INTEGRATED
DISCHARGE
PLANNING
Code of
Practice
for
Health Service ExecutiveCode of Practice for
Integrated Discharge Planning
Part 1: Background
HSE Code of Practice for Integrated Discharge Planning. Version 1.0. September 2008 .
This is a controlled document and may be subject to change at any time
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R ead er I n f o r m at i o n
Directorate: Health Service Executive (HSE)
T itl e: HSE C ode of P ractice f or I ntegrated D ischarge P lanning
Docum en t P urp os e: Standards & R ecommended P ractices— P art 1
Author: HSE N ational I ntegrated D ischarge P lanning Steering C ommit-
tee
P ub l ication Date: Septemb er 2 0 0 8
T arg et Aud ien ce: A ll relevant healthcare providers
Des crip tion : T he C ode of P ractice is a guide to the standards of practice re-
quired in the management of integrated discharge planning in
the HSE, b ased on current legal requirements and prof essional
b est practice
S up ers ed ed Docs : A ll previous local and national documents relating to integrated
discharge planning
R ev iew Date: Septemb er 2 0 0 9
C on tact Detail s : W inif red R y an,
N ational Hospitals O f f ice,
Q uality , R isk and C ustomer C are D irectorate,
M id- W estern R egional Hospital (N enagh)
N enagh,
C o. T ipperary ,
I reland.
E m ail : winif red.ry an@ hse.ie
W eb : www.hse.ie
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Fiona Quinn,
Winter Initiative,
HSE,
31/33 Catherine Street.
Limerick,
Ireland.
Email : [email protected]
Web: www.hse.ie
HSE Code of Practice for Integrated Discharge Planning. Version 1.0. September 2008 .
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F o r ew o r d
Foreword
The Code of Practice has been produced by the National Integrated Discharge Planning
Steering Committee as a guide to the required standards of practice in the management of
integrated discharge planning in the HSE and in any facility providing services on behalf of the
HSE.
The Code of Practice was drafted by members of the National Integrated Discharge Planning
Steering Committee and was prepared by utilising published guidance from expert bodies, and
existing best practice guidance and standards. Information has also been drawn from various
expert groups and reference sources. A national consultation process on the draft Code was
undertaken and feedback, where appropriate, was incorporated into the final version of the
Code. Work on the Code also benefited greatly from the input of Liz Lees, Consultant Nurse
( Acute M edicine) R G N, Dip N, B Sc ( hons) , Dip HSM , M Sc.
The Code provides:
1. A framework for consistent, coherent management of integrated discharge planning in
the Health Service Executive.
2. A reference point against which continual improvement and consultation can take
place.
The Code applies to healthcare facilities providing services on behalf of the Health Service
Executive under S.3 9 of the Health Act 20 0 4 . It is allied to work being undertaken on the
Transformation Programme—Develop integrated services across all stages of the care journey.
This is an evolving document because standards and practices in relation to integrated
discharge planning will change over time, particularly in the context of emerging primary care
teams and networks. It will therefore be subject to regular review and updated as necessary.
Part 1 - Background
HSE Code of Practice for Integrated Discharge Planning. Version 1.0. November 2008.
This is a controlled document and may be subject to change at any time. 3
HSE Code of Practice for Integrated Discharge Planning. Version 1.0. September 2008 .
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Contents
The document has been prepared in five main parts. There is an overall table of contents
following the foreword. E ach part of the document also has its own contents page, which
provides a detailed breakdown of all the sections and subsections in that part of the document.
Part 1 Backgrou nd T h i s p art p rov i de s t h e f ou ndat i on f or al l s t andards and re com m e nde d
p ract i ce s de t ai l e d i n t h e re m ai nde r of t h e docu m e nt .
Part 2 S tandards T he standards for integrated discharge planning are describ ed in this
section.
Part 3 Recommended
Practices
T his part identifies the recommended practices that are intended to
define correct management of integrated discharge planning.
Part 4 A u dit T ool T he au dit tool relates to the standards for integrated discharge planning
in the H ealth S erv ice E x ecu tiv e.
Part 5 A dditional Re-
sou rces & A p-
pendices
T his part inclu des a glossary , list of ab b rev iations and a reference list.
A ppendices inclu de the memb ership of the N ational I ntegrated D is-
charge Planning S teering C ommittee.
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Contents
ContentsF orew ord
P a rt 1
B a c k g rou nd P a g e
1. Introducti on 10
2 . H ow h e a l th ca re org a ni s a ti ons ca n i m p rov e th e i r di s ch a rg e p ra cti ce 13
3 . D e v e l op m e nt of th e H S E Inte g ra te d di s ch a rg e p l a nni ng C ode of P ra cti ce 15
P a rt 2
S ta nd a rd s
1. C om m uni ca ti on a nd cons ul ta ti on 6
2 . O rg a ni s a ti ona l s tructure a nd a ccounta b i l i ty 8
3 . M a na g e m e nt a nd k e y p e rs onne l 10
4 . E duca ti on a nd tra i ni ng 11
5 . O p e ra ti ona l p ol i ci e s a nd p roce dure s 13
6 . Inte g ra te d di s ch a rg e p l a nni ng p roce s s 15
7 . A udi t a nd m oni tori ng 2 1
8 . K e y p e rf orm a nce i ndi ca tors 2 3
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Part 3
R e c o m m e n d e d p rac ti c e s Pag e
1. Communication with patients/families/carers 7
2 . M ultidisciplinary team 11
3. Nurse (or HSCP/Other) facilitated discharge 14
4. Key task s pre-admission 18
5 . Key task s on admission 2 2
6 . Key task s during in-patient stay 2 6
7. Key task s 2 4 hours b efore discharge 2 9
8. Key task s day of discharge 31
9 . F ollow-up post-discharge and evaluation 33
10 . Self-discharge/discharge against medical advice 35
11. People who are homeless/living in temporary /insecure accommodation 37
12 . Planning discharge from hospital for people with dementia 38
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Contents
Part 4
A u d i t to o l
1. Introduction 5
2. G uide l ine s f or using th e audit tool 6
3 . R isk l e ve l cate g orie s 15
4 . S tandards f or inte g rate d disch arg e p l anning 16
5 . Q ual ity im p rove m e nt action p l an 18
6 . S tandard scoring sum m ary sh e e t 19
7 . Auditors’ note s 20
Part 5 A d d i ti o n al re s o u rc e s an d ap p e n d i c e s
1. R e f e re nce s
2. Abbre viations
Ap p e ndix 1: M e m be rsh ip of national inte g rate d disch arg e p l anning ste e ring com m itte e
Appendix 2: List of key stakeholder groups
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1. Discharge Checklist
2. Key Tasks
A ppendix 1: M em bership of N ational Integrated Discharge Planning Steering Com m ittee
A ppendix 2: List of key stakeholder groups
3. Patient Inform ation Brochure
4. References
5. A bbreviations
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Contents
Contents – Bac k ground P age
1 . I ntroduc ti on 1 0
1.1 Integrated discharge planning
1.2 W ho le sy stem s appro ach
1.3 C o m m o n A ssessm ent P ro cess and C o m m o n S u m m ary A ssessm ent R eco rd
1.4 T he principles o f integrated discharge planning
1.5 F acilitating b est practice
1.6 W hat is the b enef it?
2 . H ow h eal th c are organi sati ons c an i m p rov e th ei r di sc h arge p rac ti c e 1 3
2 .1 M anagem ent su ppo rt
2 .2 C linical leadership
2 .3 Inf o rm atio n sharing
2 .4 E du catio n and training
2 .5 C hange m anagem ent and o rganisatio nal learning
3 . D ev el op m ent of I ntegrated D i sc h arge P l anni ng Code of P rac ti c e 1 5
3 .1 Intro du ctio n
3 .2 D ef initio n
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Introduction
1 Introduction
1. 1 Inte g ra te d dis ch a rg e p l a nning
Patients being discharged from hospital should receive a seamless transition from one
stage of care to the next. A coordinated and patient centred approach to planning for
discharge can lead to increased satisfaction with healthcare services, reduced length of
stay and prevention of unplanned readmissions.
A patient centred approach to integrated discharge planning occurs when hospitals,
general practitioners (G Ps) and other Primary, Community and Continuing Care
(PCCC) providers coordinate care for the patient from the hospital to the community.
E ffective integrated discharge planning supports the continuity of healthcare, between
the healthcare setting and the community, based on the individual needs of the
patient. I t is described as “ the critical link between treatment received in hospital by
the patient and post- discharge care provided in the community” ...N S W D epartment of
H ealth (2 0 0 6 ).
1. 2 W h ol e s y s te m s a p p roa ch
O ur services cannot work in isolation from each other. E ffective multi- agency and
multi- disciplinary working is essential to manage the patient’ s j ourney from pre-
admission through hospital discharge to the community. T o achieve a truly patient
centered approach to integrated discharge planning, all stakeholders must accept their
inter- dependency and must work together to ensure that there are no gaps in services
or duplication of efforts. F or example, this approach may involve individuals or teams
working innovatively to enable the j oined up delivery of services that support
individual needs and the transition to an appropriate setting.
Achieving a whole systems approach req uires the enhancement and development of
relationships, built upon effective communication and cooperation, between primary,
community and continuing care (PCCC), hospitals, transport services and the relevant
voluntary sectors.
E ffective integrated discharge planning relies on knowledge of available healthcare
services, partnerships between organisations and a clear understanding of respective
roles. T he increased emphasis on a whole systems approach challenges us to
coordinate services across organisational boundaries in order to deliver seamless and
appropriate services for patients.
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Introduction
1.3 Common Assessment Process and Common Summary Assessment
R ecord
In December 2006, following a Government decision, the Minister for Health &
Children announced plans for a significant change in how long term residential care is
provided and paid for. U nder the new legislation, the HSE has statutory responsibility
to ensure that people with demonstrated need will be able to access state funding for
long term residential care. To effectively implement this scheme a number of processes
have been implemented by the HSE as follows:
Common Assessment Process ( CAP) and Common Summary Assessment
R ecord ( CSAR ) .
Integrated Care Pathways— eq uitable access to Home Care & L ong Stay Care
( Public & Private) .
1.4 T he principles of integ rated discharg e planning
Integrated discharge planning is considered as a process, not an event. The
process will encompass key elements: written discharge information, provision
of a discharge plan and an estimated length of stay.
Supporting this process, integrated discharge planning systems should include:
i. The allocation of responsibilities across healthcare services ( which
involves defining roles and identifying and reviewing communication
channels) .
ii. Well-defined discharge policies, procedures and activities.
iii. Discharge documentation that accompanies the patient throughout the
episode of care.
iv. Provision for stakeholder feedback and response to that feedback.
v. Methods for managing impediments to good discharge practice.
A documented discharg e plan should commence at or before admission to
hospital. The discharge plan should be subj ect to ongoing assessment
throughout the hospital stay to take account of changes in patient and carer
health and social status.
The assessment and discharge process must be person centred. The patients’
interests and wishes should be taken into account when considering future care
options. This should involve ongoing consultation with the patient and his/her
family/carer/advocate.
Integrated discharge planning is the responsibility of all healthcare providers
in partnership with the patient/carer/family. A staff member should be
identified as being responsible for ensuring that all aspects of integrated
discharge planning have been addressed by the time of discharge.
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Introduction
A multi-disciplinary and multi-agency approach is the most appropriate one
for the development and implementation of discharge plans. T o achieve best
practice the multi-disciplinary teams should work together collaboratively and
in a planned and integrated manner. In addition to hospital and community
staff, it is important that integrated discharge planning includes the transport
services and voluntary/ non-statutory partners.
Effective integrated discharge planning should be co nsistent for all patients
receiving care in the healthcare system.
T he ability to discharge effectively is dependent on the av ailab ility o f a range o f
serv ices to meet ongoing or longer-term care needs. T hus the discharge plan
should take account of any additional resources required to effect the discharge
and work towards a resolution.
1 . 5 F acilitating b est practice
F acilitating best practice involves the following steps:
1 . P atient assessment that is thorough and covers pathological, physiological,
psychological, social and cultural needs (including the patients’ home(s) and
social circumstances).
2 . P lanning that the patient, carer, nurse, doctor and other appropriate members
of the multidisciplinary team conduct together. T he documentation of this
discharge plan is filed in the patient healthcare record and regularly revised.
3 . T he plan’s implementatio n, which involves patient and carer education,
referrals to hospital-based and P C C C services, and communication with P C C C
service providers and general practitioners (G P s).
4. T he f o llo w -up of patients after discharge, to evaluate the effectiveness of the
planned interventions and ensure continuity of care.
1 . 6 W h at is th e b enef it?
G etting discharge right benefits everyone:
P atients want information about their treatment, how long they are likely to
stay in hospital and when they can ex pect to be discharged. T his helps the
patient to access services when they need them, have their needs identified and
have care delivered in a setting appropriate to their needs.
Improved pre-planning of patient care will result in less stress for staf f and a
better working environment.
H ealth care f acilities will be enabled to employ their valuable resources to
max imum effect.
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Ho w h eal t h c ar e o r gan i s at i o n s c an s u c c es s f u l l y i m p r o v e t h ei r d i s c h ar ge p r ac t i c e
2 How healthcare organisations can successfully improve their
d ischarge practice
2. 1 M anagement support
Management should support the change and review new integrated discharge
planning policies and procedures for integration into day to day patient care.
Management should provide ongoing support of work practice change by
involving all relevant healthcare staff and encouraging them to learn from
examples of success.
2. 2 C linical lead ership
S uccessful improvement of integrated discharge planning involves the
championing and clinical leadership of improved patient care processes.
The hospital consultant has continuing clinical and professional
responsibility for patients under his/ her care and each member of the multi-
disciplinary team has a k ey leadership role to play with regard to their area of
expertise within the team.
2. 3 I nformation sharing
Effective communication between hospitals, GPs, PCCC, voluntary and private
service providers is essential to ensure a coordinated patient j ourney from pre-
admission through to discharge. To ensure q uality and timely communication, there
should be a uniform approach to information management across the public sector in
acute and the PCCC sectors. This may involve:
Conducting multi-disciplinary and multi-agency forums to discuss integrated
discharge planning issues.
Conducting formal education sessions for particular groups or services.
Educating hospital and PCCC staff about the healthcare services available in
the region.
W ork ing together to develop local service directories. These directories may
include contacts, service descriptions and process information. They may also
contain referral forms and a description of the eligibility criteria for each
service.
Ensuring local service directories are accessible to staff and up-to-date, and
encouraging staff to use them.
I dentifying information needed to help staff communicate with other
healthcare providers.
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Ho w h eal t h c ar e o r gan i s at i o n s c an s u c c es s f u l l y i m p r o v e t h ei r d i s c h ar ge p r ac t i c e
Considering privacy and confidentiality issues when implementing
information systems.
Developing patient information with patients/families/carers to ensure that
it is relevant, legible and understandable.
2.4 Education and training
Staff should be informed and educated about any changes in integrated
discharge planning practice.
Staff should be given the k nowledge, sk ills and tools to identify and
implement real improvement in integrated discharge planning.
Training needs analysis should be conducted as part of staff induction
programmes and ongoing integrated discharge planning training needs
should be identified.
2.5 C h ange m anage m e nt and organis ational l e arning
A ll staff involved in the integrated discharge planning process should
participate in the improvement effort.
P atients should also be involved in changing work practice that directly or
indirectly improves patient care.
The organisation should evaluate whether change improves patient care,
reduces delays, reduces duplication and increases patient and staff
satisfaction.
The organisation should generate a culture that is comfortable with change
and seek s continuous improvement in integrated discharge planning.
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Development of the Integrated Discharge Planning Code of Practice
3 Development of Integrated Discharge Planning Code of
Practice
3. 1 Introdu ction
The Code of Practice was developed as follows:
Extensive literature search.
Consideration of the opinion of experts knowledgeable in the subj ect.
Consideration of the available current best practice, both in Ireland and
internationally, that may impact on integrated discharge planning.
Organisation of a series of national workshops to discuss integrated discharge
planning with key stakeholder groups.
Development of draft standards and recommended practices that were
distributed for consultation to key stakeholders.
Incorporation of feedback, where appropriate, into the final version of the
Code.
3. 2 Definition
The Integrated Discharge Planning Standards present a standardised approach to
integrated discharge planning in the Health Service Executive ( HSE) , from pre-
admission to post-discharge. The aim of the Standards is to enhance patient safety and
improve continuity of care from the hospital to the home and community. The
Standards will be used to direct and evaluate integrated discharge planning practices in
the HSE.
