Hospital Discharge Meg Davey Business Manager, Stroke, Rehabilitation and Older People 24 th November 2008

Discharge post MPN Focus needed ….. Effective discharge planning processes Clarity of pathways Scale of discharge delays Re-admission rates Discharge facilitation team resources Meeting discharge training needs

In essence…… Getting the patient experience right : quality care/treatment specialised area length of stay discharge date support services

MAU to discharge group …..Discharge workstream Draft PID and PIP established in April 2008 Engagement with MDT’s ELHT discharge delay reporting to understand nature and scale of delays Utilise existing forums for wider engagement MPN Multi-agency Discharge Service MADS MADS group re-branded as ‘Integrated Discharge and Admission Avoidance Process’ IDAAP

Initial findings.…. Delays……. 34 % Social services 18 % Ward based delays 17 % ELHT Rehab 9% Pharmacy, diagnostics 7% PCT Rehab 7% Mental Health 5% OT / Equipment 3% Housing, transfer out of Trust

Progress to date …… Successfully integrated discharge facilitation services Understand nature and scale of discharge delays Unity House – Discharge support teams based at ELHT Discharge training needs highlighted Pathway development / access / monitoring Student nurse training Planning ahead – neuro-rehab, falls, stroke ABI team / Community Stroke Team

Re-admission rates – (re-admission within 28 day period)

Current developments ‘Closer to home’ IDAAP continues eSAP project Discharge resource file Review of discharge policy Learn from experience – failed discharge review Information leaflet for patients Links within B&D PCT / Comm matrons

ELHT focus…. Emergency Care Programme Board – Rehabilitation and discharge workstream NHSLA level 3 standards for discharge Performance monitoring Role of the Matron and Lead Matron Business Manager and Clinical Director, Matron for Stroke, Rehabilitation and Older People Partnership working ie OPP, Social Services Equity of service provision