That’s a success for us.

Bethany poster

David Bailey and Rachel Lennon

Acute Discharge Case Managers, Southmead Hospital

We work with the most complex patients where more specialist support is needed. We also support ward colleagues to manage timely and safe discharges for all patients.

This is often people with mental ill health, dual diagnosis, drug and alcohol addiction, homelessness or social admissions.

We identify patients early, at the front door, to enhance patient experience and communication. It allows us to manage expectations and reduce length of stay, as well as maximising community services and increasing ward staff’s clinical capacity.

In addition to admission avoidance, we assist with rapid discharge for end-of-life patients, providing equipment, care and financial advice.

We work in different parts of the hospital. Rachel, a physiotherapist, works at the front door, where the focus is on avoiding admission by working with partners to identify a suitable non-hospital pathway as soon as they’re medically ready. David, an occupational therapist, works on MSK and neuro wards. Discharge case managers support each hospital ward.

When we have patients where the pathway doesn’t provide the specialist support that’s needed, we’re involved with community multidisciplinary meetings to find a suitable solution.

We recently discharged a vulnerable 69-year-old who was sofa-surfing, with no fixed address. He had a complex background, including drug abuse, possible undiagnosed learning difficulties, poorly managed diabetes and his family reported he was being financially abused.

The proposed option for him to be discharged to a hostel would have increased his chances of coming into contact with drugs, which could ultimately have increased risk of death. We worked with Bristol City Council social workers and housing teams, drug and alcohol services and Sirona community services to consider all the options.

Through this, he was discharged to extra care housing with a care package in place to support him. This was a really positive outcome for the patient.

We also see social admissions – for example, where couples are admitted together because the person who needs medical attention cares for their partner, who can’t manage without them. We then find ways to support the vulnerable partner, for example, through temporary respite care.

Another focus of our role is educating our colleagues as we have extensive skills, knowledge and expertise in discharge. We lead training about things like mental health capacity, homelessness and how to complete the Transfer of Care Document (ToC Doc).

We don’t get a lot of feedback, but the nicest we’ve had tends to come from the homeless community. They’re thankful for our support and feel listened to. One chap sent a message to say he’s got a job and a flat. That’s a great outcome.

We have a privileged role, stepping into a patient or family’s life and having a chance to make a difference.

David Bailey and Rachel Lennon poster

 

Freddie Bouchier

Social Prescribing Link Worker, Southern Brooks

My role is to be someone who is not a clinician; is not in scrubs or a uniform, who, in a busy hospital, just has a little more time to sit and chat with patients.

We try and draw out a more holistic picture of what is going on. When people are in hospital, they are medically unwell, but once that aspect is fixed, they need to get out of hospital because it isn’t the right place once they’re well. But it’s not always that simple.

That’s where we slot in. Talking to people, getting to know them, building that relationship with people and finding out what’s important to them. We try and really put them in charge of their care; how they see their life and how they see any problems they have or solutions they need, we work with them to draw that out.

This role is about building people up and nurturing something a little bit more long term. It can be a bit confusing being in hospital; you’re unwell, you’ve got lots of different people coming to see you, so we just try and keep it really simple, talk to them about what they need and build that relationship.

I feel like I’m supporting the clinical team, but also filling a really specific gap where there are people coming into hospital and the things that are stopping them leaving – which can be really small things – are not covered by other services. Someone just might not have any food in at home, but that’s stopping them being able to go home safely. Usually, it’s not a massive amount that’s needed to help most people get home.

We can help by telling people about local groups or charities that can help and supporting them in a more long-term way by connecting them with their local community. We stay in touch with people after they have been discharged too to make sure they have the right support in place long term. I think the role will actually help make communities stronger and more resilient in the long run; and that’s so important in improving things for everyone.

I hope people feel listened to, and helped and understood in a way they might not have been previously.

Freddie Bouchier poster

Jessica Cole

Acute Occupational Therapist, North Bristol Trust

Occupational Therapy generally is about being person-centred and helping people to achieve meaningful goals. We look holistically at the person, not just looking at their medical condition, but looking at their mental health, the people around them, their home environment and their whole situation.

What we do is different for everyone, we have to be so individualised; we have to be really good at talking to people and listening to them. We take the time to build that relationship, to understand how their mind works, in order to help us develop individualised treatment plans and rehab plans that are meaningful and useful to that person.

The ‘occupation’ in Occupational Therapy refers to tasks; we look at what someone needs and wants to do. The physiotherapist might say you need to do these exercises to strengthen your leg. In comparison, we might come in and say how do we make these exercises meaningful – it might be we say you’ve got carers putting cream on your legs, if you do that yourself you can make sure you have the right amount on and you’re looking after your own skin. In doing it themselves they’re bending and stretching and doing the strengthening exercise, but through something that feels useful to them; they’re doing it without realising. That can be more motivating.

We are always looking at how we can get people home safely and manage things for themselves; making sure there are the services in place so the things they want to aim for are achievable for them. Toileting is a major thing. If someone can’t go to the toilet on their own, you know they will not be going home independently. It’s so important.

For us, we need the time to get to know people. We probably spend longer with the patient than most other professionals. We want to know, not only what their short-term goals are, but their medium and long-term goals too. Everyone else whips in and out; although we must be focused on discharge, and we are time pressured, occupational therapy is about individual holistic wraparound support.

