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Knowledge Hub.

Discharge Planning and Community Resources.

27th April 2023

Freeing up beds for hospitals is one of the major topics in modern healthcare. And effective discharge planning is an important tool that could help ease pressure on hospital wards.

By improving patient flow and releasing more hospital beds for urgent care, we can improve long-term patient care, reducing time spent in hospital and lessening the risk of readmission.

Section 91 of the Health and Care Act 2022 – which came into effect on 1st July 2022 – means local authorities are no longer required to carry out long-term care assessments before discharging a patient.

Instead, hospitals, community health professionals and social workers should work together to implement Discharge 2 Assess (D2A): connecting patients with community resources, assessing patients at home, and ensuring continuity of care after discharge.

Coordinating so many elements and organisations, however, is a difficult task for a system that’s already under pressure – with a lack of effective communication, dated technology and limited resources causing significant delays.

We look at how community resources can be used in discharge planning, the role social workers and care teams have in the movement of patients into safe and secure accommodation, and how technology can – and should – be a blessing, not a burden.

Discharge to Assess (D2A) – At-Home Care

Discharge to Assess (D2A) aims to ensure that patients who are clinically ready for discharge and no longer need a hospital bed can leave hospital and have their follow-up care assessment in the most suitable setting – usually their own home.

Evidence suggests D2A could:

  • Significantly improve health outcomes for patients, with less people going into long-term care
  • Reduce the average length of stay in hospital
  • Put less pressure on busy hospital wards.

Joint working is essential to implement D2A successfully. The system encourages healthcare and social workers to collaborate on the patient’s discharge – working together to deliver the best outcome and enhancing the professional relationship across disciplines.

Barriers to Effective Patient Discharge

Delivering a joined-up service, however, is hard. There are many barriers that can impede effective hospital discharge in the UK, including:

  • Poor communication – Coordinating hospital staff, social workers and community carers can be difficult, and poor communication often leads to confusion and delays in the discharge process.
  • Lack of community resources – Limited resources and support services in the community can make it difficult for patients to access the care they need after discharge.
  • Complex health needs – Patients with complex health needs, such as those with multiple chronic conditions, may require a more comprehensive discharge plan, involving multiple healthcare professionals and support services.
  • Limited patient and family involvement – If patients and their families are not involved in their discharge planning, this can lead to a lack of understanding and cooperation that often leads to readmission.
  • Lack of integration: Information technology is also frequently cited by healthcare and social workers as a blocker towards effective discharge. Non-integrated systems mean staff must remember different passwords for different systems in order to update paperwork and coordinate planning – causing delays and frustrations for all involved.

Social Work and Discharge Planning

Social workers are often involved in the discharge planning process, particularly for older adults or individuals with disabilities.

Practitioners navigate complex healthcare and social service systems to ensure all aspects of a patient’s post-discharge care are addressed.

This requires careful coordination and diplomatic handling to ensure healthcare providers, family members and community resources are all on the same page – a feat that’s frequently obstructed by miscommunication, convoluted technology and limited resources.

The task has become increasingly harder with increasing operational pressures across the UK in both social care and the NHS.

With community carers and social workers struggling to cope, Liquidlogic aim to provide software solutions that can facilitate communication and improve workflow efficiencies.

Hospital Discharge Planning Process

Planning for discharge should begin on admission to hospital for emergency treatment, and sooner – pre-admission – for patients undergoing planned and elective procedures.

Social workers should be involved at an early stage of the discharge planning process – as part of a multi-disciplinary team of hospital, community health, and social care providers – to plan post-discharge care and long-term needs assessments.

Patients should also be consulted on their discharge plans from the beginning. Family, friends or carers who have been authorised by the patient should also be consulted and informed of developments.

Most hospitals use a pathway system to refer patients for post-acute care:

  • Pathway 0 – Patient requires no additional support and returns home (this includes a care home if that is their usual place of residence).
  • Pathway 1 – The patient requires some additional care, for instance: nursing, therapy, new equipment, etc. They return home with interim support.
  • Pathway 2 – Patient requires further rehabilitation. They are transferred to a non-acute bed until they can safely go home.
  • Pathway 3 – The patient has complex health and/or social care needs that require longer-term care and further assessment. They might return home but may also need to be transferred to a new long-term bed or nursing home.

The multi-disciplinary team will work together to understand and assess which path is best suited to each patient and how to address their individual needs.

The Solutions: Hospital Discharge Planning Software, Tools and Models

The key to effective discharge planning is communication and collaboration.

By actively involving patients and their families in their discharge planning, hospital staff and social workers can ensure they understand their own care plan and are prepared for their transition back home.

Integrated software solutions can also help by offering a smooth link between disciplinary teams, allowing authorised access to up-to-date patient records across both health and social care.

Liquidlogic is a leading supplier of social care software and IT systems in the UK. Our Adult Social Care System Software (LAS) links with healthcare IT systems – including Orion, Cerner and CareCentric by Graphnet – to import a patient’s shared care records.

Practitioners across hospital, community, and social care services can use a Single Sign-On (SSO) to view a live feed of their patient’s record on the Liquidlogic platform. This real-time access to a single, secured, shared record ensures a joined-up service that saves time and supports clear decision-making.

Healthcare staff can view any social care information, such allocated case worker, associated carers, disability and any risks, protection notices, and current care plans.

Similarly, social workers can access a patient’s health record alongside their social care data. This might include:

  • GP record
  • Medications (current, past, allergies)
  • Risks and warnings
  • Investigations and referrals
  • Hospital admissions and discharges

Having this coordinated data at their fingertips gives health and social care professionals a better understanding of a patient’s needs as a whole – helping make the best clinical and care decisions for each individual patient.

“The CareCentric system has been in place for almost a year in both adults and children’s services and we can already see the benefits. Our social work professionals can make better decisions because they are presented with the complete view of a person.

“There are also time-saving efficiencies linked to a reduction in making and answering calls to gather information – instead the data is there in front of them. The information that social care now has access to is terrific. The information which health has access to is phenomenal."

Mike Roberts – Central Systems Support Team Manager at St Helens Council

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