S tandards = Organisational structures and processes needed to identify, assess and
manage specified risks in relation to integrated discharge planning.
Each standard has a title, which summarises the area on which that standard
focuses.
This is followed by the standard statement, which explains the level of
performance to be achieved.
The rationale section provides the reasons why the standard is considered to be
important.
The standard statement is expanded in the section headed criteria, where it
states what needs to be achieved for the standard to be reached.
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Development of the Integrated Discharge Planning Code of Practice
Recommended Practices = recommendations concerning best practice in relation to
integrated discharge planning.
The Recommended Practices are intended to define correct management of integrated
discharge planning. They are also intended to serve as the basis for policy and
procedure development in integrated discharge planning in acute hospitals and local
health offices.
Each recommended practice has an introdu ction, which summarises the area
on which the recommended practice focuses.
This is followed by the recommended practice scope, which explains the
obj ective of the recommended practice and why it is considered to be
important.
The contents section outlines the contents of the recommended practice.
This is expanded in the section headed procedu re, where it states how each
recommended practice can be achieved.
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Health Service ExecutiveCode of Practice for
Integrated Discharge Planning
Part 2: Standards
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Part 2
Par t 2
S t an d ar d s
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Contents
Cont e nt s – S t andar ds P ag e
1 . Com m u ni c at i on and c ons u l t at i on 6
1.1 Standard Statement
1.2 R ati o nal e
1.3 C ri teri a
2 . O r g ani s at i onal s t r u c t u r e and ac c ou nt ab i l i t y 8
2 .1 Standard Statement
2 .2 R ati o nal e
2 .3 C ri teri a
3 . M anag e m e nt and k e y p e r s onne l 1 0
3 .1 Standard Statement
3 .2 R ati o nal e
3 .3 C ri teri a
4 . E du c at i on and t r ai ni ng 1 1
4 .1 Standard Statement
4 .2 R ati o nal e
4 .3 C ri teri a
5 . O p e r at i onal p ol i c i e s and p r oc e du r e s 1 3
5 .1 Standard Statement
5 .2 R ati o nal e
5 .3 C ri teri a
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6 . I n t egrat ed d i s c h arge p l an n i n g p ro c es s 1 5
6.1 Standard Statement
6.2 R ati o nal e
6.3 C ri teri a
7 . A u d i t an d m o n i t o ri n g 2 1
7 .1 Standard Statement
7 .2 R ati o nal e
7 .3 C ri teri a
8 . K ey p erf o rm an c e i n d i c at o rs 2 3
8 .1 Standard Statement
8 .2 R ati o nal e
8 .3 C ri teri a
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Communication and consultation
1 Communicat ion and cons ult at ion
1. 1 S t at e me nt
Appropriate and effective mechanisms shall be in place for communication and
consultation on matters relating to integrated discharge planning, with key
stakeholders within and outside the organisation.
1. 2 R at ionale
Interactive, timely ex change of information with key stakeholders creates an
empowering infrastructure and environment. These are important factors for enabling
the integrated discharge planning process and for continually improving and
enhancing performance over the continuum of care.
1. 3 Cr it e r ia
1 . The organisation shall develop a set of shared values, behavioural guidelines and
quality principles in support of the H ealth S ervice E x ecutive C ode of Practice for
Integrated Discharge Planning that are reflected in job descriptions and vision
statements.
2 . H ealthcare workers and patients shall be given an opportunity to provide feedback
on these values, guidelines and quality principles.
3 . These values, guidelines and quality principles shall be reflected in each
departments’ business plans.
4. The organisation shall develop and implement a practical methodology for sharing
best practice in relation to integrated discharge planning, both internally and with
key stakeholders.
5. The organisation shall inform their staff, local healthcare providers and patients
about the H ealth S ervice E x ecutive C ode of Practice for Integrated Discharge
Planning.
6 . E ducational material shall be provided using a variety of different media as
required.
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Communication and consultation
7. H ealthcare providers and k ey stak eholders shall b e encouraged to use customer
f eedb ack mechanisms to help inf orm service improvement and learning.
8. The organisation shall have in place a f ormal sy stem f or recording and analy sing
customer f eedb ack in relation to integrated discharge planning.
9. The organisation shall have in place a programme to reduce customer complaints
in relation to integrated discharge planning.
10. R elevant inf ormation f rom recording and analy sing customer f eedb ack in relation
to integrated discharge planning shall b e used to continuously improve the service.
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2 Organisational structure and accountability
2.1 S tandard S tatem ent
Responsibility for integrated discharge planning shall be clearly defined and there shall
be clear lines of accountability throughout the organisation.
2.2 Rationale
The CEO/ Manager (i.e. hospital CEO/ manager or local health office manager)
through the senior management team, is responsible for ensuring that there are
effectiv e arrangements for integrated discharge planning.
2.3 C riteria
1 . I ndiv idual responsibility for integrated discharge planning shall be defined
throughout the organisation and there shall be clear lines of accountability leading
up to the most senior manager of the organisation.
2 . The scope of responsibility shall include the competence of contractors where the
organisation buys in serv ices and professional liability where the organisation buys
in or sells serv ices to other organisations.
3. I ntegrated discharge planning shall be a standard item on the agenda of the
appropriate committee in the organisation. The D ischarge Co-ordinator (or
designated indiv idual) shall submit regular reports on management of integrated
discharge planning to the committee.
4 . A monthly report on the effectiv eness of integrated discharge planning shall be
submitted to the appropriate committee for rev iew. This committee, which shall
include in its membership the CEO/ Manager or CEO/ Manager nominee, shall
present the report (with suggestions, where appropriate) to the management team.
5. Each organisation shall identify a discharge co-ordinator (or designated
manager...see note overleaf). The duties of the designated person shall not be
confined to any one aspect of the integrated discharge planning function but shall
encompass all integrated discharge planning processes wherev er they occur within
the organisation.
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Each organisation shall identify discharge co-ordinators (or a designated
m anager... see note overleaf ). The duties of the designated person shall not be
confined to any one aspect of the integrated discharge planning function but shall
encom pass all integrated discharge planning processes wherever they occur within
the organisation.
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6. The discharge co-ordinator (or designated individual) shall have responsibility and
authority for developing and monitoring policies, continuous q uality
improvement and/ or strategies for integrated discharge planning for approval by
the or appropriate committee.
7. The discharge co-ordinator (or designated individual) shall attend appropriate
meetings and conferences, local and national, relevant to integrated discharge
planning, to increase their knowledge and improve their ability to undertake the
role.
8. The discharge co-ordinator (or designated individual) shall undertake the
dissemination of information relating to integrated discharge planning, where
relevant, to all key stakeholders, both within the organisation and externally.
9. The discharge co-ordinator (or designated individual) shall work with clinicians
and departmental/ line managers to develop and improve the systematic approach
to integrated discharge planning.
10. The discharge co-ordinator (or designated individual) shall be responsible for
ensuring that the integrated discharge planning audit activity under the
responsibility of each head of department has been completed.
11. Each individual delivering care along the care continuum (this includes staff at
ward level and staff in PCCC services) shall be made aware of their responsibility
in relation to integrated discharge planning.
Note: S maller organisations may decide that the role of the discharge co-ordinator is
best performed as part of the duties of a discharge co-ordinator in a larger
organisation in the network/ PCCC region. W hat is important is that:
The CEO/ Manager takes active responsibility for integrated discharge planning.
The reporting pathways are clearly defined.
The resources devoted to integrated discharge planning are adeq uate.
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Management and key personnel
3 Management and key personnel
3.1 Standard Statement
Appropriately qualified key personnel shall be in place to ensure that integrated
discharge planning is provided safely, efficiently and cost- effectively.
3.2 R ati o nal e
T o ensure a high quality and safe, integrated discharge planning process.
3.3 C ri teri a
K ey persons and responsibilities shall be as follows:
1. T he CEO/Manager ( i.e. hospital CEO /manager or local health office manager)
shall put in place arrangements to ensure effective and efficient management of
integrated discharge planning.
2 . A discharge co-ordinator ( or designated individual) shall be identified, shall have
formally defined responsibilities in accordance with these Standards and shall be
provided with the necessary resources and authority to discharge these
responsibilities.
3. T he discharge co-ordinator ( or designated individual) shall have an appropriate
combination of experience and qualifications to undertake his/her role.
4. T he discharge co- ordinator ( or designated individual) shall work with designated
N u rses ( or H S CP s/Others) for integrated discharge planning and shall ensure that
these personnel have been trained to the necessary standard of competence.
5 . H eal thcare p rof essional s shall have appropriate training on the principles of
integrated discharge planning and shall have a good knowledge of the Health
Service Executive Code of Practice for Integrated Discharge Planning.
6 . Appropriate I CT ex p ertise and support shall be available for integrated discharge
planning.
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E d u c at i o n an d t r ai n i n g
4 Education and training
4.1 S tandard S tatem ent
Education and Training in relevant aspects of integrated discharge planning shall be
provided to all new and existing staff members (both permanent and temporary).
4.2 Rational e
All clinical and administrative staff should have a general knowledge of the principles
of integrated discharge planning.
4.3 C riteria
1 . I n addition to g eneral induction training th ere s h al l b e a s tructured integ rated
dis ch arg e p l anning f oundation training p rog ram m e f or rel ev ant m anag ers and s taf f
com m ens urate w ith th eir w ork activ ity / res p ons ib il ity to incl ude th e f ol l ow ing :
i. Communication with patients/families/carers in relation to integrated
discharge planning.
ii. Multidisciplinary team.
iii. Nurse (or HS CP/Other) facilitated discharge.
iv. K ey tasks before admission.
v. K ey tasks on admission.
vi. K ey tasks during admission.
vii. K ey tasks 2 4 hours before discharge.
viii. K ey tasks on day of discharge.
ix. F ollow- up post discharge and evaluation.
x. S elf- discharge/discharge against medical advice.
xi. I nformation technology training specific to the integrated discharge planning
function.
2 . I nduction training in integrated discharge planning shall be provided to each staff
member (where relevant) and shall be documented in the individuals training record.
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3. Staff from acute and PCCC services shall participate in joint training sessions. Such
sessions shall have a common focus and shall include a focus on person centred care
across the continuum of care.
4 . Acute and PCCC services shall work in partnership to provide training opportunities
which shall increase staff understanding of the role that their services play in the
continuum of care, and the sk ills req uired.
5. T here shall be a continuing programme of training (internal organisation training on
HSE Code of Practice for I ntegrated Discharge Planning) and education (external
professional education) for staff on integrated discharge planning. Departmental
records of staff attendance at further training in integrated discharge planning shall be
k ept.
6 . T raining shall be supported with adeq uate resources and facilities.
7 . Competencies in integrated discharge planning across the organisation shall be
assessed and records shall be k ept.
8. A formal appraisal system shall be in place to monitor staff performance and to
identify individual training needs.
9. T he organisation shall undertak e an annual training needs analysis for integrated
discharge planning and shall develop a training plan to support the needs identified.
Note: I ntegrated discharge planning principles and processes shall be incorporated into
undergraduate and postgraduate clinical education for all disciplines.
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Operational policies and procedures
5 Operational policies and procedures f or integrated discharge
planning
5.1 S tand ar d S tatem ent
Written policies, procedures and guidelines for the integrated discharge planning
process shall be based on the Health Service Executive Recommended Practices for Integrated
D ischarge Planning ( Part 3 ) , shall be available, implemented and shall reflect relevant
legislation and published professional guidance.
5.2 Ratio nale
Formal documented control of integrated discharge planning within a quality
management system is necessary to monitor each aspect of the patient j ourney in order
to demonstrate compliance with current legislation and guidance. This will reduce
risks to patients, staff and the organisation and will ensure person centred care across
the patient pathway.
5.3 C r iter ia
1. The organisation shall have documented policies, procedures and guidelines for all
of the key elements of the integrated discharge planning process as outlined in the
recommended practices sections of the HS E Code of Practice for I ntegrated
D ischarge Planning. These policies, procedures and guidelines (where assessed as
relevant), shall include:
i. Communication with patients/families/carers in relation to integrated
discharge planning.
ii. M ultidisciplinary team working.
iii. Nurse (or HS CP/Other) facilitated discharge.
iv. K ey tasks pre- admission.
v. K ey tasks on admission.
vi. K ey tasks during in- patient stay.
vii. K ey tasks 2 4 hours before discharge.
viii. K ey tasks on day of discharge.
ix . Follow- up post discharge and evaluation.
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Operational policies and procedures
x. Self-discharge/discharge against medical advice.
xi. M edication management.
xii. P rocedures with dealing for vulnerable patient groups, e.g. people who are
homeless/living in temporary accommodation and people with dementia.
xiii. IT training.
2. All policies and procedures associated with integrated discharge planning shall
comply with current legislation, H ealth Service E xecutive guidance and published
professional guidance.
3. The appropriate committee shall approve policies, procedures and guidelines for
integrated discharge planning in the organisation.
4. There shall be a system to ensure each department or service has access to a
current copy of the approved integrated discharge planning policies, procedures
and guidelines pertinent to its activities.
5 . All relevant staff shall be req uired to read the integrated discharge planning
policies and procedures relevant to their area of work and to sign a statement to
indicate that they have read, understood and will comply with same.
6 . All policies and procedures associated with integrated discharge planning shall be
controlled documents (showing date of issue and revision number) to ensure that
current versions are available to all who need to use them.
7 . M aster copies shall be kept in a secure location in accordance with good records
management practices.
8. Obsolete documents shall be removed from all points of use and dealt with, in line
with good records management practices.
9. A biennial review of all policies, procedures and documents associated with
integrated discharge planning shall be undertaken to check their relevance and
issue status.
10. A document management system for the control and management of integrated
discharge planning policies and procedures shall be available within the
organisation.
11. All electronic data shall be stored securely, backed up and audited regularly.
12. Access to data/records shall be restricted to authorised named persons and
specified information shall be maintained in line with relevant legislation.
13. Staff shall have access to the Intranet as appropriate.
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Procedures for dealing with vulnerable patient groups, e.g. people who are
hom eless/living in tem porary accom m odation and people with dem entia.
ICT training.
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Integrated discharge planning process
6 Integrated discharge planning process
6. 1 S tandard S tatement
Integrated discharge planning shall include the patient and as appropriate, the family/
carer in the development and implementation of the patient’s discharge plan and shall
ensure that steps are taken to address necessary linkages with other healthcare
providers in order to ensure a seamless transition from one stage of care to the nex t.
6. 2 R ationale
T o ensure that every patient discharged from a Health S ervice Ex ecutive (HS E)
healthcare facility and from those facilities providing services on behalf of the HS E, is
transitioned safely to the community with appropriate arrangements for their
continuing care.
6. 3 C riteria
Assessment
1. Pre-admission assessments shall be conducted for patients who have planned
admissions to hospital.
2. Patient assessment regarding potential for delayed discharge shall begin either
prior to admission or at first presentation to the hospital.
3. Patient assessment shall continue throughout the patient’s hospital stay.
4. S tandardised, up-to-date, patient healthcare records shall be readily accessible at
pre-admission and throughout the patient’s stay in hospital.
5. T he healthcare facility shall have in place defined agreements regarding access
(including prioritisation of access) and response times for both internal and
ex ternal diagnostic services.
Note: The Common Summary Assessment Record (CSAR) should be utilised, where appropriate.
R ef erral
6. Referral shall be made to the other members of the multi-disciplinary team as
appropriate (this includes referral to PCCC services) and this shall be documented
in a timely manner.
7. Referral shall be made to the diagnostic services by the appropriate personnel and
this shall be documented as appropriate.
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8. Receipt of referrals shall be documented on a integrated discharge planning
track ing form in the patient’ s healthcare record within 24 hours of receiv ing the
referral. N ote: this includes referral from hospital to P C C C serv ices.
Nurse (or HS CP/Other) facilitated discharge
9. The suitability of the patient for Nurse (or HSCP/Other) facilitated discharge
shall be agreed with admitting clinician in conjunction with the multi-disciplinary
team.
10 . W ithin one hour of patient admission to the ward, an appropriate and competent
Nurse (or HSCP/Other) from the ward shall be identified and assigned to actively
manage the patient pathway of care.
11. The healthcare record shall indicate that it is a Nurse (or HSCP/Other) facilitated
discharge and the name of the Nurse (or HSCP/Other) shall be documented.