I work with the amputee service. If people have had an amputation and are saying I am basically stuck in one room once I get home, we will get them home safely, but then make the right referrals to make sure they have what they need to not be stuck; housing referrals, adaptation referrals, referrals to wheelchair services, referrals to charities for ongoing support managing their condition, mental health support for them and their family, as well as referrals for ongoing physical rehab.

We don’t just think about the person in hospital, we think around them. Will they be able to do this in their own home, at their friend’s home, in their work environment, in their afternoon clubs? Hospitals have wide corridors and smooth floors; home just isn’t like that so we have to think about how it will be at home.

It is important to make sure people are linked in with the right services on discharge. For example, if you know they are desperate to get back to work but that isn’t going to happen quickly, we make sure the referrals are in place for someone who can help them work towards that. We make sure they are followed up appropriately; even if we can’t fix something right now, we make sure the referrals are in place for someone to help them with that longer term.

We have to be realistic too, we do manage expectations. For people who have had a major life event like an amputation or a stroke life really can feel like it sucks. From the hospital we are limited in what we can access and achieve, and discharge options are limited, which can really impact people’s mental health. Part of managing expectations though is also about giving realistic hope. If people say ‘I’m stuck in my house’ we might be saying that’s true right now, but not forever – there are lots of other options. If they have the motivation, there are always options out there.

What I really like about occupational therapy is you can make it what you want it to be; it is treating the whole person, using what works for them, to inspire and motivate them, which makes the biggest difference.

We really listen to people. When you are in hospital it feels like lots of people are doing things to you; whereas we do things with people. We work in partnership with people to achieve their aims.

Jessica Cole poster

Luisa Covill

Social Worker, South Gloucestershire in-reach hospital social worker team

I have conversations with people in hospital about their social care needs. I start by speaking to the person to find out how they are and what they can and can’t do and what they want to happen when they are discharged. Ordinarily, I then gather information from physio and occupational therapists, along with updates from the medical team, to better understand the current situation.

In this process of assessment, I also consult our recording system to see if the person is known to us, access the GP and other medical notes, and talk to the person’s family with their consent, to get a really rounded view.

Through this, I gain a sound understanding of what it was like just before the person was admitted, as well as the situation leading up to it (this could be months and years). Then, I work with everyone involved to look at the best way forward to facilitate discharge – does what the person want, along with their physical and cognitive presentation, match what we can recommend and offer?

We do have to manage expectations. Sometimes the person is, for example, able to walk and, on the face of it, able to go home, but this may be tricky in reality. For example, I had a person who lives in an old building with uneven flagstone floors – the walking aid they needed just wouldn’t work on that floor; they couldn’t get upstairs to bed; and because the house was listed a stairlift couldn’t be installed. It’s things like this we have to look at and, as part of a team, work as far as possible to overcome them. We are coordinators. That would be a better word for us.

We support a large number of people who are admitted with respiratory and urinary tract infections, as well as falls. There are also social admissions where one half of a couple has been looking after the other. For example, the husband, a carer, comes in with a heart attack, but his 90-year-old wife can’t manage alone. In such cases, he is being supported medically, but she is also, unfortunately, in an acute hospital bed when her need is social.

There are also situations when the person did not have formal care in place at home, but, when talking to their next of kin, we realise the person was just about able to live at home because their family members were supporting them with 24/7 care which is not sustainable.

I think we bring it all together. We listen to the person, involve them in decisions and, when appropriate, their family, so that together we can come up with a way forward that is hopefully sustainable.

We have those difficult conversations because there are difficult decisions to be made. There are some risks we can mitigate; things we can put in place or remove, but, in some cases, we have to make everyone, including families, aware of what the risks of different options are so they can make decisions.

Every case is so different, with so many moving parts. I never cease to be amazed by people. We see it from everyone’s viewpoint – from all angles.

Luisa Covill poster

Ruth Speers

Social Worker, North Somerset Council

I give people without a voice, a voice.

Social work is about advocating for and supporting people when they’re struggling or things aren’t going as well as they could. We empower people to make decisions about their own lives.

As a safeguarding specialist, my role is to my role is to work with adults who have care and support needs who are at risk of abuse or neglect. We help keep them safe in line with their wishes and feelings.

There’s a school of thought that you’re born a social worker, you’re not made into one. That really resonates with me. Being a social worker is an identity. I believe it stems from the natural way we see the world, not how we have been taught to see it.

Social work is values-led. We tend to have a sense there’s injustice and a strong urge to address that and make society fairer.

We receive referrals for people who are going through or have been through the Discharge to Assess process and there might be risk of abuse of neglect at home, which could include self-neglect.

Unfortunately, social work – particularly safeguarding – is poorly represented and often still seen as scary – by both professionals and people. Depending on the circumstances, people don’t always welcome our involvement, but we tailor our language and approach to make it less scary.

Our work is about listening to understand what matters to people. Sometimes we have to meet in the middle, but we don’t ‘do to’ people.

We assess the risk, then work with people to make small steps to reduce or eliminate the risk, while respecting people’s choices and human rights. We support people to take positive risks. There is no point in making people safe if you also make them miserable.

As an example, someone who is self-neglecting might need a deep clean of their home to reduce the risk of fire or infestation. But they might not be ready to take that step, so we build a trusting relationship with them to make gradual improvements to them reach their goals.

The best thing about my job is supporting people from a wide range of backgrounds and building positive relationships with them. I also love multiagency working – everyone’s perspective is different.

Ruth Speers poster