Literature

There is extensive literature on the subject of delayed discharge and the pathway between hospital and home for older people. Below is a summary of the key problems and solutions, as identified in the literature, and a list of key resources for further reading.

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Problems identified in the literature

At point of admission

The majority of hospital admissions for older people are unplanned. More needs to be done to support older people at the point of admission to hospital and to prevent unnecessary admissions.

During discharge planning

During early discharge planning within acute settings there is often little engagement with the older person receiving care, their family or their informal carer about decisions concerning their discharge and ongoing care arrangements. As a result, older people and their families and/or informal carers are not routinely asked about their home circumstances, nor how they will cope following discharge.

Furthermore there is a lack of communication between acute care and outside agencies such as GPs, local authorities and community based care providers at this early stage in the planning. This can cause delays later in the pathway when these agencies are given insufficient time to accommodate a discharge.

At point of discharge

Transportation is a major issue when discharging an older person from hospital either to their home, a community hospital or a care home. Lack of communication between the acute setting and community based service providers means that there is often inadequate notice of discharge and transport is often requested with less than 24 hours notice, resulting in the older person being unnecessarily delayed in acute care.

Medication issues often arise due to lack of communication between health practitioners in acute and primary care settings. This can often result in an unnecessary readmission to acute care.

Following discharge, older people often experience delays or inadequacies in the provision of community based services, resulting in little assistance if the appropriate care packages are not in place at the time of discharge. As older people often live alone, this can mean they go unsupported for some time, again, resulting in an unnecessary readmission.

Essential aids such as commodes are usually provided before or 'soon after' discharge but it can be several weeks or even months for other aids or adaptations to be put in place.

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Solutions identified in the literature

Strategic

There needs to be closer communication throughout all aspects of the pathway: between acute and community health, health and social care, housing and wider community organisations. The implementation of the integration agenda offers a renewed opportunity to transcend these traditional boundaries. It will, however, require that the delivery of good quality outcomes for the individual is a priority.

There is a need for central government action in order to overcome the financial, legal and administrative obstacles to joint working. This will support health care, social care and housing agencies to work in partnership with one another to increase their own internal efficiency and develop shared solutions to local problems.

There needs to be improved links and communication resource links between health professionals based in acute and primary care at all stages in the pathway to ensure problems arising from medication changes are overcome and readmissions are reduced.

Prior to admission

Wherever possible the discharge should be planned before or at the point of admission. This would be supported by identification of all problems likely to arise being identified early alongside the appropriate action that would be taken in this event. Older people should undergo early screening prior to or at the point of admission to allow this information to be fed into their discharge plan. As part of this, multidisciplinary teams should be allocated clear lines of responsibility. In cases of unplanned admissions, they should also experience an early review by a senior clinician in the emergency department at point of admission.

During discharge planning

There is a need for acute care to take a collaborative and multidisciplinary approach to discharge planning at an early stage in the older person's pathway either prior to or at the point of admission. This would be supported by ongoing and effective communication throughout the planning process between the older person, their family, health and social care professionals within acute and primary care and community services. In addition, improved relationships and effective communication channels are essential between health and social care practitioners working in the acute setting and those based in the community.

It may also be advantageous to employ a designated (named) person to ensure that all stages of the discharge plan are fulfilled and to ensure that the discharge is timely and linked to appropriate support services within the community.

A 'discharge checklist' could be put in place to address: primary care workloads; social work assessment; ambulance transport; discharge prescription; social services; day hospital; continuing care facilities; housing. This information could then be shared with all those involved in the pathway including hospital and community based practitioners, the older person, their family and informal carer.

At point of discharge

Progress has been made towards the pathway from hospital to home and discharge process becoming outcomes-focused and person-centred but more still needs to be done. This will require ongoing monitoring to ensure the older person's outcomes are being met.

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Further reading

Please visit our Learning Exchange collection for a list of suggested further reading.