12. The Nurse (or HSCP/Other) shall be up to date on all aspects of the patient care
pathway, particularly focusing on the current medical and nursing condition and
discharge plan.
Estimated length of stay
13. Each patient shall have an estimated length of stay.
14. The estimated length of stay shall be identified by the admitting consultant in
conjunction with the multi-disciplinary team, during pre-assessment, on the post-
tak e ward round or within 24 hours of admission to hospital and shall be
documented in the patient’s healthcare record.
15 . The estimated length of stay shall be based on the anticipated time needed for
tests and interventions to be carried out and for the patient to be clinically stable
and fit for discharge. Note: the actual length of stay is dependent on the patient’s
condition and circumstances.
16. The estimated length of stay shall be discussed and agreed with the patient/family
and carers.
17 . The estimated length of stay shall be proactively managed against the treatment
plan (usually by ward staff) on a daily basis and changes shall be communicated to
the patient/carer.
18 . A ny changes to the estimated length of stay shall be communicated to the PCCC
services, as appropriate.
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Treatment plan
19. Each patient shall have a medical treatment plan.
20. The medical treatment plan shall be discussed and agreed with the patient/family
and carers.
21. The medical treatment plan shall be documented in the patient’s healthcare
record.
D i s c h arg e plan
22. I ntegrated discharge planning shall commence at pre-admission or on admission
and shall include information about the patients’ pre-admission abilities in
relation to potential discharge issues.
Trans po rt arrang ements
23. Transport arrangements shall be confirmed 24 hours before discharge.
C o mmu ni c ati o n
24 . Peri-operative services or pre-admission clinics shall communicate planned
admissions to PCCC service providers before admission.
25 . The hospital shall notify PCCC service providers of unplanned admissions at the
time of hospitalisation, as appropriate.
26. When aware of a patient’s admission, PCCC service providers shall contact the
hospital department ( as appropriate) to discuss premorbid health status to ensure
continuity of care while the patient is in hospital.
27. The hospital shall advise PCCC service providers, as appropriate, of the planned
discharge date as soon as possible, and at least two days prior to patient discharge
( for patients who are in-patients for five days or longer) to enable them to plan the
necessary post-hospital service commencement.
28. Two-way communication between the hospital and the GP and other PCCC
service providers, as appropriate, shall be arranged to ensure such services are
available and in place for the patient to use when needed post discharge.
29. The discharge check list shall be completed twenty four hours before discharge to
ensure all of the above activities have been carried out.
30. The family/carers, GP and other PCCC service providers shall be contacted at
least the day before discharge to confirm that the patient is being discharged and
to ensure that services are activated or re-activated, as appropriate.
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31. At the time of leaving the hospital, each patient shall be provided with an
information pack containing relevant information such as patient/carer plan, a
medication record, and information.
32. Information and education shall be provided to the patient and the family/carer
in the appropriate language, verbally and in written form relating to:
i. The anticipated course of treatment and estimated length of stay.
ii. O ngoing health management.
iii. An appropriate post- discharge contact to answer q ueries and address
concerns.
iv. M edications.
v. The use of aids and eq uipment.
vi. F ollow- up appointments.
vii. PCCC based service appointments.
viii. Possible complications and warning signs.
ix . W hen normal activities can be resumed.
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Transfer and discharge communication
33. The transfer or discharge communication shall include information under the
following headings:
Organisation Name.
Patient identification information.
Responsible clinician name and contact details.
Ward or department or specialty issuing the discharge document ( including
contact details) .
Patient’s registered GP details/referring clinician if different.
Patient’s PH N details.
D iagnoses on discharge ( including problem list) .
Patient alerts/allergies.
I nfection status ( as appropriate) .
Presenting problem/complaint ( include current diagnoses) .
Procedures and investigations.
Results of investigations.
Relevant findings on sy stems review, ex amination findings and summary of
management care plan.
F unctional state ( self- care/baseline mobility /walk ing aids and appliances)
on discharge.
Medications and diets including nutritional supplements and relevant
information on administration of medicines.
The name, signature, grade and contact details of the member of staff who
has completed the transfer/discharge communication.
D ischarge plan.
The name, signature, grade and contact details of the member of staff who
has completed the discharge plan.
The name and title of the receiving clinician in the case of a transfer.
34 . Transfer/discharge communications shall be multi- disciplinary where multi-
disciplinary care is to be continued.
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35. A copy of the transfer/discharge communication which is completed before
discharge shall be sent to the patient, the patients GP, PHN and other healthcare
providers (e.g. Nursing Home) and a further copy shall be retained in the
healthcare record.
36. T ransfer/discharge communication shall be authorised by the relevant responsible
healthcare professionals (including contact details) .
37. A copy of the Common S ummary Assessment R ecord (CS AR ) shall be included,
where appropriate.
38. Where a decision to recommend the patient for long-term residential care has
been made, it shall be documented in the healthcare record that the patient was
informed within fifteen days of that decision being made.
Time of discharge
39. E ach patient discharge shall be effected (i.e. hospital bed becomes available for
patient use) by 1 2 noon on the day of discharge. T his includes completion of all
necessary discharge procedures, documentation of the time of discharge in the
healthcare record and communication with patients, carers and other healthcare
providers (where relevant) .
F ol l ow- u p of discharge pl an
4 0 . Contact shall be made with all referred patients within three days post discharge
(either via telephone and/or contact with the GP and other PCCC service
providers) to find out if the problems identified as requiring intervention post-
discharge were adequately addressed and to deal with any new problems.
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A u d i t an d m o n i t o r i n g
7 Audit and monitoring
7.1 S tandard S tatement
Audits shall be carried out to ensure that the local policies and procedures for
integrated discharge planning conform to the required Standards and that the
processes undertaken conform to the policies and procedures. The audit results shall
be used to identify opportunities for improvement.
7.2 Rational e
Audit is necessary to provide evidence that the system of integrated discharge planning
in place is effective.
7.3 C riteria
1. Audit of integrated discharge planning shall include:
i. Accountability arrangements.
ii. Staff knowledge, expertise and resources.
iii. P rocesses, including risk management arrangements.
iv. P olicies, procedures and guidelines.
2. Each relevant head of department shall be responsible for preparing a written
agreed programme which shall ensure that all aspects of integrated discharge
planning within their department are audited at least once a year.
3. Each relevant head of department shall be responsible for ensuring that the audit
is conducted in accordance with this programme.
4. Each relevant head of department is responsible for ensuring that any deficiencies
identified during audit are reported and discussed with line management [and the
discharge co-ordinator (or designated individual)] and for verifying the efficacy of
remedial actions undertaken.
5. The discharge co-ordinator (or designated individual) shall be responsible for
ensuring that the audit activity, under the responsibility of each relevant head of
department has been completed.
6. The appropriate committee shall be responsible for the implementation and
monitoring of a integrated discharge planning audit and monitoring programme
in each organisation.
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Each relevant head of department is responsible for ensuring that any deficiencies
identified during audit are reported and discussed with line management and the
discharge co-ordinator (or designated individual) and for verifying the efficacy of
remedial actions undertaken.
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A u d i t an d m o n i t o r i n g
7. Audit results shall be fed back to the discharge co-ordinator (or designated
individual) , the appropriate committee, relevant staff and the organisation
management team.
8. Audit results shall be included in the appropriate annual report.
9. Audit results shall be used to help inform and improve integrated discharge
planning practices.
10. The audits shall be carried out by appropriately trained auditors.
11. The senior management team shall submit an annual assurance statement on
audit findings for consideration and approval by the Network Manager/Assistant
National Director Primary Community and Continuing Care (PCCC) .
12. The Network Manager/Assistant National Director PCCC shall submit annual
assurance statements on audit findings to the Director of the National H ospitals
O ffice/Director of Primary, Community and Continuing Care.
13 . E x ternal national audits of integrated discharge planning shall be carried out as
appropriate under the direction of the Assistant National Directors of Quality,
R isk and Customer Care.
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The audits shall be carried out by appropriate personnel trained in the audit tool.
14. The audit should form part of a cycle of continuous improvement and re-auditing
going forward.
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Key p er f o r m an c e i n d i c at o r s
8 Key perf ormance indicators
8.1 S tandard S tatement
Key performance indicators that are capable of show ing improvements in the efficacy
of integrated discharge planning in the organisation shall be used.
8.2 Rationale
Key performance indicators are designed to demonstrate improvement in the
performance of integrated discharge planning services over time.
8.3 C riteria
Assessment
1. Patient assessment shall begin either prior to admission or at f irst presentation to
the hospital.
Ref erral
2. Receipt of referrals shall be documented on a integrated discharge planning
tracking form in the patient’s healthcare record w ithin 24 hou rs of receiv ing the
ref erral. N ote: this includes referral from hospital to PC C C services.
N u rse ( or H S C P / O ther)
3 . W ithin one hou r of patient admission to the w ard, an appropriate and
competent N urse ( or H S C P/ Other) shall be identified and assigned to actively
manage the patient pathw ay of care.
4. This N urse ( or H S C P/ Other) shall be up to date on all aspects of the patient care
pathw ay, particularly focusing on the current medical and nursing condition and
discharge plan.
E stimated leng th of stay
5 . E ach patient shall have an estimated length of stay.
6. The patient’s estimated length of stay shall be identified du ring pre- assessment,
on the post- tak e w ard rou nd or w ithin 24 hou rs of admission to hospital and
shall be documented in the healthcare record.
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Nurses (or HSCPs/Others)
Within one hour of patient admission to the ward, appropriate and
com petent N urses (or H SCPs/O thers) shall be identified and assigned to actively
m anage the patient pathway of care.
These N urses (or H SCPs/O thers) shall be up to date on all aspects of the patient car
pathway, particularly focusing on the current m edical and nursing condition and
discharge plan.
Each patient shall have a docum ented length of stay.
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Key p er f o r m an c e i n d i c at o r s
7. The estimated length of stay shall be discussed and agreed with the patient/family
and carers.
T reatment plan
8 . E ach patient shall have a medical treatment plan.
T ranspo rt arrangements
9 . Transport arrangements shall be confirmed 2 4 ho urs b efo re discharge.
C o mmunicatio n
10. The hospital shall advise PCCC service providers, as appropriate, of the planned
discharge date as soon as possible, and at least two days prio r to patient discharge
( fo r patients who are in- patients fo r fiv e days o r lo nger) to enable them to plan
the necessary post- hospital service commencement.
T ransfer/D ischarge co mmunicatio n
11. A copy of the transfer/discharge communication which is completed b efo re
discharge shall be given to the patient and sent to the patients GP, PHN and other
healthcare providers (e.g. Nursing Home) and a further copy shall be retained in
the healthcare record.
T ime o f discharge
12. E ach patient discharge shall be effected (i.e. hospital bed becomes available for
patient use) by 1 2 no o n on the day of discharge. This includes completion of all
necessary discharge procedures, documentation of the time of discharge in the
healthcare record and communication with patients, carers and other healthcare
providers (where relevant).
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A copy of the transfer/discharge communication which is completed before
discharge shall be given to the patient and sent to the patient’s GP, PHN and other
healthcare providers (e.g. Nursing Home) and a further copy shall be retained in
the healthcare record.
Each patient discharge shall be effected (i.e. hospital bed becomes available for
patient use) no later than 12 noon on the day of discharge. This includes completion
of all necessary discharge procedures, documentation of the time of discharge in the
healthcare record and communication with patients, carers and other healthcare
providers (where relevant).
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Health Service ExecutiveCode of Practice for
Integrated Discharge Planning
Part 3: Recommended Practices
41
HSE Code of Practice for Integrated Discharge Planning. Version 1.0. September 2008 .
This is a controlled document and may be subject to change at any time
Directorate: Health Service Executive (HSE)
T itl e: HSE C ode of P ractice for Decontamination of Reusable Invasive
Medical Devices
Docum en t P urp os e: Standards & Recommended P ractices
Author: Decontamination of Reusable Invasive Medical Devices Steering
C ommittee
P ub l ication Date: July 2007
T arg et Aud ien ce: A ll staff in the HSE who work in C entral Decontamination
Units, Endoscopy Units, Dental Services and other relevant staff
with responsibility for decontamination of reusable invasive
medical devices
Des crip tion : T he C ode of P ractice is a guide to the standards of practice re-
quired in the decontamination of reusable invasive medical de-
vices in C entral Decontamination Units, Endoscopy Units and
Dental Services, based on current legal requirements and profes-
sional best practice
S up ers ed ed Docs : N A
R ev iew Date: July 2009
C on tact Detail s : W inifred Ryan,
N ational Hospitals O ffice,
Q uality, Risk and C ustomer C are Directorate,
Mid-W estern Regional Hospital (N enagh)
N enagh,
C o. T ipperary,
Ireland.
E m ail : [email protected]
W eb : www.hse.ie
Directorate: Health Service Executive (HSE)
T itl e: HSE C ode of P ractice for Discharge P lanning
Docum en t P urp os e: Standards & Recommended P ractices— P art 3
Author: HSE N ational Discharge P lanning Steering C ommittee
P ub l ication Date: A pril 2008
T arg et Aud ien ce: A ll relevant staff in the HSE
Des crip tion : T he C ode of P ractice is a guide to the standards of practice re-
quired in the management of discharge planning in the HSE,
based on current legal requirements and professional best prac-
tice
S up ers ed ed Docs : ?
R ev iew Date: A pril 2009
C on tact Detail s : W inifred Ryan,
N ational Hospitals O ffice,
Q uality, Risk and C ustomer C are Directorate,
Mid-W estern Regional Hospital (N enagh)
N enagh,
C o. T ipperary,
Ireland.
E m ail : [email protected]
W eb : www.hse.ie
Page 3
Par t 3
P art 3
R ecom m en d ed P ractices
f or in teg rated d is charg e p l an n in g
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Page 4
Contents
Contents – Pa r t 3
Pa g e
1 Com m u ni c a ti on w i th p a ti ents/ f a m i l i es/ c a r er s 7
1.1 Introduction
1.2 S cop e
1.3 C onte nts
1.4 P roce dure
2 M u l ti - di sc i p l i na r y tea m 11
2 .1 Introduction
2 .2 S cop e
2 .3 C onte nts
2 .4 P roce dure
3 N u r se ( or HS CP/ O th er ) f a c i l i ta ted di sc h a r g e 14
3 .1 Introduction
3 .2 S cop e
3 .3 C onte nts
3 .4 P roce dure
4 K ey ta sk s p r e- a dm i ssi on 18
4 .1 Introduction
4 .2 S cop e
4 .3 C onte nts
4 .4 P roce dure
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Contents
Page
5 K ey t as k s o n ad m i s s i o n 2 2
5.1 Introduction
5.2 S cop e
5.3 C onte nts
5.4 P roce dure
6 K ey t as k s d u r i n g i n - p at i en t s t ay 2 6
6 .1 Introduction
6 .2 S cop e
6 .3 C onte nts
6 .4 P roce dure
7 K ey t as k s 2 4 h o u r s b ef o r e d i s c h ar ge 2 9
7 .1 Introduction
7 .2 S cop e
7 .3 C onte nts
7 .4 P roce dure
8 K ey t as k s o n d ay o f d i s c h ar ge 3 1
8 .1 Introduction
8 .2 S cop e
8 .3 C onte nts
8 .4 P roce dure
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Contents
Page
9 F o l l o w - u p p o s t d i s c h ar ge an d ev al u at i o n 3 3
9.1 Introduction
9.2 S cope
9.3 Contents
9.4 P rocedure
1 0 S el f - d i s c h ar ge/ d i s c h ar ge agai n s t m ed i c al ad v i c e 3 5
10.1 Introduction
10.2 S cope
10.3 Contents
10.4 P rocedure
1 1 Peo p l e w h o ar e h o m el es s / l i v i n g i n t em p o r ar y / i n s ec u r e ac c o m m o d at i o n 3 7
11.1 Introduction
11.2 S cope
11.3 Contents
11.4 P rocedure
1 2 Pl an n i n g d i s c h ar ge f r o m h o s p i t al f o r p eo p l e w i t h d em en t i a 3 8
12.1 Introduction
12.2 S cope
12.3 Contents
12.4 P rocedure
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Communication with patients/families/carers
1 Communicat ion wit h pat ie nt s /car e r s /f amilie s
1. 1 I nt r oduct ion
Patients , fam il ies and carers who are ful l y engaged at al l s tages of the adm is s ion to,
length of stay in and discharge from hospital can better understand what is happening
and what outcomes are ex pected. For patients who are discharged home, education
about self-management can reduce re-presentations and readmissions to hospital. Part
of this education should deal with medication management, since re-presentation to
hospital is often associated with medication mismanagement.
