Discharge to Assess (D2A) Pathway Changes. Improving flow and follow up out of The RD&E Acute.
The following changes relate to patients being discharged from The RD&E Acute Hospital into care home settings on the following pathways:
Pathway 2 – Transfer for rehabilitation in a care home setting for up to 28 days
Pathway 3 – Transfer for longer term care in a care home setting for up to 28 days
In line with all of the national guidance, our desire to strengthen our D2A model (for The Acute pathway) and improve patient experience, we are making the following changes and need you to be aware, so we can continue to work together well.
We aim to support individuals to leave hospital safely, into the right care home, within the following timeframes from being medically optimised:
• Individuals with end of life needs 24 hours
• Pathway 2 Rehabilitation in a care home setting 48 hours
• Pathway 3 Longer term care in a care home setting 72 hours
These changes are in place from 19 July 2021
Single Point of Access (SPOA) within The RD&E Acute Hospital
SPOA staff based on the wards will complete an assessment for all patients referred for Pathways 2 or 3 transfers into a care home. There will be daily liaison with the Bed Bureau, care homes and the community health and social care teams as required.
Trusted Assessors (TA)
The TAs will work alongside SPOA, continuing to work with individuals with End of Life needs. The TAs will progress an assessment on the ward and provide follow up within 24 hours, by call or face to face, for these individuals who are discharged to a care home.
Bed Bureau (BB)
The Bed Bureau will progress all health and social care referrals for an individual leaving The RD&E Acute Hospital, being discharged into a care home. They will source the care home bed using The Capacity Tracker, progressing referrals to the market within 2 hours of receipt, aiming to send offers back to SPOA within 4 hours. We recognise that this is a challenge, but we want to do all we can together to support individuals to leave hospital when they are medically optimised.
Complex Hospital Discharge Team (CHDT)
As per the D2A model, all social care assessments will take place after the individual has been discharged.
The CHDT will:
• Complete the 24 hour follow up call and ongoing case management for all patients on Pathway 3 (longer term care) and as required on Pathway 2 (rehabilitation). In general, patients leaving hospital on Pathway 2 will receive rehabilitation with an aim to returning home and will therefore continue to be followed up by the community health teams.
• As required, The CHDT will take part in Continuing Healthcare Assessments and carry out Care Act Assessments within four weeks, along with offering advice and information to individuals who will fund their own ongoing care.
Please note that all Community Hospital discharges will continue to be followed up and managed by the Community Health and Social Care Teams (CHSCT), as currently in place.