Gill Massey, RGN, Dip NHS Management, Senior Sister, Discharge Planning Team
Andrea Gibbs, Dip HE, Junior Sister, Discharge Planning Team
Leanne Govey, Dip HE, Junior Sister, Discharge Planning Team
Denise Rehbein, Discharge Support Worker, Discharge Planning Team
Sukhvinder Dobb
Dr. J. Bernstein, Consultant Geriatrician
Dr. S. Arianayagam, Consultant Geriatrician
Dr. E. Giallombardo, Consultant Physician
Pat Dominey, Modern Matron
Julie Cairns, Modern Matron
Jacki Metcalf, Nurse Consultant for Older People

• To reduce delayed patient discharges and facilitate the efficient use of acute hospital beds combined with a seamless discharge process
• The appropriate utilisation of community services and community hospital beds to aid patient rehabilitation

• Numbers of hospital delayed discharges
• Numbers of medical transfers of care
• Numbers of patient whose admission is greater than 7 days
• Reduction in acute beds by circa 55 beds

• Development of the discharge planning team
• Education and support for discharge planning for the wards and clinicians by the discharge planning team
• Re-drafted the NHS Trust discharge planning policy
• Introduction of the discharge risk assessment for the early identification of complex discharges
• Multidisciplinary work with complex/problematic discharge planning issues
• Early inclusion and support from hospital management
• Strengthened multidisciplinary work by social meetings and information sharing
• Strengthened inter-agency work via the discharge planning team
• Developed a management led focus on patient length of stay
• Development and introduction of care home of choice policy
• Adoption of Primary Care Trust intermediary care team patient support
• Introduction of government policy for the reimbursement of the NHS Trust by social services for delayed patient discharge
• Development of Trust-wide discharge documentation to improve communication
• Development of a patient database to prevent duplication and ensure timely referrals and assessments
• Discharge Planning Audit, the results of which were disseminated through the divisions to all wards and clinicians
• Palliative care inter-agency work
• Increased hours of assessment by the mental health liaison team

• Multidisciplinary work, internally and externally to the NHS Trust
• Discharge is everyone’s business and not defined to one particular group of professionals
• Early indicators for complex cases
• Sharing the results with all staff and at all levels
• Adopting best practice from other hospitals and adapting the information to our local environment
• Senior medical engagement and commitment
• Information sharing is the key
• Sharing responsibility and risk
• Being proactive as opposed to reactive for assessments
• Multidisciplinary team work and decision making within the emergency department prior to admission
• Be aware of external factors and implications on discharge planning

Gill Massey, Senior Sister, Discharge Planning Team
North Hampshire Hospital NHS Trust, UK
gill.massey@nhht.nhs.uk

Storyboard presentation at IHI's 2006 National Forum