1.2 Scope
The obj ective of this procedure is to provide guidelines in relation to integrated
discharge planning and communication with patients, families and carers.
1.3 C on t en t s
Section One: Estimated length of stay
Section Two: D ischarge plan
Section Three: I nformation pack
Section Four: I ndividualising information
Section Five: Medication management
Section Six : Feedback
1.4 Procedure
Sect i on O n e: E s t i m a t ed l en g t h of s t a y
The estimated length of stay should be identified as soon as possible (at pre-
admission or on admission) and discussed with patients, families and carers.
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Communication with patients/families/carers
Section Two: Discharge plan
The discharge plan should be developed with the patient/ family/ carer in
order to ex plore options for the patient’s care post hospitalisation, including
family members, voluntary services and other healthcare providers.
The discharge plan should be discussed with the patient/ family/ carers to
ensure that they understand the plan, medication management regime and so
on.
The C ommon Assessment Process ( C AP) and C ommon S ummary
Assessment R ecord ( C S AR ) shall be ex plained to the patient/ family, where
appropriate.
Section Three: I nf orm ation pack
An information pack should be developed in which to keep all information
brochures and sheets for the patient/ family/ carer.
Patient information should be developed with patients/ families/ carers, to
ensure that it is relevant, legible and understandable.
Patients and carers should be involved in determining what information
should be provided.
The inf orm ation pack may include the following:
i. The names and telephone numbers of hospital/ PC C C contacts in the
event that the patient has questions following discharge.
ii. Details about the patient’s medical condition.
iii. Details about the patient’s health management, including activity and
diet advice.
iv. Details about ongoing investigations, including any special instructions.
v. The date, time and location of the appointments for any investigations,
where possible.
vi. Medication management information, including instructions on
administration, the management of side- effects, and storage.
vii. Details about follow- up appointments, including the name and address of
the healthcare provider, the date and time of the appointment and the
reason for the appointment.
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Communication with patients/families/carers
Section Four: Individualising information
The Nurse (or HSCP/Other) who is facilitating discharge should find out
what is important to the patient/carer and what are their concerns.
Medical terms should be clearly explained.
I nformation, either written or verbal, should be timely, repeated and checked
out to ensure patients and carers understand that information.
The Nurse (or HSCP/Other) who is facilitating discharge should check that
the patient/carer understands the diagnosis, the reason for particular
treatments and how to perform or use treatments.
The Nurse (or HSCP/Other) who is facilitating discharge should check
whether the patient/carer understands what follow-up is required and why
this is required.
The Nurse (or HSCP/Other) who is facilitating discharge should confirm
that the healthcare facility and the patient/carer have a shared understanding
of the problem and the plan of action.
The Nurse (or HSCP/Other) who is facilitating discharge should confirm
that the patient/carer agrees with the plan of action.
Members of the multidisciplinary team should give the patient/carer and
family members an opportunity to ask questions.
The needs of patients with poor vision, cognitive deficits, cultural and
language barriers should be considered.
The method of education which is best suited for a specific patient
population or individual should be assessed.
Section Five: M edication management
A complete medication management history, including over-the-counter and
complementary medicines should be taken.
Contraindications, allergic reactions and interactions between medications
should be checked.
The pre-admission medication management list should be reconciled with the
list of medication prescribed on the hospital drug chart and any anomalies
resolved.
D osing should be simplified where possible.
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Communication with patients/families/carers
Patients (families/carers) should be provided with verbal and written
information including:
i. Medicine contents.
ii. H ow to take the medicine.
iii. A ctions of the medicine.
iv. Benefits, adverse effects and side effects of the medicine.
The medication management details listed on the discharge summary/
communication, the discharge prescription and the patient information
should be cross checked for accuracy.
Patients (families/carers) should be taught to monitor their medication use.
Patients (families/carers) should be taught self-monitoring skills (for ex ample
peak flow measurement, blood glucose readings, blood pressure).
Patients (families/carers) should be helped to learn how to obtain their test
results (for ex ample, drug levels, blood glucose tests, clotting times).
Patients (families/carers) should be provided with medication management
charts.
C ounselling and family/carer therapy should be provided for complex
medication management regimes (for ex ample, insulin, antidepressants,
biologicals).
Education regarding self-management should be documented in the patients
healthcare record.
Section Six : F eedb a ck
Healthcare services should learn ab out the effectiveness of their integrated
discharge planning b y ob taining patient/ family/ carer feedb ack on the q uality
of discharge processes in the acute hospital and P C C C settings.
T his information should b e used to give feedb ack to staff ( particularly positive
reinforcement of activities that meet patient and carer needs) and to identify
how to improve integrated discharge planning practices.
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Education regarding self-management should be documented in the patient’s
healthcare record.
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M u l t i d i s c i p l i n ar y t eam
2 M ul t i di s ci pl i na ry T ea m
2.1 I nt roduct i on
Multidisciplinary teams are groups of professionals from different disciplines, who
work together to provide comprehensive patient assessment and treatment. The
benefits of effective multidisciplinary team work ing include timely and effective patient
discharge, increased patient confidence, continuity of q uality care, enhanced
communication and partnership regarding resource management. The patient, their
carer and family must be viewed as essential members of this multidisciplinary team.
2.2 Scope
The obj ective of this procedure is to provide guidelines in relation to the
multidisciplinary team and integrated discharge planning.
2.3 C ont ent s
Section One: Membership
Section Two: Roles and responsibilities
Section Three: Documentation and the healthcare record
Section Four: Team meetings
Section Five: Case conferences
2.4 Procedure
Sect i on O ne: M emb ers h i p
Regular multi-disciplinary forums across the hospital and local health office
should be established to ensure admission, discharge and transfer of care are
planned appropriately.
The multidisciplinary team should consist of any number of people who are
involved in patient care, including hospital, primary and P CCC services staff.
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The multidisciplinary team should consist of any number of people who are
involved in patient care, including hospital and PCCC services staff.
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M u l t i d i s c i p l i n ar y t eam
Section Two: Roles and responsibilities
The responsibilities of the multi-disciplinary team in taking a more pro-active
approach to discharges should be clarified.
Responsibilities should be agreed around the following:
i. Who can identify and document the estimated length of stay?
ii. Who can review the patient?
iii. H ow multi-disciplinary decisions are made about when the patient is
clinically stable and fit for discharge or safe to transfer?
Staff in the acute hospital services should be informed and educated about
P C C C services and vice versa.
Section Th ree: D ocu m entation and th e h ealth care record
The estimated length of stay should be documented in the patient’ s
healthcare record.
The treatment plan should be documented in the healthcare record, reviewed
daily and updated in response to changing needs.
The discharge plan should be documented in the healthcare record, reviewed
daily and updated in response to changing needs.
Relevant internal referrals ( diagnostics, health & social care professionals,
specialist nursing services, liaison services, etc) should be made to the various
members of the multidisciplinary team and this should be documented as
appropriate.
The C ommon Summary A ssessment Record ( C SA R) should be completed,
where appropriate.
Receipts of referrals should be documented on an integrated discharge
planning tracking form in the patient’ s healthcare record within 2 4 hours of
receiving the referral.
The patient’ s healthcare record should be kept up to date and legibly signed
by each member of the multi-disciplinary team.
P rogress should be documented as intervention commences.
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The patient’s healthcare reco rd should be kept up to date and legibly signed
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M u l t i d i s c i p l i n ar y t eam
Section Four: Team meetings
The multidisc iplinary team should meet to further plan patient c are, set goals
and adjust timeframes for discharge, where necessary.
Family members and carers should be encouraged to attend multi-disciplinary
team meetings where appropriate. O therwise they should be k ept informed
of-up-to date integrated discharge planning arrangements. This information
should be documented.
Multi-disciplinary review team meetings should be planned, where
appropriate, to ensure continuity of patient care.
Section Five: Case conferences
Where there are complex needs or significant input of services req uired by
the multi-disciplinary team/PCCC services, a case conference may well be
appropriate and should be considered.
Typically, this should involve all/any k ey personnel from each service to
establish the needs of the client and how best they may be delivered.
The case conference should also include patients, families and carers as
appropriate.
Note: The Common Assessment Process (CAP) and Common Summary Assessment Record
(CSAR) shoul d b e undertak en f or those p ati ents w ho w i l l req ui re access to l ong term
resi denti al care.
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N u r s e ( o r H S C P/ O t h er ) f ac i l i t at ed d i s c h ar ge
3 Nurse (or HSCP/Ot her) f acilit at ed discharg e
3.1 I nt roduct ion
Many patients will require healthcare services from a number of different disciplines
including medicine, nursing and health and social care professionals. Effective
integrated discharge planning will thus need to reflect a full understanding of the
patient’s medical condition and the resources that the patient can access on discharge
from the hospital. Research indicates that assigning responsibility to a named
individual for coordinating progress through the system results in improved and timely
integrated discharge planning.
3.2 Scope
The obj ective of this procedure is to provide guidance in relation to Nurse (or HSCP/
Other) facilitated discharge.
3.3 Cont ent s
Section One: General principles
Section Two: Criteria for the Nurse (or HSCP/Other) to undertak e discharge
Section Three: Education and training
Section F our: D ischarge framework
Section F ive: I nforming patients
Section Six : L egal liability
3.4 Procedure
Sect ion One: G eneral principles
The suitability of the patient for Nurse (or HSCP/Other) facilitated discharge
should be agreed by the admitting consultant in conj unction with the multi-
disciplinary team.
Within one hour of patient admission to the ward, an appropriate and
competent Nurse (or HSCP/Other) from the ward should be identified and
assigned to actively manage the patient pathway of care.
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N u r s e ( o r H S C P/ O t h er ) f ac i l i t at ed d i s c h ar ge
This Nurse (or HSCP/Other) should be up to date on all aspects of the
patient care pathway, particularly focusing on the current medical and
nursing condition and discharge plan.
The healthcare record should indicate that it is a Nurse (or HSCP/Other)
facilitated discharge and the name of the Nurse (or HSCP/Other) should be
documented.
If the patient is transferred to another ward or healthcare facility, the Nurse
(or HSCP/Other) who is facilitating discharge should provide a formal
transfer of responsibility to the Nurse (or HSCP/Other) who is facilitating
discharge in that ward or healthcare facility.
If the Nurse (or HSCP/Other) who is facilitating discharge is off duty, a
second named team member should provide cover to ensure continuity of
care planning.
The Nurse (or HSCP/Other) who is facilitating discharge should source and
co-ordinate client information and links with families, carers, primary care
teams and voluntary agencies where appropriate.
This two-way process of information sharing should be standardised and
formalised.
The format of this communication should be agreed locally (e.g. e-mail or fax)
and these details should be readily available.
Section Two: Criteria for Nurse (or HSCP/Other) to undertake discharge
The ability to advocate on behalf of the patient and family/carer.
The ability to educate patients, family/carer and other staff.
A dvanced clinical knowledge in the speciality area.
Well-developed communication and negotiation skills.
The ability to work as a member of the multidisciplinary team.
Detailed knowledge of what services are available and to whom.
The ability to assess and make critical decisions regarding discharge.
The support of their manager/director of nursing/lead clinician to confirm
that:
i. Their post is one in which they will have the need and opportunity to
initiate and authorise discharge.
ii. Local protocols and patient criteria have been developed, agreed and are
in operation
iii. They will have access to, and the support of, the multi-disciplinary clinical
team.
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If the patient is transferred to another ward or healthcare facility, the Nurses
(or HSCPs/Others) who are facilitating the transfer or discharge should provide
a formal transfer of responsibility to the Nurses (or HSCPs/Others) who are
facilitating discharge in that ward or healthcare facility.
If the Nurse (or HSCP/Other) who is facilitating discharge is off duty, an
other named team member should provide cover to ensure continuity of
care planning.
The Nurses (or HSCPs/Others) who are facilitating discharge should source
and co-ordinate client information and links with families, carers, PCCC
Services and voluntary agencies where appropriate.
Nurses (or HSCP/Other) should be up to date on all aspects of the
patient care pathway, particularly focusing on the current medical and
nursing condition and discharge plan.
If the Nurses (or HSCPs/Others) who are facilitating discharge are off duty, a
second named team member should provide cover to ensure continuity of
care planning.
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N u r s e ( o r H S C P/ O t h er ) f ac i l i t at ed d i s c h ar ge
Section Three: Education and training
Nurses (or HSCPs/Others) preparing for a role within discharge should
undertake specific education and training.
The training programme should provide the Nurse (or HSCP/Other) with
supervision, support and opportunities to develop competence in authorised
discharge practice.
Competency in integrated discharge planning should be successfully
completed and authorised by their line manager through appraisal.
The Nurse (or HSCP/Other) should inform their manager if they feel that
their competence or confidence in their discharging abilities is no longer at
an acceptable or safe level.
The Nurse (or HSCP/Other) should not continue with discharge activities in
this case until their needs have been addressed and competence is restored.
Section Four: Discharge framework
Nurses (or HSCPs/Others) who have successfully completed the specific
training in relation to integrated discharge planning and demonstrated
competency will become a Nurse (or HSCP/Other) with responsibility for
patient discharge, authorised by their line manager.
Nurses (or HSCPs/Others) should only discharge patients in the ward or
clinic setting in which they are working or in their area of clinical
responsibility.
Nurses (or HSCPs/Others) should only discharge patients where it has been
documented that no further medical review prior to discharge is required.
Before discharging, the Nurse (or HSCP/Other) should have carried out a
holistic assessment of the patient, which should include obtaining results of
all tests/procedures carried out. Where these are not available, medical staff
should be informed.
The decision to discharge should take cognisance of patient choice and
involvement, and all treatment and care should be considered. Nurses (or
HSCPs/Others) authorised to discharge should also recognise those
situations where it is inappropriate for them to authorise discharge.
I t is the responsibility of each Nurse (or HSCP/Other) to ensure that all the
discharge details are complete and written clearly and legibly.
The Common A ssessment Process (CA P) and Common Summary
A ssessment R ecord (CSA R ) should be undertaken for those patients who will
require access to long term residential care.
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Nurses (or HSCPs/Others) preparing for a role within discharge planning
should undertake specific education and training.
Before discharging, the Nurses (or HSCPs/Others) should have carried out a
holistic assessm ent of the patient, which should include ensuring all relevant
test results have been obtained.
The decision to discharge should take cognisance of patient choice and
inv olv ement, and all treatment and care should be considered. N urses ( or
HSCPs/Others) authorised to discharge should also recognise those
situations where it is inappropriate for them to authorise discharge.
I t is the responsibility of each N urse ( or HSCP/Other) to ensure that all the
discharge details are complete and written clearly and legibly.
The Common A ssessment Process ( CA P) and Common Summary
A ssessment R ecord ( CSA R ) should be undertaken for those patients who will
req uire access to long term residential care.
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N u r s e ( o r H S C P/ O t h er ) f ac i l i t at ed d i s c h ar ge
Section Five: Informing patients
Nurses (or HSCPs/Others) authorised to discharge should ensure that
patients are aware of the scope and limitations of Nurse (or HSCP/Other)
facilitated discharge.
Section Six : L egal l iab il ity
The healthcare organisation, as the employer, will invariably be fix ed in law
with vicarious liability for the tortious acts or omissions of Nurses (or
HSCPs/Others) authorised to discharge, provided that they are acting
lawfully and within the normal parameters and scope of their duties of
employment.
I n order to protect the organisation from ex posure to liability, it is important
that:
i. Their duties and responsibilities are clearly defined.
ii. They have undergone the appropriate training and the preparation.
iii. They are deemed competent and qualified to undertake the role and are
subj ect to appraisal by line management.
iv. The framework for authorised discharge has been followed and the
member of staff has been designated with the necessary authority by the
healthcare organiz ation to undertake the role.
v. The provision of this recommended practice has been followed by the
member of staff at all times.
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Nurses (or HSCPs/Others) authorised to discharge should ensure that
patients are aware of the duties of employment and scope of Nurse
(or HSCP/Other) facilitated discharge.
