A Patient with very complex needs is discharged into the community
Discharging anyone back into the community after a period in hospital always brings challenges. A successful discharge can only be achieved where the patient is central in the process and there is collaborative working across all departments.
The journey in this case study began when a patient expressed a wish to return home. The Clinical Commissioning Group (CCG) and Holy Cross teams agreed that with support, the patient’s aim appeared achievable.
From this starting point, the Holy Cross Team took on the role of the facilitator. It was a long and complex process and it took almost a year to achieve the goal. It required the commitment of the patient’s family, the agreement of the CCG and the collaboration of NHS services in the community. An agency was engaged to provide the package of 24-hour home care.
In this case the patient was ventilator dependent and a number of services were enlisted to formulate the discharge plan.
Clinical Commissioning Group
- Agreement to package of care
- Initial meeting with multi-disciplinary team at Holy Cross Hospital to discuss family/relatives/access/adaptations/benefits/grants/agency/services required
- Proposed a visit home by occupational therapist for access and assessment
- Proposed a visit home for the patient
- Lane Fox Unit, St Thomas’ Hospital – required for ventilator and tracheostomy
- Environmental Control Service – patient is a user of communication equipment provided by ECS for use with Skype, internet, TV control, computer access
- General hospital local to patient’s home in case of admission
- Electricity service – priority services for re-connection in event of power failure
- Hoist supplier for home
- Community nursing
- GP services
- Social Care OT/Housing
- Wheelchair services
- Speech and language therapist
- Agency – to provide 24-hour nursing care and have staff competent in ventilator and tracheostomy management
- Competency training – getting the agency to work at Holy Cross to familiarise staff and the patient with routines
- Holy Cross provided respiratory training and shadowing shifts for agency staff
Other Administration Provided by Holy Cross
- Essential and useful contact information
- Guidelines for manual/power wheelchair
- Positioning guidelines when in bed and chair
- Information relating to provision of equipment
- Equipment list
- Discharge summary report/discharge letter/management information
- Information relating to community physio if required
- Information for family support
- Transport and nurse escort on the day of travel home
- Informed the GP of patient’s return home
- Arrange for oxygen supply via the GP – as required
We did encounter difficulties but with the professional support of all concerned the discharge was achieved and the ongoing care and responsibilities were handed over to the agency and community services. The patient was able to spend Christmas and New Year with her family and is looking forward to enjoying her garden.