Hospital Discharge: Discharge to Assess Beds Enter and View

Discharge to Assess (D2A) is a national default model for the NHS. Under D2A schemes, planning, assessment, and arranging ongoing care takes place in the D2A setting rather than the hospital. The NHS is responsible for determining which pathway a patient takes from hospital, and for identifying the match between a patient and a D2A bed.

We surveyed residents about their journey from their previous place of residence, admission to hospital and then discharge to the care home.

We talked to residents and staff about what was working well and what could be improved, and collated the feedback to make suggestions about how D2A could have a positive impact on the outcomes for people being discharged from hospital.

What we heard:

• All people met with stated their admission to hospital was unplanned, with many experiencing a fall or accident at home. Therefore, none had anticipated being in a residential setting, with many stating their preferred option would be a return home. Some recognised their situation had changed dramatically and reluctantly accepted they may require long term residential care.
• It was unclear what rehabilitation services and support people received whilst in hospital. However, people had mostly been in hospital for lengthy periods of time and so their motivation and abilities to self-care had been reduced.
• The information provided by hospitals to care homes as part of the admission process was often inadequate.
• The majority of people referred through the D2A scheme remained in long term residential care.
• The chances of a person being able to return home were increased where there was an allocated social worker for the care home who worked specifically with the residents placed through the D2A scheme. They had contact with the person soon after their admission and worked proactively and effectively with the care home, the person and their families to obtain the best outcome for the person.
• Linked with the above, social workers were able to access rehabilitation services quickly compared to situations where there was a delay in allocating a social worker, and a delay in identifying and arranging relevant rehabilitation services for the person.

Our recommendations include:

1. NHS Sussex should consider focussing some resources for the D2A scheme on those people where it is possible that they will be able to return home following a period of reablement and rehabilitation in residential care. The D2A scheme in East Sussex appears to be focussed on people are assessed in hospital as likely to need long-term residential or nursing care. The D2A scheme could potentially offer short-term support for people to help them recover in a community bed-based setting in residential care. There is a precedent for this reablement approach in West Sussex.
2. A short document needs to be produced by NHS Sussex setting out what the D2A scheme is and how it operates. This would ideally be co-produced with patients, carers and families, as well as care homes. This would be given to patients using the scheme as well as their relatives, so they know what to expect.
3. Nurses’ assessments provided by East Sussex Healthcare Trust (ESHT) and other NHS Trusts need to be carried out at the time of discharge and be in sufficient detail to enable the care home to make a preliminary assessment as to whether it is likely they will be able to meet the needs of that person. A short, one page set format could be devised with key headings, such as any specific health related needs, mobility, diet and mental health issues. This would provide a consistency to the discharge process.
4. The Hospital Discharge and Community Support Guidance stresses the importance of a multidisciplinary discharge team as well as the importance of working with the person being discharged and their carer or family. The Transfer of Care Hubs (TOCHs) at ESHT hospitals and other NHS Trusts should ensure that hospital multidisciplinary teams, including social workers, create clear goals and aims for people identified for ‘discharge to assess’ beds.
5. East Sussex Adult Social Care and Health should ensure timely allocation of social workers for people being discharged through the D2A scheme so that rehabilitation services can be started and/or continued immediately on admission to the care home and a plan for next steps is identified on admission to the care home.
6. NHS Sussex need to align rehabilitation services with discharge to care homes so that therapeutic input can be instigated quickly to maximise the chances of people being able to return home.
7. Healthwatch East Sussex should work with Care for the Carers to highlight the importance of identifying and involving carers in discharge planning, including promoting the NHS Think Carer E-learning developed with NHS Sussex for hospital staff. ESHT and other NHS Trusts should roll out this training to hospital staff to improve the involvement of carers in discharge planning.

Our report concludes that if these recommendations are adopted, more people may be able to return home and in a quicker timescale than currently the case. This may have a positive impact on the delayed discharges as the turnover in the D2A beds in care homes will be shorter, resulting in more people being able to be discharged from hospital. This would assist with the problem of large numbers of people being medically fit for discharge whose discharge is delayed.