The healthcare organisation, as the employer, will invariably be fixed in law
with vicarious liability for the tortious acts or omissions of Nurses (or
HSCPs/Others) authorised to discharge, provided that they are acting
lawfully and within the normal parameters and scope of their duties of
employment and professional practice.
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Key tasks pre-admission
4 Key tasks pre-admission
4.1 I ntroduction
Pre-admission assessments are conducted for patients who have planned admissions to
hospital. Such assessments are usually required for patients requiring elective
procedures. The pre-admission assessment determines the patient’ s fitness for
procedures and ensures that adequate arrangements are made in preparation for
hospitalisation and for planning the discharge process.
4.2 S cope
The ob j ective of this procedure is to outline the principles of b est practice for pre-
admission assessment.
4.3 Contents
Section One: A ssessment
Section Two: Estimated length of stay
Section Three: Integrated discharge planning
Section Four: Referral
Section Five: Medication management
Section Six : C ommunication
4.4 Procedure
S ection O ne: A ssessment
Pre-admission assessments should b e conducted for patients who have
planned admissions to hospital. Such assessments are usually required for
patients requiring elective procedures.
Patient assessment should b egin either prior to admission or at first
presentation to the hospital.
A n anaesthetic assessment should b e performed where relevant ( this may b e
performed in an anaesthetic clinic) .
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Key tasks pre-admission
The procedure, risks and expected outcomes should be explained to the
patient and carer.
Options and preferences for hospital care and treatment and convalescence,
as well as patient concerns should be discussed.
An assessment should be carried out concerning:
i. The presence of a carer, the home environment for convalescence and/or
the req uirements for home modifications
ii. S ocial issues which need to be attended to ( such as financial
arrangements and sick ness benefits).
iii. R ehabilitation.
iv. The delivery of PCCC services if req uired ( including eligibility for access
to services).
Where other healthcare professionals across the continuum of care provide
care relating to the condition for which hospital admission is occurring, those
practitioners should be involved in the pre-admission process.
S tandardised, up-to-date, client/healthcare records should be readily
accessible at pre-admission.
Section Two: Estimated length of stay
Each patient should have an estimated length of stay.
The estimated length of stay should be identified during pre-assessment, on
the post-tak e ward round or within 2 4 hours of admission to hospital.
The estimated length of stay should be based on the anticipated time needed
for tests and interventions to be carried out and for the patient to be
clinically stable and fit for discharge.
The estimated length of stay should be discussed and agreed with the patient/
family and carers.
The estimated length of stay should be communicated to the PCCC service
providers, as appropriate.
The estimated length of stay should be documented in the patient’ s
healthcare record.
iii. Rehabilitation.
iv. The delivery of PCCC services if req uired ( including eligibility for access
to services).
Where other healthcare professionals across the continuum of care provide
care relating to the condition for which hospital admission is occurring, those
practitioners should be involved in the pre-admission process.
S tandardised, up-to-date, client/healthcare records should be readily
accessible at pre-admission.
Section Two: Estimated length of stay
Each patient should have an estimated length of stay.
The estimated length of stay should be identified during pre-assessment, on
the post-tak e ward round or within 2 4 hours of admission to hospital.
The estimated length of stay should be based on the anticipated time needed
for tests and interventions to be carried out and for the patient to be
clinically stable and fit for discharge.
The estimated length of stay should be discussed and agreed with the patient/
family and carers.
The estimated length of stay should be communicated to the PCCC service
providers, as appropriate.
The estimated length of stay should be documented in the patient’ s
healthcare record.
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Social issues which may impact on the patient’s stay.
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Key tasks pre-admission
Section Three: Integrated discharge planning
Integrated discharge planning should be commenced by gathering
information about the patients’ pre-admission abilities in relation to potential
discharge issues.
The discharge plan should be discussed and agreed with the patient/family
and carers.
The discharge plan should be communicated with PCCC service providers, as
appropriate.
The discharge plan should be documented in the patient’s healthcare record.
Section Four: Referral
Referral should be made to the other members of the multi-disciplinary team
by the appropriate personnel and this should be documented as appropriate.
Referral should be made to the diagnostic services by the appropriate
personnel and this should be documented as appropriate.
Referral should be made to the PCCC services by the appropriate personnel
and this should be documented as appropriate.
Receipts of referrals should be documented on a integrated discharge
planning track ing form in the patient’s healthcare record within 2 4 hours of
receiving the referral.
The Common Assessment Process ( CAP) and Common Summary
Assessment Record ( CSAR) should be undertak en for those patients who will
req uire access to long term residential care.
Section Fiv e: M edication m anagem ent
A medication management discharge plan should be developed and co-
ordinated for each patient.
Staff should obtain an accurate pre-admission list, including prescription and
over the counter medicines, nutritional support and other therapies such as
herbal products, at the time of admission.
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Section Five: Medication management
A medication management discharge plan should be developed and co-
ordinated for each patient.
Staff should obtain an accurate pre-admission list, including prescription and
over the counter medicines, nutritional support and other therapies such as
herbal products, at the time of admission.
Receipts of referrals should be documented on an integrated discharge
planning tracking form in the patient’s healthcare record within 24 hours of
receiving the referral.
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Key tasks pre-admission
Patient’s admission medication should be reviewed in consultation with the
patient’s GP, community pharmacist or other relevant clinicians, with a view
to:
i. I dentif ying the appropriateness and ef f ectiveness of current medication
management, and rationalising current medication management if
appropriate.
ii. Paying particular attention to any problems associated with current drug
therapy, including any possible relationship with the current medical
condition.
iii. D ocumenting allergies and any previous adverse drug reactions.
A ny necessary pre- admission medication management or treatment should be
commenced.
Section Six: Communication
Peri-operative services or pre-admission clinics should communicate planned
admissions to PC C C service providers before admission.
Information and education should be provided to the patient and the family/
carer in the appropriate language, verbally and in written form relating to:
i. The anticipated course of treatment and estimated length of stay.
ii. L ik ely req uirements post-discharge.
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Peri-operative services or pre-admission clinics should communicate planned
admissions to PCCC service providers before admission.
Changes in the patient’s medication or condition between pre-admission
and date of planned admission should be communicated by PCCC to
the acute hospital.
Information and education should be provided to the patient and the family/
carer in the appropriate language, verbally and in written form relating to:
i. The anticipated course of treatment and estimated length of stay.
ii. Likely requirements post-discharge.
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Key tasks on admission
5 Key tasks on admission
5.1 I ntroduction
Management of inpatient admissions and discharges is essential to enhance the q uality
of patient care. A f ter the patient has b een admitted to hospital, the acute hospital
service should work with P CCC service providers to provide an integrated service
delivery sy stem.
5.2 Scope
T he ob j ective of this procedure is to outline the principles of b est practice f or
integrated discharge planning on patient admission.
5.3 C ontents
Section O ne: A ssessment
Section T hree: E stimated length of stay
Section T hree: T reatment plan
Section F our: D ischarge plan
Section F ive: R ef erral
Section Six : Medication management
Section Seven: Communication
5.4 Procedure
Section O ne: A ssessment
P atient assessment should b egin either prior to admission or at f irst
presentation to the hospital.
P atient assessment should continue throughout the patient’ s hospital stay
whenever the patient’ s condition changes.
T he procedure, risks and ex pected outcomes should b e ex plained to the
patient and carer.
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Key tasks on admission
Options and preferences for hospital care and treatment, as well as patient
concerns should be discussed.
An assessment should be carried out concerning:
i. R ehabilitation, the presence of a carer, the home environment for
convalescence and/or the req uirements for home modifications.
ii. S ocial issues which need to be attended to ( such as financial
arrangements, sick ness benefits, compensation req uirement) .
iii. The delivery of PCCC services if req uired.
Where other healthcare professionals across the continuum of care, provide
care, relating to the condition for which hospital admission is occurring,
those practitioners should be involved in the admission process.
S tandardised, up-to-date, client/healthcare records should be readily
accessible at admission.
The Common Assessment Process ( CAP) and Common S ummary
Assessment R ecord ( CS AR ) should be undertak en for those patients who will
req uire access to long term residential care.
Section Two: Estimated length of stay
Each patient should have an estimated length of stay.
The estimated length of stay should be identified during pre-assessment, on
the post-tak e ward round or within 2 4 hours of admission to hospital.
The estimated length of stay should be based on the anticipated time needed
for tests and interventions to be carried out and for the patient to be
clinically stable and fit for discharge.
The estimated length of stay should be discussed and agreed with the patient/
family and carers.
The estimated length of stay should be communicated to the PCCC service
providers, as appropriate.
The estimated length of stay should be documented in the patient’ s
healthcare record.
Section Two: Estimated length of stay
Each patient should have an estimated length of stay.
The estimated length of stay should be identified during pre-assessment, on
the post-tak e ward round or within 2 4 hours of admission to hospital.
The estimated length of stay should be based on the anticipated time needed
for tests and interventions to be carried out and for the patient to be
clinically stable and fit for discharge.
The estimated length of stay should be discussed and agreed with the patient/
family and carers.
The estimated length of stay should be communicated to the PCCC service
providers, as appropriate.
The estimated length of stay should be documented in the patient’ s
healthcare record.
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Key tasks on admission
Section Three: Treatment plan
All patients should have a treatment plan.
Section Four: Discharge plan
Co-ordinating and implementing discharge activities should start as soon as
the treatment plan is developed.
I ntegrated discharge planning should be commenced w ithin tw o day s of
admission by gathering information about the patients pre-admission abilities
in relation to potential discharge issues.
The discharge plan should be discussed and agreed with patient/family and
carers.
The discharge plan should be communicated with PCCC service providers, as
appropriate.
The discharge plan should be documented in the patient’ s healthcare record.
The Common Assessment Process ( CAP) and Common S ummary
Assessment Record ( CS AR) should be undertak en for those patients who will
req uire access to long term residential care.
Section Fiv e: R ef erral
Referral should be made to the other members of the multi-disciplinary team
by the appropriate personnel and this should be documented as appropriate.
Referral should be made to the diagnostic services by the appropriate
personnel and this should be documented as appropriate.
Referral should be made to the PCCC service providers by the appropriate
personnel and this should be documented as appropriate.
Receipts of referrals should be documented on a integrated discharge
planning track ing form in the patient’ s healthcare record within 2 4 hours of
receiving the referral.
Section Six : M edication management
A medication management discharge plan should be developed and
coordinated for each patient.
S taff should obtain an accurate medication management history, including
prescription and over the counter medicines, nutritional support and other
therapies such as herbal products, at the time of admission.
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Integrated discharge planning should be commenced as soon as possible and
certainly within two days of admission by gathering information about the
patient’s pre-admission abilities in relation to potential discharge issues.
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Key tasks on admission
An accurate pre-admission medication management list should be
established. Where necessary, this should be done in consultation with the
patient’s GP, community pharmacist or other relevant clinicians, with a view
to:
i. I dentifying the appropriateness and effectiveness of current medication
management, and rationalising current medication management if
appropriate.
ii. Paying particular attention to any problems associated with current drug
therapy, including any possible relationship with the current medical
condition.
iii. D ocumenting allergies and any previous adverse drug reactions.
I f it is not possible to take a complete or accurate medication management
list on admission, a request should be made to take one as soon as is practical
after admission.
Section Seven: Communication
The hospital should notify PCCC service providers of unplanned admissions
at the time of hospitalisation.
Once notified of a patient’s admission, PCCC service providers should
contact the hospital department to discuss premorbid health status to ensure
continuity of care while the patient is in hospital.
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The hospital should notify appropriate PCCC service providers of
unplanned admissions at the time of hospitalisation.
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Key tasks during in-patient stay
6 Key tasks during in-patient stay
6.1 I ntroduction
Effectiv e integrated discharge planning includes preparing a plan for discharge. S ome
important elements of a discharge plan include the estimated length of stay and the
destination of the patient on discharge. T he discharge plan should b e sub j ect to
ongoing assessment throughout the hospital stay to tak e account of changes in patient
and carer health and social status.
6.2 Scope
T he ob j ectiv e of this procedure is to outline the principles of b est practice for
integrated discharge planning during admission.
6.3 C ontents
S ection O ne: A ssessment
S ection T w o: T reatment plan
S ection T hree: Estimated length of stay
S ection F our: D ischarge plan
S ection F iv e: N urse ( or H S C P / O ther) facilitated discharge
S ection S ix : C ommunication
6.4 Procedure
Section O ne: A ssessm ent
P atient assessment should continue throughout the patient’ s hospital stay.
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Section Two: Treatment plan
The treatment plan should be monitored on a daily basis and changes should
be communicated to the patient.
Any changes to the treatment plan should be communicated to the PCCC
service providers as appropriate.
Any changes to the treatment plan should be documented in the healthcare
record.
Section Three: Estimated length of stay
The estimated length of stay should be proactively managed against the
treatment plan (usually by ward staff) on a daily basis and changes should be
communicated to the patient.
Any changes to the estimated length of stay should be communicated to the
PCCC service providers as appropriate.
Any changes to the estimated length of stay should be documented in the
healthcare record.
Section F ou r: D ischarge p lan
The discharge plan should be proactively managed against the treatment plan
(usually by ward staff) on a daily basis and changes should be communicated
to the patient.
Any changes to the discharge plan should be communicated to the PCCC
service providers as appropriate.
Any changes to the discharge plan should be documented in the healthcare
record.
Section Four: Discharge plan
The discharge plan should be proactively managed against the treatment plan
(usually by ward staff) on a daily basis and changes should be communicated
to the patient.
A ny changes to the discharge plan should be communicated to the P C C C
service providers as appropriate.
A ny changes to the discharge plan should be documented in the healthcare
record.
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The Common Assessment Process (CAP) and Common Summary
Assessment Record (CSAR) should be undertaken for those patients who will
require access to long term residential care.
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Key tasks during in-patient stay
Section Five: Nurse (or HSCP/Other) facilitated discharge
The suitability of the patient for Nurse (or HSCP/Other) facilitated discharge
should be agreed with the multi-disciplinary team.
Within one hour of patient admission to the ward, an appropriate and
competent Nurse (or HSCP/Other) from the ward should be identified and
assigned to actively manage the patient pathway of care.
This Nurse (or HSCP/Other) should be up to date on all aspects of the
patient care pathway, particularly focusing on the current medical and
nursing condition and discharge plan.
The healthcare record should indicate that it is a Nurse (or HSCP/Other)
facilitated discharge and the name of the Nurse (or HSCP/Other) should be
documented.
Section Six : Com m unication
The hospital should advise PCCC service providers of the planned discharge
date as soon as p ossib le and at least tw o day s p rior to p atient discharge (for
patients who are in-patients for five days or longer) to enable them to plan the
necessary post-hospital service commencement.
Two-way communication between the hospital, the G P, the community
pharmacist and other PCCC service providers should be arranged to ensure
such services are available and in place for the patient to use when needed
post discharge.
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Key tasks twenty-four hours before discharge
7 K ey tasks tw enty-f our hours bef ore discharge
7.1 I ntroduction
Towards the end of the hospital stay, all discharge plans should have been put in place.
Services should be organised and implemented as appropriate, to ensure that there are
no delays on the day of discharge or in the provision of services for the patient
following discharge from hospital.
7.2 Scope
The obj ective of this procedure is outline the principles of best practice for integrated
discharge planning twenty-four hours before discharge.
7.3 C ontents
Section O ne: D ischarge arrangements
Section Two: Transport arrangements
Section Three: M edication management
Section F our: C ommunication
Section F ive M edical certificate
Section Six : P atient education
7.4 P rocedure
Section O ne: D ischarge arrangem ents
D ischarge arrangements should be confirmed with the patient, their family/ carers
and the P C C C service providers.
Section T w o: T ransport arrangem ents
Transport arrangements should be confirmed 24 hours bef ore discharge.
The clinical and/ or mobility needs of the patient should be specified, where
appropriate.
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Key tasks twenty-four hours before discharge
Section Three: Medication management
Medication management review should take place in a planned and timely fashion
before the patient leaves the hospital.
Where appropriate, the patient’ s own medication management should be reviewed
to remove any expired or discontinued medication before return to the patient.
A rrangements should be put in place to facilitate continuity of the patient’ s
medication management supply.
D ispensing of adequate medication, where required, to ensure continuity of
supply, should be facilitated through the Pharmacy D epartment.
