Understanding discharge planning & packages of care

Discharge planning looks at finding the right care and support on discharge. This might be discharging them to their own address with an appropriate pack of care (which is discussed here) or discharging them to a home (which is discussed in another article).

As a junior doctor, understanding how patients’ health and social care needs are assessed and how care packages are organised will help you have a proactive role in discharge planning. It will also enhance your contribution to ward MDTs or discharge meetings. Having some basic understanding of packages of care should also help you with communicating with families about discharges.

Never promise a patient or family about what care or home can be provided.alert-warning
It is important to understand that what is offered is based on a complex assessment of needs, funding & availability by all members of the MDT. Promising a certain home or care does not help the patient or family.

Occupational therapists
Occupational therapists (OTs) assess patients who have had a functional deterioration during admission, or patients who previously required care support. They carry out functional assessments (in a hospital or in a home environment), identifying areas where the patient may require extra aid.

The functional assessment covers:
  • Physical health needs (drug therapies, skincare, continence, nutrition, mobility)
  • Mental health needs (psychological and emotional needs, memory loss, communication)
  • Social care (home safety, washing, cooking)
The functional assessment may need to be complemented by a home visit to get a realistic snapshot of the patient’s home environment.

After their functional assessment, the OTs will make recommendations about what equipment or personal support is needed. These are discussed with the patient and their next of kins.

Examples of home adaptations and equipment that can be put in place are:
  • Hospital bed, hoist
  • Commode, raised toilet seat
  • Rails in bathroom, easier taps to turn
  • Frame, stairlift
  • Adapted cutlery
  • Key safes, intercoms
  • Pendant alarm
OTs from the hospital will only organise changes that need to be in place prior to discharge (‘discharge-dependent’) - an assessment by a community OT may be needed to establish a need for further adaptations, such as ramps or widened door frames.

OTs also sometimes recommend for packages of care to be put in place - these involve visits at home from carers. This ranges from once daily package of care to four times a day (QDS).

Packages of care can be single or double-up (two carers come in at once), depending on the amount of assistance required.

Packages of care may not be sufficient to address all the health and social care needs of patients. In the cases below, the option of a care home should be considered:
  • Care needed for more than 8 hours a day
  • Night care needs
  • 24/7 access to registered nurse needed
OTs may also recommend an assessment in the patient’s home environment on discharge - this is done through the Discharge to Assess (D2A) pathway.

If patients do not require a care package but would benefit from additional physiotherapy, they can also be discharged with home rehabilitation.

Social workers
Once recommendations have been made by OTs, social workers will be notified of these recommendations and can start working on their own assessments. Their role is to establish whether a patient would be eligible for NHS-funded care and to direct patients and relatives appropriately if this is not the case.

The Community Care (Delayed Discharge) Act 2003 details how NHS hospitals should communicate with social care about discharges of inpatients. In MDTs, you may hear people talking about some sections of the act:
  • Notification of Assessment (Section 2) is a notification is used to alert the council of a patient’s likely need for community care services. This triggers the assessment by social workers (within three days).
  • Notification of Discharge (Section 5) is a notification informs the council of a patient’s proposed discharged date. Once the patient is medically ready to be discharged home, the care arrangements agreed on can be put into place.
Funding
Eligibility for funding is complex and frequently changing, but a broad understanding is helpful. If a patient has only social care needs (support with their activities of daily living) then these are typically means-tested and paid through social services (local authority). If a patient is found to have nursing care needs, then they may be eligible for part or full funding by the NHS depending on their level of need. In the UK, most people have to pay for at least part of their care.

For social care, patients may need to pay for their own care if they have significant savings. There are also some non-means tested allowances which social services will advise on.

If they are eligible for social service funded care, this money will usually go directly to the care agency. If patients want more choice over care providers they may opt for a Personal Budget which they can direct to a certain care agency or someone they choose (known as direct payments).

For nursing care, NHS continuing healthcare is to identify those with significant physical or mental health needs who are entitled to free social care funded solely by the NHS. The MDT completes a checklist to identify which patients are eligible which covers areas such as breathing, nutrition, continence, or behaviour.

After the checklist is completed, a multidisciplinary team meeting happens, and a Decision Support Tool is used to determine whether the patient is eligible for NHS funded care. This decision is passed on to the CCG.

If patients are not eligible for NHS continuing healthcare but live in a nursing home, they may be eligible for some support through NHS-funded nursing care.

For patients approaching the end of life, there is a possibility to Fast Track their assessment (placement can be arranged as quickly as 48 hours). Contrary to what you may hear, there is no set prognosis that qualifies patients for Fast Track - clinicians must simply believe that the patient is rapidly deteriorating and nearing the end of life. This allows patients to receive fully funded care.

Care home assessments
Finally, you should be aware that care homes may send representatives to hospitals to assess patients and see whether they would be able to provide the care necessary.

We hope that this article gave you an overview of what goes on during discharge planning, and will help you make sense of the social care jargon used in MDTs.

Resources

Care Packages
Care homes
Needs assessment
Home adaptations
D2A
Written by Dr Amedine Duret (FY1)
Edits by Dr Akash Doshi (CT2)
Reviewed & further edits by Dr Corrinne Quah (Consultant Geriatrician)