Hospitals need to appoint a single discharge coordinator in order to stop the ‘revolving door of care’ for adults in hospital with social care needs, according to the National Institute of Health and Care Excellence (NICE) guidance released today.
The guidance aims to ensure people with social care needs leave hospital in a “coordinated and timely way” and avoid repeated hospital stays.
It calls for hospitals to appoint a single person responsible for co-ordinating an individual’s discharge, and commissioners of health and social care services to “develop a multi-agency plan to address pressures on services, including bed shortages”.
The discharge coordinator role could be specially created or the responsibility could be handed to a member of the multidisciplinary team. It would involve that person being the main point of contact for the patient/their family/other health professionals, sharing updates on the person’s health including medicines information and working with the hospital and community-based teams to agree a discharge plan.
They should also agree a plan for ongoing treatment and support with the community-based multidisciplinary team who will be providing care and ensure that any specialist equipment and support is in place before the person is discharged from hospital, if it is required.
According to the latest information from the National Audit Office, one million people were readmitted to hospital as an emergency within 30 days of discharge in 2012-13, costing the NHS £2.4 billion.
The NICE guidance also advises how to create closer communication between health and social care teams. This includes GPs and other relevant practitioners who are responsible for transferring people to hospital (including care home managers) sharing all appropriate information with the hospital when a person with social care needs is admitted.
Moreover, after the person is discharged the community-based multidisciplinary team should maintain contact through regular phone calls and home visits, and a community-based nurse or GP calling or visiting people at risk of hospital readmission 24 to 72 hours after discharge.
The person being cared for should also know how to contact their community-based health and social care team after they have left hospital, the guidance states.
Tony Hunter, chief executive of the Social Care Institute for Excellence (SCIE), said: “It’s really good that the guideline focuses on what should happen in hospital, from admission onwards and throughout someone’s stay, so that their discharge isn’t rushed or unplanned. We’re keen to encourage good collaboration between health and social care and people’s experience of transition between hospital and home is a key indicator on how well integration is working.”
See the full guidance here