Communication should be made with the patient’ s community pharmacy
concerning the following:
i. Special arrangements for administration of medication (e.g. via enteral
feeding tube, provision of compliance aids).
ii. Special arrangements for ordering, supply or facilitation of funding of
medication (e.g. unlicensed or difficult to source medication,
extemporaneous preparation, High-Tech medication, use of the Hardship
scheme).
Section F ou r: C ommu nication
D ischarge information (transfer or discharge communication) should be prepared.
This may include a description of the unresolved, ongoing problems listed on the
hospital care plan, key test results, medication regimen, emergency contact person,
contact number and availability.
The discharge check list should be completed to ensure all of the above activities
have been carried out.
The family/carers, GP, PHN and other PCCC service providers should be
contacted at least the day before discharge to confirm that the patient is being
discharged and to ensure that services are activated or re-activated.
Section F iv e: Medical certif icate
The medical (sick) certificate should be written if required. Note: Social Welfare
certificates have to be issued by a General Practitioner (GP).
Section Six : P atient edu cation
The patient should have received and been educated in the use of any aids/
equipment.
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Communication should be made with the patient’s community pharmacy
concerning the following:
i. Special arrangements for administration of medication (e.g. via enteral
feeding tube, provision of compliance aids).
ii. Special arrangements for ordering, supply or facilitation of funding of
medication (e.g. unlicensed or difficult to source medication,
ex temporaneous preparation, High-Tech medication, use of the Hardship
scheme).
Section Four: Communication
D ischarge information (transfer or discharge communication) should be prepared.
This may include a description of the unresolved, ongoing problems listed on the
hospital care plan, key test results, medication regimen, emergency contact person,
contact number and availability.
The discharge check list should be completed to ensure all of the above activities
have been carried out.
The family/carers, GP, PHN and other PCCC service providers should be
contacted at least the day before discharge to confirm that the patient is being
discharged and to ensure that services are activated or re-activated.
Section Fiv e: M ed ical certif icate
The medical (sick) certificate should be written if required. Note: Social Welfare
certificates have to be issued by a General Practitioner (GP).
Section Six : P atient ed ucation
The patient should have received and been educated in the use of any aids/
equipment.
Dispensing of adequate medication, where required, to ensure continuity of
supply, should be facilitated through the Pharmacy Department. Where this
does not apply, the Community Pharmacy will provide one week’s emergency
supply to medical card holders.
The patient should have received and been educated in the use of any aids/
equipment as appropriate.
Medical (sick) certificates should be written if required for employees to give to
their Employers. Certificates for persons who wish to apply for Disability Benefit
must go to their own GP as these certificates are only available to GPs and are
supplied by the Department of Social and Family Affairs.
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K ey t as k s o n d ay o f d i s c h ar ge
8 Key tasks on day of discharge
8.1 I ntrodu ction
On the day of discharge, the patient should be ready to leav e the hospital at the agreed
time and the patient/carer/receiv ing healthcare facility should hav e sufficient
information to guarantee continuity of care. Good integrated discharge planning
practices suggest that on the day of discharge all arrangements for PCCC serv ices
should hav e been put in place and v ery little new information should be imparted to
the patient or carer.
8.2 Scope
The obj ectiv e of this procedure is to outline the principles of best practice for
integrated discharge planning on the day of discharge.
8.3 C ontents
Section One: Patient
Section Tw o: Time of discharge
Section Three: Communication
8.4 P rocedu re
Section O ne: P atient
The patient should be confirmed as clinically fit and safe for discharge.
Patient should be discharged from the w ard to their place of residence/transfer
healthcare facility or the discharge lounge.
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Section Two: Time of discharge
Each patient discharge should be effected (i.e. hospital bed becomes available for
patient use) by 12 noon on the day of discharge. This includes completion of all
necessary discharge procedures, documentation of the time of discharge in the
healthcare record and communication with patients, carers and other healthcare
providers (where relevant).
S e c t i on T h r e e : C om m u ni c a t i on
No patient should leave the hospital until the details of admission, medication
management changes (including addition/deletions) and arrangements for follow
up have been communicated to the healthcare provider(s) nominated by the
patient as being responsible for his or her ongoing care.
A t the time of leaving the hospital, each patient should be provided with an
information pack containing relevant information such as patient/carer plan, a
medication management record, and information on the availability and future
supply of medication.
H ospitals should confirm with PCCC service providers that the patient has left
the hospital and that service provision needs to commence.
Information and education should be provided to the patient and the family/carer
in the appropriate language, verbally and in written form relating to:
i. O ngoing health management.
ii. A n appropriate post discharge contact to answer q ueries and address
concerns.
iii. GP letter.
iv. M edication management.
v. The use of aids and eq uipment.
vi. F ollow- up appointments.
vii. PCCC based service appointments.
viii. Possible complications and warning signs.
ix . W hen normal activities can be resumed.
The transfer/discharge communication and discharge prescription should contain
a complete and comprehensive list of all medication the patient is to continue
tak ing on discharge from hospital. W here possible, any pre- admission medication
which was discontinued during the hospital stay should be listed, outlining a brief
reason for discontinuation. There should be no ambiguity as to whether a
medication which is absent from the list was discontinued or omitted
unintentionally.
Note: the patient’ s community pharmacist should be included in any
communications concerning medication management.
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Each patient discharge should be effected (i.e. hospital bed becomes available for
patient use)no later than 12 noon on the day of discharge. This includes completion
of all necessary discharge procedures, documentation of the time of discharge in the
healthcare record and communication with patients, carers and other healthcare
providers (where relevant).
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Follow up post discharge and evaluation
9 Follow up post discharge and evaluation
9.1 I ntroduction
The purpose of following up a patient after they have been discharged from hospital is
two-fold:
i. To evaluate the impact of the planned interventions on the patient' s recuperation
and possibly identify recurrent and new care needs.
ii. To assess the effectiveness and efficiency of the discharge process.
This part of the discharge process is key to ensuring continuity of care for the patient.
9.2 Scope
The obj ective of this procedure is to provide guidelines in relation to follow up post
discharge and evaluation.
9.3 C ontents
Section One: General principles
Section Two: Tips for telephone follow-up
9.4 Procedure
Section O ne: G eneral principles
All planned interventions should be monitored for their impact on the patient (as
identified in the care plan) . This may involve follow-up of patients post discharge
(either via telephone and/ or contact with the GP and other PCCC service
providers) to find out if the problems identified as requiring intervention post
discharge were adequately addressed and to deal with any new problems.
Teaching initiated in the hospital should also be reinforced and assurance
provided to the patient and their home carers.
The ex pected outcomes identified on the care plan should inform the questions
asked of the patient.
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All planned interventions should be monitored for their impact on the patient (as
identified in the care plan). This may involve follow-up of patients post discharge
to find out if the problems identified as requiring intervention post discharge were
adequately addressed and to deal with any new problems.
Teaching initiated in the hospital should also be reinforced and assurance
provided to the patient and their home carers.
The expected outcomes identified on the care plan should inform the areas
to be evaluated.
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S el f d i s c h ar ge/ d i s c h ar ge agai n s t m ed i c al ad v i c e
10 Self-discharge/discharge against medical advice
10.1 I ntroduction
Healthcare professionals should provide patients with sufficient information during
their hospital stay to enable them to understand their medical treatment. In cases
where a patient decides to self-discharge or takes discharge against medical advice they
should be informed of the risk they are taking and possible consequences of their
actions.
10.2 Scop e
The obj ective of this procedure is to provide guidelines in relation to self discharge/
discharge against medical advice.
10.3 Contents
S ection One: General principles
10.4 P rocedure
Section O ne: G eneral p rincip les
Every effort should be made to persuade the patient to avail of treatment.
If available, the registrar on duty should see the patient prior to their self-discharge
and reinforce the need to stay for treatment.
The senior nurse on duty should witness the ex planation and discussion regarding
discharge between doctor and patient.
There should be clear documentation in the healthcare record regarding the
events.
W ith the patients’ permission, the person nominated by the patient should be
informed of patient’s decision to self-discharge.
The patient and family/ carer should sign a document to indicate that the patient
made a decision to self-discharge which was contrary to medical advice. This
document should be signed by the doctor/ nurse if the patient refuses to sign.
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With the patient’s permission, the person nominated by the patient should be
informed of the patient’s decision to self-discharge.
The patient and family/carer should sign a document to indicate that the patient
made a decision to self-discharge which was contrary to medical advice. This
document should be signed by the doctor/nurse if the patient refuses to sign.
Local incident reporting policy should be complied with.
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Peo p l e w h o ar e h o m el es s o r l i v i n g i n t em p o r ar y o r i n s ec u r e ac c o m m o d at i o n
11 People who are homeles s or liv ing in t emporary or ins ecure
accommodat ion
11.1 I nt roduct ion
Better integrated health and social care can help prevent the inappropriate use of
specialist or acute healthcare and can help prevent or reduce homelessness. People
who are homeless or living in temporary or insecure accommodation are more lik ely to
suffer from poor physical, mental and emotional health than the rest of the
population, and hospitalisation presents an opportunity to deal with underlying
medical, social and mental health problems and to address their accommodation
needs.
11.2 Scope
T he obj ective of this procedure is to provide g uidelines in relation to discharg e of
people who are homeless or living in temporary or insecure accommodation.
11.3 Contents
S ection One: General principles
11.4 P r oced u r e
Secti on O ne: G ener a l pr i nci pl es
A hospital admission and discharg e policy should be developed in partnership by
the hospital, PCCC service providers, the voluntary sector and the local authority.
Homeless people should be identified on admission and PCCC services and
homelessness services should be notified.
PCCC services and homelessness services should be notified when homeless
people are due for discharg e.
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Pl an n i n g d i s c h ar ge f r o m h o s p i t al f o r p eo p l e w i t h d em en t i a
12 Planning discharge from hospital for people with dementia
12.1 I ntroduction
People with dementia may find acute hospitals stressful and this can have a
detrimental effect on their dementia. T hey should therefore only be admitted when
their physical care needs demand the sort of specialist interventions that are only
available in general hospitals.
12.2 S cope
T he obj ective of this procedure is to provide guidelines in relation to discharge from
hospital for people with dementia.
12.3 Contents
S ection One: General principles
12.4 Procedure
S ection O ne: G eneral principles
People with dementia should only be admitted to acute wards when there is
nowhere else appropriate to manage their physical health problems.
People with dementia should be identified and referred to the discharge
coordinator as soon as possible.
T here should be an agreed care pathway for in place for people with dementia.
T here should be a procedure in place for moving patients with dementia following
a period of acute care.
People with dementia should be returned to their usual place of residence as
quickly as possible.
Information should be available regarding local and national services for people
with dementia.
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12.2 Scope
The objective of this procedure is to provide guidelines in relation to discharge from
hospital for people with dementia.
12.3 Contents
S ection One: General principles
12.4 P r oced u r e
Secti on O ne: G ener a l pr i nci pl es
People with dementia should only be admitted to acute wards when there is
nowhere else appropriate to manage their physical health problems.
People with dementia should be identified and referred to the discharge
coordinator as soon as possible.
There should be an agreed care pathway for in place for people with dementia.
There should be a procedure in place for moving patients with dementia following
a period of acute care.
People with dementia should be returned to their usual place of residence as
quickly as possible.
Information should be available regarding local and national services for people
with dementia.
People with dementia can have complex needs and may find acute hospitals
stressful and this can have a detrimental effect on their dementia. They should
therefore only be admitted when their physical care needs demand the sort of
specialist interventions that are only available in general hospitals. It is recognised
that dementia can sometimes lead to complex discharge needs but not necessarily
so. The authors are aware that there are sensitivities around categorising patients
into such groups.
People with dementia with complex discharge needs should be identified and
referred to the discharge co-ordinator as soon as possible.
There should be an agreed care pathway in place for people with dementia.
Information should be available regarding local and national services for people
with dementia and their carers.
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Health Service ExecutiveCode of Practice for
Integrated Discharge Planning
Part 4: Audit Tool
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Par t 4
Par t 4
A u d i t T o o l
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Contents
Contents
Page
1. Introduction 5
2 . G uidel ines for using th e audit tool 6
3 . R isk l ev el categ ories 15
4 . Standards for integ rated disch arg e pl anning 16
Standard 1—C ommunication and consul tation
Standard 2 —Org anisational structure & accountab il ity
Standard 3 —M anag ement and k ey personnel
Standard 4 —E ducation and training
Standard 5—Operational pol icies and procedures
Standard 6 —Integ rated disch arg e pl anning process
Standard 7—A udit and monitoring
Standard 8—Key performance indicators
5. Q ual ity improv ement action pl an 18
6 . Standard scoring summary sh eet 19
7. A uditors notes 2 0
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80
81
90
91
93
94
95
1. Introduction
2. Guidelines for using the audit tool
3. Risk level categories
4. Standards for integrated discharge planning
Standard 1— Com m unication and consultation
Standard 2— Organisational structure & accountability
Standard 3— M anagem ent and key personnel
Standard 4— Education and training
Standard 5— Operational policies and procedures
Standard 6— Integrated discharge planning process
Standard 7— Audit and m onitoring
Standard 8— Key perform ance indicators
5. Q uality im provem ent action plan
6. Standard scoring sum m ary sheet
7. Auditors notes
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Introduction
1 Introduction
1 . 1 Standards for integ rated disch arg e p lanning in th e H ealth Serv ice E x -
ecutiv e
During 2 008 , standards for integrated discharge planning in the Health Service Execu-
tive were developed using a consistent methodology. A literature review was
undertaken which included a search for all relevant guidance and evidence. Expert
opinion was also sought for the standards. A national consultation process was under-
taken and feedback where appropriate was incorporated into Version 1.0 of the
standards. An audit tool ( based on the ' Safety and Health Audit Tool for the
Healthcare Sector) was then developed to assist in the monitoring for the standards.
1 . 2 A udit
Audit is a function of all developing and progressive organisations. The outcome from
an audit can facilitate an organisation to be knowledgeable about its areas of non-
conformance and to identify and implement corrective action where necessary.
1 . 3 A udit tool
This audit tool in this document relates to the principles of integrated discharge
planning and includes: organisational structure and accountability, audit and
monitoring and communication and consultation. The audit tool can be used to
provide objective data on conformance with the standards within the Health Service
Executive. Y ear-on-year data can assist in monitoring the effectiveness of integrated
discharge planning programmes and assist in strategic planning to meet long term
integrated discharge planning objectives.
1 . 4 L ev els of audit
There are two levels of audit against the HSE standards for integrated discharge plan-
ning: self-assessment and external review.
Self assessment is a process whereby the organisation measures its conformance against
national standards. Each organisation will be asked to undertake a self-assessment exer-
cise for its service against the standards. This will be completed annually, signed by the
CEO/manager and sent to the Network Manager/Assistant National Director for Pri-
mary, Community and Continuing Care as appropriate.
E x ternal rev iew uses the same national standards to independently measure the or-
ganisation through an on-site audit. The findings from the audit will be summarised in
a written report and organisations will be supported in the development of quality im-
provement action plans.
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Healthcare Sector) was then developed to assist in the monitoring of the standards.
This audit tool relates to the principles of integrated discharge planning and includes:
organisational structure and accountability, audit and monitoring and communication
and consultation. The audit tool can be used to provide objective data on conformance
with the standards within the Health Service Executive. Year-on-year data can assist in
monitoring the effectiveness of integrated discharge planning programmes and assist in
strategic planning to meet long term integrated discharge planning objectives.
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G u i d el i n es f o r u s i n g t h e au d i t t o o l
2 Guidelines for using the audit tool
2. 1 I ntegrated disc harge p lanning audit tool
The audit tool is intended for use by the discharge co-ordinator, staff with a
demonstrated interest in integrated discharge planning and trained audit personnel.
2. 2 P lanning the audit p rogram m e
It is envisaged that the appropriate committee will plan and prioritise the use of the
audit tool based on a review of specific policies or in response to specific clinical inci-
dents.
2. 3 T im e req uired
The time req uired to complete a specific audit will vary according to the tool, the size
of the organisation, the type of procedures audited and the experience of the auditor.
2. 4 C onform anc e
A conformance categorisation has been incorporated into the scoring system to pro-
vide a clear indication of conformance. The allocation of conformance levels is based
on the scores obtained. F or the purpose of these audits the categories will be allocated
as follows: minimal conformance 7 5 % or less, partial conformance 7 6 -8 4 % and con-
forming 8 5 % or above.
2. 5 F eedb ac k of inform ation and rep ort findings
It is advised that the auditor should verbally report any areas of concern and of good
practice to the head of department in charge of the area being audited prior to leaving.
