Short Guide to help clinicians improve identification of the right patients for

the discharge to assess pathway

The discharge to assess pathway is designed to support patients to have an early

supported discharge. The guidance below describes how suitable patients can be
identified throughout the emergency pathway. The issues identified below are not
barriers to discharge, instead they should be viewed as reasonable challenges for the
MDT to resolve on behalf of the patient.

1. Assessment at point of first contact:

This is the best time to get accurate history from the paramedic, carer or relative
accompanying the patient about the baseline condition of the patient and the home
circumstances. It is worth telephoning the family or carer to get the history if no one
has accompanied the patient. IN particular, take note of their
o Normal behaviour
o Cognition
o Mobility
o Eating
o Bowel habits
o Medications

It is important to note the current package of care (POC), and family support
available. All this is included in the CGA (Comprehensive Geriatric Assessment)
which should be started on arrival.

At the point of arrival, it is important to ensure rapid intervention with therapy

assessments if appropriate on presentation, (not every patient routinely needs
OT/PT) so that discharge planning can occur as a priority from the first point of
contact to the service.

The aspiration is to get the patient well enough and functionally able to be rapidly
discharged with
o no support
o family support
o healthcare support
so that they can return to their usual situation in their own home as quickly as possible.

2. Think discharge from the point of first contact:

It is important to establish an Expected Date of Discharge to enable the MDT to co-

ordinate their efforts. It is also an important requirement for notification of social
services.

Ensure that early contact is made with social services ( Packages of care and
reablement) and community teams with expected discharge dates so that they are
prepared for discharge to avoid any delay.

Aim to return the patient to the place where they came from - a good outcome
measure is the proportion of patients returning to their own home.
3. Planning for Discharge home:

Medical issues:
o Are there any medical /nursing needs for the patient that can only be provided in an
acute hospital? If not, progress with discharge plans.
o Can any medical care be continued at home ? For example, IV antibiotics, home
oxygen, diuretics etc. which would enable discharge.

Mobilty:
o Is the patient at baseline mobility? If not can physiotherapy provide aids to make
them safe and reduce falls risk.
o Do they have stairs? Will they need a stairs assessment pre-discharge?
o Do they need a home falls assessment as part of an OT package?
o Will they benefit from a falls clinic or ongoing community physiotherapy?

Safety at home:
o OT assessment is best carried out at home rather than in artificial conditions in the
hospital where the patient is not familiar with the layout or equipment. If there is
concerned that the assessment at home may fail, retain the hospital bed for a few
hours until the OT has called in to give the outcome of the assessment.
o Can the patient eat and drink to keep nourished?
o How much help is needed and who will provide it?

Support network:
o If the patient is discharged home are there any care needs or support that family or
other agencies such as Age UK are able to provide? Is anyone able to stay overnight
on discharge to provide support on the day of discharge?
o If the patient has increased POC needs can this be done through the existing POC or
can CERT provide additional calls to expedite discharge?

Patient choice:
o What matters to the patient and what does the patient want? (one patient declined
an afternoon POC, as she wanted to meet up with her friends socially for lunch)
o Psychosocial Needs: Would they benefit from services such as night sits, befriending
services, financial advice and other services available through various agencies to
provide additional support on discharge?

Readmission:
o It is helpful to provide follow up contact details and a telephone check up the day
after discharge so that support for patient and carers is maintained, new issues may
be indentified that can be pro-actively managed in advance to avoid a crisis and
unplanned out of hours admissions.
o Be prepared for re-admissions, this is inevitable in this group of If the patient is re-
admitted it should be to the same team so the discharge momentum is carried
through. It is not necessarily a failure of discharge.
o Do not hesitate to discharge the patient again on the day of readmission if you are
confident of your assessment.

4. Discharge to a D2A step down bed in community hospitals:

If a patient needs more than 4 POC per day at discharge or they are deemed to need
24 hour care. If their normal place of residence was home, think of a step down bed
in a community (D2A bed)
 Continued reablement or nursing support in the step down setting, can often enable
return to home with appropriate POC or CERT at home.

Clinical Audit

Are we effective in identifying patients for discharge to assess?

Monitoring effectiveness is an important aspect of improvement; it is only by doing this

can we learn what is working and what is not working. This is best achieved by doing a
case file review, in this case we may start by looking at all patients admitted over the age
of 85 years. After studying the case notes each patient can be allocated to one of the
boxes in the 2x2 matrix below (Clinical Audit Template). The data will provide
information as to how effectively the system is operating and a direction as to how it can
be further improved. It is important to be challenging, perhaps, by involving an external
partner in the case file review.

The total number of patients managed on D2A & the number of success appropriate to
and managed on the D2A pathway should be plotted on a daily run chart to understand
variability and step changes in how the system is functioning. The aim should be to see a
gradual increase in use with the gap between the two lines reducing over time and less
variability between days.

Clinical Audit Template