In February, Claire Fare became Discharge Hub Lead, providing clinical leadership and expertise through support, advice and specialist knowledge about all aspects of discharge.
“In total, 80% of the patients we discharge are classified as D2A0, which means they leave without needing further care,” said Claire. “The remaining 20% are discharged on D2A (discharge to assess) pathways, which means they do have care requirements. I’m actively involved in the discharge of these patients, helping to ensure they receive continuity throughout their care pathway.
“Patients who require care at home, with or without therapy input, are classed D2A1. Those who need a bed, either in the community for rehabilitation or a short-term residential bed for further assessment, are D2A2, and patients with complex nursing needs or fast track end-of-life patients are D2A3. Everyone who is discharged on one of these pathways is assessed within six weeks of discharge, hence the ‘discharge to assess’ element.
“I manage a team of Specialist Discharge Nurses who offer support and advice for more complex patients, as well as Discharge Co-ordinators who support wards with all aspects of discharge.
“We’re part of the Integrated Discharge team and work with community response teams to provide care and reablement – collaborative working is essential and we all work hard to implement a ‘home first’ ethos around discharge.”
Thanks to Claire’s specialist knowledge, experience and expertise, she can discharge the most complex cases with the support of her team and the wards.
“I’ve been a nurse for more than 30 years, and my background is in medicine for the elderly,” she said. “I worked on acute wards until seven years ago, when I became a Continuing Healthcare Specialist Nurse, then joined the Complex Discharge team as a Specialist Nurse two years later.
“In 2019 I left the Trust to work as a Fast Track Practitioner, case managing end-of-life patients in the community, returning this year to take up my current role.”
Claire also oversees quality of care issues relating to discharges, which are recorded as adverse incidents by district nurses, community units, care homes, social care teams or any professional supporting a patient who has had an issue with their discharge. They are transferred to Datix by her team and, following an investigation, a response is created and sent to the reporter. Claire collates information around common themes and issues that need addressing, and has launched “Discharge Newsbites”, a monthly newsletter distributed across the Trust to share learning.
Her team also supports long length of stay reviews – it’s an NHS England requirement that all patients with a length of stay over 21 days are reviewed, with clear next steps to progress their journey. “We’ve taken the initiative to review all patients over 14 days, reviewing their criteria to reside, next steps and support with discharge planning,” said Claire.
“It’s key to start discharge planning before someone is medically ready to leave – patients who’ve been in an acute hospital bed for an extended period are likely to need support with discharge planning.”
Following recent changes to discharge pathways – and with more changes planned in the future – the wards need assistance in understanding processes.
“I’m keen to set up training sessions and perhaps introduce mandatory training for all staff around discharge,” said Claire. “The Integrated Discharge team is small and we don’t have capacity to support all discharges, so the opportunity to upskill ward staff is vital to maintain patient flow and ensure safe and timely discharges.
“Discharge has changed hugely in the past few years. Covid allowed us to implement ‘discharge to assess’ pathways which have since been adopted and embedded, we no longer assess people’s long-term care needs in hospital, and the introduction of discharge funding has changed the way we operate. I believe that this, combined with our ‘home first’ ethos, has enabled us to truly put our patients first and to discharge more complex patients home than ever before.”
Thursday 8th of July 2021 12:15:21 PM