A written report should also be developed by the auditor and should be given to the
relevant head of department for action. The report should clearly identify areas req uir-
ing action. The head of department is responsible for developing an action plan to
address the issues identified within a given timescale.
The audit team may decide to re-audit the ward/department if there are concerns or a
minimal conformance rating is observed. A system of feedback to the appropriate com-
mittee on the action taken by wards/departments should be in place. This may involve
feedback meetings or the return of completed action plans to the discharge co-
ordinator.
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G u i d el i n es f o r u s i n g t h e au d i t t o o l
2.6 Scoring
Eight standards for audit of integrated discharge planning are described in the audit tool work-
sheets. Each standard is stated and followed by questions based on the standard criteria. Below
is an explanation of the abbreviation used under each criterion.
I = I nterview
O = O bservation
D = D ocumentation
Y = Y es
P = Partial
N = N o
I nstructions on the comp letion of a standard work sheet
In order to effectively audit integrated discharge planning it is necessary that all standards are
audited as part of the audit process. The auditor can repeat a full audit of all standards at regu-
lar intervals in order to measure the level of improvement in the effectiveness of integrated
discharge planning.
There are eight standards in the audit tool and for each standard there is a worksheet, which
details a list of questions to be answered. There is specific information to be completed in
each worksheet and this is explained below:
Step 1 :
F or each question the auditor can use an “ X” to indicate the appropriate answer, which is
“ Yes” , “ Partial” or “ No” . In this example we will assume the answer is “ No”
1 Y P N
I
O
D
E ach individual delivering care along the care continuum ( this in-
cludes staff at ward level and staff in PCCC services) shall be made
aware of their resp onsibility in relation to integrated discharge p lan-
ning?
S upporting Evidence/ C omments
Yes Partial No Total score
S core 1 0 S core 5 S core 0
X
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G u i d el i n es f o r u s i n g t h e au d i t t o o l
Step 2
For each question the auditor can use an “X” to indicate the method of verification used in
trying to get an answer to the question. The auditor may have interviewed ( I ) an employee,
observed ( 0 ) a particular work practice or reviewed a particular document ( D ). The auditor
may have used all three methods. For this example the auditor interviewed an employee and
used an “X” to indicate this on the worksheet.
Step 3
The auditor can then detail some supporting evidence or comments to explain the reason for
the relevant answer. I n this example the answer to the question was “No” because staff were
not aware of their responsibilities in relation to integrated discharge planning.
Step 7
X
1 Y P N
I
O
D
E ach individual delivering care alo ng the care co ntinuum ( this in-
cludes staff at ward level and staff in PCCC services) shall be made
aware o f their respo nsibility in relatio n to integ rated discharg e plan-
ning ?
S upporting E vidence/ C omments
X
X
1 Y P N
I
O
D
E ach individual delivering care alo ng the care co ntinuum ( this in-
cludes staff at ward level and staff in PCCC services) shall be made
aware o f their respo nsibility in relatio n to integ rated discharg e plan-
ning ?
S upporting E vidence/ C omments
No evidence of staff being made aware of their responsibilities.
X
Yes Partial No Total score
S core 1 0 S core 5 S core 0
Yes Partial No Total score
S core 1 0 S core 5 S core 0
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G u i d el i n es f o r u s i n g t h e au d i t t o o l
Step 4
The auditor can use an “X” to indicate the appropriate answer for each question, which will be
“Yes”, “Partial” or “No”.
T h e d i f f er en t s c o r i n g o pti o n s a r e a s s et o u t b el o w :
If the auditor selects “Yes” as his/her answer to the question, then the auditor uses an “X” to
select “Yes” in the score table and enters a total score of “10” in the score table. An answer of
“Yes” means there is full evidence of conformance and this is allocated a score of 10.
If the auditor selects “No” as his/her answer to the question, then the auditor uses an “X” to
select “No” in the score table and enters a total score of “0” in the score table. An answer of
“No” means there is no evidence of conformance and this will be allocated a score of “0.
If the auditor selects “Partial” as his/her answer to the question, then the auditor uses an “X”
to select “Partial” in the score table and enters a total score of “5” in the score table. An an-
swer of “Partial” means there is evidence of a reasonable level of conformance and this will be
allocated a score of “5”.
N O X
Score 0
Y ES X
Score 10
PA R TIA L X
Score 5
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Step 5
The auditor should check that he/she has entered the appropriate total score in the score table
for each question.
Step 6
The criterion score is then calculated as a percentage. This is explained by a worked example
below:
Number of Q uestions in Standard: 1 3
Maximum Standard Score ( M S )
( Total Number of Q uestions x Maximum Score ( 1 0 ) ) : 1 3 0 ( 1 3 x 1 0 )
A ctual Standard Score ( A S ) ( Sum of the total scores for each question) 1 0 0
Note: I n this example the actual score used is 1 0 0 , however the actual score will vary depend-
ing on the scores allocated to each question.
Standard Score as a percentage = A S/ M S x 1 0 0 / 1
I n this example Standard Score as a percentage = 1 0 0 /1 3 0 x 1 0 0 /1 = 7 6 . 9 2 %
Note: Where a question in a standard is not applicable, it will not be given a score.
Example:
I n t h e ab o v e c as e; i f t h er e w er e o n ly 1 2 q u es t i o n s appli c ab le t h en t h e maxi mu m c r i t er i o n s c o r e ( M S )
w o u ld b e 1 2 0 ( 1 2 x 1 0 ) .
Yes No Partial T otal sc ore
S c ore 1 0 S c ore 0 S c ore 5 0
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G u i d el i n es f o r u s i n g t h e au d i t t o o l
The auditor repeats Step 1-6 for each question in the standard worksheet.
Step 8
When a standard has been fully audited, the auditor can detail a summary of the results in the
standard report form. This information can be taken from the worksheet or the auditor may
use his/ her own notes taken during the audit. This report form should be completed for each
standard. An example of what information can be included in this report form is detailed be-
low.
Step 9
Standard 2: Organisational structure and accountability
Responsibility for integrated discharge planning shall be clearly defined and there shall be
clear lines of accountability throughout the organization.
Summary of documentation audited and referenced
Summary of main findings of the audit
C onformance in the area
Managers are aware of responsibilities
N on- conformance in the area
Standard Score: 1 0 0 / 1 3 0 7 6 . 9 2 %
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Guidelines for using the audit tool
The areas of non-conformance in each standard report form should be transferred to a quality
improvement action plan. A n ex ample of a blank quality improvement action plan is detailed
in section 5 of this document. B elow is an ex ample of the type of information that w ould be
documented in this quality improvement action plan by the auditor.
The auditor may have a number of areas of non-conformance for each standard. The quality
improvement action plan w ill need to be ag reed in consultation w ith the senior manag ement
committee ( or appropriate committee) . The action plan is used to summarise the main find-
ing s of the audit and it is used as a tool for continuous improvement.
Note: The auditor may use the auditors note section in section 7 of this document to compile
further relevant information.
Standard Area of Non Conformance Corrective Action Responsible Person Time-frame
Review
1 Staff not aware of their responsibilities in relation to integrated discharge planning
Discuss with each relevant H ead of department
Discharge co-ordinator
Dec 2008 Feb2009
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G u i d el i n es f o r u s i n g t h e au d i t t o o l
STANDARD SCORING SUMMARY SHEET
St e p 1 0 :
Th e s c o r i n g f o r e a c h St a n d a r d i s d e t a i l e d i n a St a n d a r d Sc o r i n g Su m m a r y Sh e e t . A c o m -
p l e t e d St a n d a r d Sc o r i n g Su m m a r y s h e e t i s d e t a i l e d b e l o w a n d a b l a n k St a n d a r d Sc o r i n g
Su m m a r y s h e e t i s d e t a i l e d i n s e c t i o n 6 o f t h i s d o c u m e n t .
Standard Actual Stan-
dard Score
(AS)
M ax im um Standard
Score (M S)
T otal N um b er of
Q ues tion x M ax im um
Score (10)
Standard Score as a
p ercentag e
(AS/ M S x 100/ 1)
1 70 100 70
2 90 110 8 1.8 1
3 4 0 60 66.66
4 50 90 55.55
5 125 13 0 96.15
6 3 50 4 90 71.4 2
7 100 13 0 76.92
8 110 14 0 78 .57
Overall Audit Score 965 1,250 77.2
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G u i d el i n es f o r u s i n g t h e au d i t t o o l
Step 11:
Using the example above the overall audit score is calculated as follows.
Overall
audit score = Sum of all actual standard scores ( AS) / Sum of all maximum standard
Scores ( M S) x 1 0 0 / 1
Overall audit score = 9 6 5 / 12 5 0 x 10 0 / 1 = 7 7 . 2 %
This overall audit score can be used to benchmark performance from year to year and the indi-
vidual standard score allows the auditor to identify areas where most attention is needed.
A summary sheet with Standard and overall audit score could be attached to the quality im-
provement action plan as a full audit report.
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R i s k l ev el c at ego r i es
3 Risk level categories
A response is categorised as non-conforming if it does not meet the criteria identified in the
H ealth S ervice E x ecutive S tandards for I ntegrated D ischarge P lanning. An indication of the
seriousness of the non-conformance is given b y a risk category that is attached to each non-
conformance statement. The categorisation of risk should provide some assistance in prioritis-
ing remedial actions.
On the right hand side of each statement is a risk level categorisation. These are organised as
shown in Tab le 1.
T ab le 1 : D ef in ition of risk levels u sed in n on - con f orm an ce statem en ts
Level C a t eg o r y D es c r i p t i o n
1 Ob servation This category includes reported
facts which, although not neces-
sarily non-conformances, should
b e considered when any remedial
action is planned.
2 Low Risk The reported fact( s) indicate a
minor hazard with a low likeli-
hood of the hazard occurring.
3 Medium Risk The reported fact( s) indicate
either a minor hazard with a
significant likelihood of the haz-
ard occurring or a significant
hazard with a low likelihood of
the hazard occurring.
4 H igh Risk The reported fact( s) indicate a
significant hazard with a signifi-
cant likelihood of the hazard
occurring.
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Standards for integrated discharge planning
4 Standards for integrated discharge planning
Standard 1 : C om m u nication and consu ltation
Appropriate and effective mechanisms shall be in place for communication and consultation
on matters relating to integrated discharge planning, with k ey stak eholders within and outside
the organisation.
Standard 2 : O rganisational stru ctu re and accou ntab ility
Responsibility for integrated discharge planning shall be clearly defined and there shall be clear
lines of accountability throughout the organiz ation.
Standard 3 : M anagem ent and k ey personnel
Appropriately qualified k ey personnel shall be in place to ensure that the integrated discharge
planning service is provided safely, efficiently and cost-effectively.
Standard 4: E du cation and training
Education and Training in relevant aspects of integrated discharge planning shall be provided
to all new and existing staff members (both permanent and temporary).
Standard 5 : O perational policies and procedu res
Written policies, procedures and guidelines for the integrated discharge planning process shall
be based on the Health Service Executive Recommended Practices for Integrated Discharge Planning
( Part 3 ) , shall be available, implemented and shall reflect relevant legislation and published pro-
fessional guidance.
Standard 6 : I ntegrated discharge planning process
I ntegrated discharge planning shall include the patient and as appropriate, the family/ carer in
the development and implementation of the patient’s discharge plan and shall ensure that
steps are tak en to address necessary link ages with other healthcare providers in order to ensure
a seamless transition from one stage of care to the next.
Standard 7 : A u dit and m onitoring
Audits shall be carried out to ensure that the procedures for integrated discharge planning con-
form to the required Standards and that the processes undertak en conform to the procedures.
The audit results shall be used to identify opportunities for improvement.
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Standards for integrated discharge planning
Standard 8: Key performance indicators
Key perf ormance indicators that are capable of show ing improv ements in the ef f icacy of inte-
grated discharge planning in the organisation shall be used.
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Quality improvement action plan
5. QUALITY IMPROVEMENT ACTION PLAN Sta
n-
dar
d
Ref
er-
ence
Are
a o
f N
on
-
Co
nfo
rman
ce
Lev
el
of
Ris
k
Co
rrec
tive
Act
ion
to
be
tak
en
Res
po
nsi
ble
Per
son
Tim
e F
ram
eC
ost
Imp
lica
tio
ns
Rev
iew
of
Imp
lem
enta
-
tio
n o
f A
c-
tio
n
Co
m-
men
t
Off
ice
Use
On
ly
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S t an d ar d s c o r i n g s u m m ar y s h eet
5. STANDARD SCORING SUMMARY SHEET
Standard Actual Stan-
dard Score
( AS)
Maximum Standard
Score ( MS)
Total Number of
Question x Maximum
Score ( 1 0 )
Standard Score
as a percentage
( AS/ MS x
1 0 0 / 1 )
1
2
3
4
5
6
7
8
O v era l l A u d i t
Score
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Auditors notes
5. AUDITORS NOTES
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Auditors notes
AUDITORS NOTES
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Health Service ExecutiveCode of Practice for
Integrated Discharge Planning
Part 5: Additional Resourcesand Appendices
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Par t 5
Addit io nal R eso u r ces
and Appendices
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Contents
1. References
2. Abbreviations
Ap p end ix 1: M em bersh ip of N ational I nteg rated D isch arg e P l anning S teering C om m ittee
Ap p end ix 2: L ist of k ey stak eh ol d er g rou p s
Contents
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Part 5 - Additional
Resources and Appendices
1. Discharge Checklist
2. Key Tasks
A ppendix 1: M em bership of N ational Integrated Discharge Planning Steering Com m ittee
A ppendix 2: List of key stakeholder groups
3. Patient Inform ation Brochure
4. References
5. A bbreviations
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Discharge Checklist (please note that this is not an exhaustive list)
Own medications (once reviewed)
Own equipment
Own X-Rays
Valuables
Yes (Y)/No (N)/
Not A p p lic a b le
(NA )
P er son a l item s r etu r n ed to p a tien t
Yes (Y)/No (N)/
Not A p p lic a b le
(NA )
GeneralPractitioner (GP)
OPD (please specify)
Medicalspecialist/other hospital(pleasespecify)
Other (please specify)
F ollow u p a p p oin tm en ts
Patient understands findings and treatmentplan
Observations within normallimits
Yes (Y)/No (N)/
Not A p p lic a b le
(NA )
G en er a l *
Pain controlsatisfactory
Adequate nutrition and fluid intake
Passed urine
Alldressings checked
Transfer/Discharge communication
Medications and medication list— explained topatient/carer, as appropriate
Follow-up appointment
Yes (Y)/No (N)/
Not A p p lic a b le
(NA )
Item s a r r a n g ed for /p r ov id ed to p a tien t
Aids and appliances
Information pack
Wound care information
Relative/friend
Taxi
Ambulance
Community transport provider
T im e B ook ed
(2 4 h ou r ) T r a n sp or t
Other (please specify)
P C C C S er v ic es R efer r ed to/A r r a n g ed
Contact made withPublic HealthNurse (PHN)
Home Help
Meals on Wheels
OccupationalTherapist
Yes (Y)/No (N)/
Not A p p lic a b le
(NA )
Speech& Language Therapist
Physiotherapist
*A medical review of the patient prior to discharge is required if theanswer to any of the above questions is ‘No’
Community Pharmacist
Common Summary Assessment Record(CSAR) completed
Carer identified
Other (please specify)
Home oxygen
IV cannula�removed
Signature/Printed Name Date Time (24 hour)
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KEY TA SKS FO R STA NDA RD
A DMISSIO N A ND DISCHA RGE PRO CESS
Pre admission
� Patient assessment
� Explain procedure, risks, expected outcomes
� D iscuss options and preferences for hospital care and treatment
� D iscuss patient concerns
� Assessment concerning—social issues/rehabilitation/delivery of PCCC
services/availability of carer
� Standardised, up-to-date, healthcare records available
� Common Assessment Process (CAP) and Common Summary Assessment Record
(CSAR) should be undertaken, where appropriate
� Identify estimated length of stay (ELOS)
� D iscuss ELOS with patient/family/carers
� Record ELOS in the patient’s healthcare record
� Communicate ELOS to PCCC service providers
� Gather information regarding pre-admission abilities (potential discharge issues)
� D iscuss discharge plan with patient/family/carer
� Communicate discharge plan with PCCC service providers
� D ischarge plan recorded in the patient’s healthcare record
� Referral to other members of the multi-disciplinary team
� Referral to PCCC services
� Referral to diagnostic services
� D ocument receipt of referrals on discharge planning tracking form
� Establish pre-admission medication list, if necessary in consultation with the
patient’s GP and community pharmacist
� Commence pre-admission medication/treatment as appropriate
� Communicate planned admissions to PCCC service providers
� Provide information and education to the patient/family/carer in the appropriate
language, verbally and in written form
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On admission
� Patient assessment
� Explain procedure, risks, expected outcomes
� D iscuss options and preferences for hospital care and treatment
� D iscuss patient concerns
� Assessment concerning—social issues/rehabilitation/delivery of PCCC
services/availability of carer
� Standardised, up-to-date, healthcare records available
� Common Assessment Process (CAP) and Common Summary Assessment Record
(CSAR) should be undertaken, where appropriate
� Identify estimated length of stay (ELOS)
� D iscuss ELOS with patient/family/carers
� Record ELOS in the patient’s healthcare record
� Communicate ELOS to PCCC service providers
� Patient treatment plan available
� Co-ordinate and implement discharge plan
� D iscuss discharge plan with patient/family/carer.
� Communicate discharge plan with PCCC service providers
� D ocument discharge plan in the patient’s healthcare record
� Referral to other members of the multi-disciplinary team
� Referral to PCCC services
� Referral to diagnostic services
� D ocument receipt of referrals on discharge planning tracking form
� Obtain an accurate medication history
� Review admission medication in consultation with patient’s GP, the community
pharmacist and other relevant clinicians
� D evelop and co-ordinate a medication discharge plan
� Notify PCCC service providers of unplanned admissions
� PCCC service providers contact hospital to discuss premorbid health status
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During in patient stay
� Patient assessment
� Monitor treatment plan on a daily basis
� Communicate changes to the patient
� Communicate changes to PCCC service providers
� D ocument changes to treatment plan in the healthcare record
� Manage ELOS against treatment plan
� Communicate changes to the patient/carer
� Communicate changes to PCCC service providers
� D ocument changes to the ELOS in the healthcare record
� Manage discharge plan against treatment plan
� Communicate changes to the patient/carer
� Communicate changes to PCCC service providers
� D ocument changes to the discharge plan in the healthcare record
� MTD agree suitability of patient for nurse (or HSCP/Other) facilitated discharge
� Identify nurse (or HSCP/Other) to facilitate discharge within one hour of
admission
� D ocument the name of the nurse (or HSCP/Other) to facilitate discharge in the
healthcare record
� Advise PCCC service providers/carer of planned discharge (at least 2 days prior to
discharge)
� Arrange 2 way communication between the hospital, the GP, the community
pharmacist and other PCCC service providers
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24 hours before discharge
� Confirm discharge arrangements with the patient/family/carers and PCCC service
providers
� Confirm transport arrangements 24 hours before discharge
� Undertake medication review
� Put arrangements in place to facilitate ongoing supply of the patient’s medication
� Prepare transfer/discharge communication
� Complete discharge checklist
� Contact family/carers and PCCC service providers to confirm that the patient is
being discharged
� W rite medical (sick) certificate
� Check that the patient/carer has received and been educated in the use of any
aids/equipment
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On day of discharge
� Confirm that patient is clinically fit and safe for discharge
� D ischarge patient to place of residence/transfer healthcare facility or discharge
lounge
� D ischarge to be effected by 12 noon
� Ensure transfer/discharge communication has been communicated to the
healthcare provider(s) nominated by patient
� Confirm with PCCC service providers that patient has left the hospital and that
service provision needs to commence
� Provide patient with information pack
� Provide information and education to the patient/family/carer in the appropriate
language, verbally and in written form
� Determine if the patient needs follow-up
If follow-up is required...1. Determine who should telephone the patient post hospitalisation
2. Obtain the patient’s/carer’s consent for the follow-up call
3. Ask them to nominate a call time
4. Check that telephone details are correct
5. Check language skills and record any special needs for the telephone follow-up
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Post discharge
� Reinforce teaching initiated in the hospital
� Provide assurance to the patient and their home carers
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Health Service ExecutiveCode of Practice for
Integrated Discharge Planning
Patient Information
Brochure
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PLANNING YOUR TRANSITIO N FROM
HO SPITAL TO HOME
INTRODUCTION
� Many people require no special services after they have been discharged home.
� If you require some extra assistance then hospital staff, your GP and primary, community
and continuing care (PCCC) staff will help you to plan ahead so that the appropriate
arrangements can be made before you are discharged.
� This brochure is to prompt you (the patient) and your carer, family and friends to consider
a range of practical aspects about your return home from hospital.
YOUR DISCHARGE PLAN
� From the day you are admitted to hospital, a number of different staff involved in your care
(the multidisciplinary team) will work with you, your relatives and carers to plan your
discharge.
� Your length of stay will depend on your condition. The date of your discharge will be
agreed and discussed with you by the consultant and the multidisciplinary team.
� Please advise your nurse, as early as possible during your stay, if you think you will have any
problems with going home.
� On the day of your discharge please make arrangements to be collected no later than 12
midday. This is necessary to make way for other patients who are being admitted to
hospital.
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QUESTIO NS YOU NEED TO ASK ABOUT YOUR CARE
� How long will I be in hospital?
� W hat can I expect to happen to me during my time in hospital?
� How soon should I feel better after leaving the hospital?
� W hen can I expect to return to work?
� Are there any special instructions for my daily activities?
� W ill I need any special equipment at home? W ho will help me to arrange this? Is this
equipment covered by my insurance or medical card?
� Do I need to have follow-up tests? W ho should I follow-up with to get the test results?
� If I need help and care at home after I leave hospital, who will help me to arrange it?
� W ill I need to have other treatment following my time in hospital?, (e.g. physiotherapy).
Are there any exercises that I need to do? (If so, ask for written instructions).
� W hen I leave hospital, will I be able to go directly home?
� W ill there be any follow-up appointments?
� Do I need to schedule any follow-up visits with my doctor?
� W ill I be able to walk, climb stairs, go to the bathroom, prepare meals, drive, etc.
� W ho can I call if I have any problems after leaving the hospital?
QUESTIO NS YOU NEED TO ASK ABOUT YOUR MEDICINES
� W hat medicines will I need to take at home? Get a complete list of all your medicines at
discharge, including any changes made while you were in hospital. Take this list with you when
you leave the hospital.
� Can I get written instructions about my medicines? Ask any questions before you leave the
hospital.
� Are there any food or drinks that I should avoid while taking my medicines?
� Are there any drugs (including non-prescription drugs) or vitamins that I should not take
with my medicines?
AFTER YOU LEAVE THE HO SPITAL
� The hospital staff will let your GP/Public Health Nurse (PHN) know when you are leaving
hospital.
� W hen you leave the hospital, hospital staff will prepare a discharge communication (a
summary of medical information about your treatment in hospital and ongoing services
that have been arranged for you). This communication will be given to you and a copy will
be sent to your GP.
� You may wish to make an appointment to see your GP following discharge.
� If you feel that you are not well and/or are not managing at home, contact your GP and/or
PHN.
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TH INGS TO DO BEFO RE YOU GO H OME
� Speak to at least one hospital member about how long it might be before you will be
feeling better and can expect to resume usual activities.
� If your physical abilities have changed as a result of your illness, make sure you
understand about what you can and can’t do when you go home.
� A sk staff questions about what has happened to you, and what changes you can expect in
your health and daily activities when you return home.
� If you have any questions after you leave hospital, you may wish to contact your GP or
Public H ealth Nurse (PHN).
MULTIDISCIPLINARY TEAM
The staff involved in your care are known as the multidisciplinary team and may include the
following:
� Medical Staff (Consultant, Registrar)
� Nursing Team
� D ischarge Co-ordinator
� Community Services D ischarge Liaison Officer
� D ietician
� Physiotherapist
� Occupational Therapist
� Speech & Language Therapist
� Pharmacist
� Social W orker
� Public Health Liaison Nurse
� Chaplain / Spiritual A dvisor
H ospital/Local H ealth O ffice (LH O ) Name H ere
Phone: 555-555-5555
Fax: 555-555-5555
E-mail: [email protected]
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1. Department of Health and Children (2001). T h e N a t i o na l He a l t h S t r a t e g y: Q u a l i t y
a nd f a i r ne s s - A He a l t h S ys t e m f o r yo u .
2 . Department of Health N HS (2003 ). D i s c h a r g e f r o m h o s pi t a l : pa t h wa y, pr o c e s s a nd
pr a c t i c e D e pa r t me nt o f He a l t h , N HS ( 2 0 0 3 ) .
3 . HeB e (2003 ). A dmi s s i o ns a nd D i s c h a r g e G u i de l i ne s , He a l t h S t r a t e g y I mpl e me nt a t i o n
P r o j e c t .
4 . Lees, L. (2007). N u r s e F a c i l i t a t e d Ho s pi t a l D i s c h a r g e , M & K P ub lishing. I S B N : 9 78 1-
9 0553 9 - 12- 3 .
5. Lees, L. (2006). E mergenc y Care (Delay ed Hospital disc harge: The Health P erspec tiv e).
T h e N a t i o na l E l e c t r o ni c L i b r a r y f o r He a l t h . N LH E mergenc y Care S pec ialist Lib rary .
www.lib rary .nhs.uk / emergenc y .
6. Lees, L., Holmes, K., (2005). E s t i ma t i ng a da t e o f di s c h a r g e a t wa r d l e v e l : a pi l o t s t u dy,
V ol. 19 , N o. 17, pp 4 0 – 4 3 . N ursing S tandard. www.nursing- standard.c o.uk .
7. Lees, L., Temple, R. (2005). C o mmu ni t y C a r e : P o l i s h i ng u p t h e A c t t o e s t i ma t e a da t e
o f di s c h a r g e . I ssue F eb ruary 2005, V ol., 9 , N o., 1. pp 22 – 24 . J ournal of Health S erv ic es
M anagement. www.ihm.org.uk .
8 . Lees, L. (2004 ). M a k i ng nu r s e l e d di s c h a r g e wo r k t o i mpr o v e pa t i e nt c a r e . N ursing
Times; 100: 3 7, pp 3 0 – 3 2. www.nursingtimes.net.
9 . Lees L. (2006). N o t j u s t a no t h e r s h e e t o f pa pe r : di s c h a r g e c h e c k l i s t s . The
Communic ator: RCN disc harge planning and c ontinuing c are forum. S ummer, 4 - 5.
10. Lees L, Holmes K (2005). E s t i ma t i ng a da t e o f di s c h a r g e a t wa r d l e v e l : a pi l o t s t u dy.
N ursing S tandard. 19 , 17, 4 0- 4 3 .
11. Lees L (2004 ). I mpr o v i ng t h e q u a l i t y o f pa t i e nt di s c h a r g e f r o m e me r g e nc y s e t t i ng s .
B ritish J ournal of N ursing. 13 , 7, 3 4 5- 4 3 2.
12. N E HB (N ov 2006). C o nt i nu u m o f C a r e , D i s c h a r g e a nd T r a ns f e r o f C a r e P o l i c y.
13 . N ew S outh W ales Department of Health (2006). N S W : A ne w di r e c t i o n f o r M e nt a l
He a l t h . www.health.nsw.gov .au/ polic ies/ pd/ 2008 / P D2008 _ 005.html
1 . R ef er en c es
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Please see at t ac h ed
Please see at t ac h ed
Appendix 1: Membership of National Integrated Discharge Planning Steering
Committee
N am e T i t le
John O’ Brien National Director Winter Initiative- Chairperson
Claire Broderick , Discharge Co- ordinator, AM NCH
Dr. Garry Courtney, Consultant Physician, St L uk es Hospital, Kilk enny
Jennifer Feighan, Proj ect M anager, National Hospitals Office
Ken Fitzgibbon, Acting Assistant Director of Nursing/ Bed M anager Beaumont Hospi-
tal
Cate Hartigan, Assistant National Director PCCC
Anne Keating, Bed M anager, Cork U niversity Hospital
Helena M aguire, Senior Proj ects Officer, Sligo General Hospital
Frank M cClintock , Assistant National Director, Ambulance Service
Winifred Ryan, Joint Chairperson, NHO Healthcare Records Steering Committee
Carmel Taheny, General M anager, PCCC, Sligo/ L eitrim
David Weak liam, Consultant in Public Health M edicine, Population Health
William Reddy, Transformation Programme 1 M anager
M ary Boyd, Director of Nursing, Cork U niversity Hospital
Dr Ronan Collins, Consultant Geriatrician, AM NCH
Dr Joe Devlin ( co- opted) Consultant Rheumatologist, WRH and Joint Chairperson of NHO
Healthcare Records Group
E ddie Byrne ( co- opted) Director of Nursing, Cavan/ M onaghan General Hospital, member
of NHO Healthcare Records Steering Committee
Tamasine Grimes Research Pharmacist, AM NCH
Brendan M urphy ( co- opted) General M anager, Organisational Design & Development and mem-
ber of NHO Healthcare Records Steering Committee
Part
5 -
Add
ition
alRe
sour
ces
and
App
endi
ces
HSE Code of Practice for Integrated Discharge Planning. V ersion 1.0. November 2008.
This is a controlled document and may be subject to change at any time.112
Name Title
John O’Brien National D irector W inter Initiative - Chairperson
Claire Broderick D ischarge Co-Ordinator, AMNCH
D r. Garry Courtney Consultant Physician, St. Luke’s Hospital, Kilkenny
Jennifer Feighan Project Manager, National Hospitals Office
Ken Fitzgibbon D ivisional Nurse Manager, Medical D ivision,
Beaumont Hospital
Cate Hartigan Assistant National D irector PCCC
Anne Keating Head of Bed Management, Cork University Hospital
Helena Maguire Senior Projects Officer, Sligo General Hospital
Frank McClintock Assistant National D irector, Ambulance Service
W inifred Ryan Joint Chairperson,
NHO Healthcare Records Steering Committee
Carmel Taheny General Manager, PCCC, Sligo/Leitrim
D r. D avid W eakliam Consultant in Public Health Medicine, Population Health
W illiam Reddy Transformation Programme 1 Manager
Mary Boyd D irector of Nursing, Cork University Hospital
D r. Ronan Collins Consultant Geriatrician, AMNCH
D r. Joe D evlin (co-opted) Consultant Rheumatologist, W RH and Joint Chairperson of
NHO Healthcare Records Group
Eddie Byrne (co-opted) D irector of Nursing, Cavan/Monaghan General Hospital,
member of NHO Healthcare Records Steering Committee
Brendan Murphy (co-opted) General Manager, Organisational D esign & D evelopment and
mamber of NHO Healthcare Records Steering Committee
Tamasine Grimes Research Pharmacist, AMNCH
Virginia Pye D irector of Public Health Nursing, Longford/W estmeath
D r. Siobhan O’Halloran D irector of Nursing Services, HSE
Maureen Howley D ischarge Co-ordinator, Sligo/Leitrim
John W ickham Organisation D evelopment, HSE W est
Ms. Liz Lees Consultant Nurse, NHS and External Advisor
Appendix 2: List of Key Stakeholder Groups
Part 5 - Additional
Resources and Appendices
HSE Code of Practice for Integrated Discharge Planning. Version 1.0. November 2008.
This is a controlled document and may be subject to change at any time. 113
Key Stakeholder Groups Key Stakeholder Groups
Irish D irectors of Nursing and Midwifery Asso-
ciation
Royal College of Physicians of Ireland
Royal College of Surgeons of Ireland D epartm ent of Health and Children
Association of O ccupational Therapists of Ire-
land
National Council for Nursing & Midwifery
Psychological Society of Ireland Patient Focus
Irish Association of Speech & Language Ther-
apy
Irish Advocacy Network
Medical Social W orkers Group Patients Together
Irish Chiropodists/Podiatrists O rganisation Patient Partnership
Irish Society of Chartered Physiotherapists Hospital Pharm acists’ Association of Ireland
Irish Nutrition and D ietetic Institute Irish Association of Em ergency Medicine
Irish Patients Association Irish Gerontological Society
National Casem ix Program m e The Federation of Irish Nursing Hom es
Irish College of General Practitioners Public Health Nursing Association
Am bulance Association Bed Managers Association
Irish Medication Safety Network Irish Pharm acy U nion
Irish Hospital Consultants Association