Discharge Process
St Catherine’s aims to ensure co-ordinated, safe and timely discharge of patients from Hospice care, with appropriate arrangements made for ongoing care. Some people will require very little support from other services after discharge, whereas others may need a full range of provision.
When is discharge considered?
The discharge process is triggered either:
- when a person requests discharge from Hospice services, or...
- when the Hospice team agree that it is appropriate to plan discharge.
St Catherine's works together with patients and families to provide personalised care that understands individual wishes, including where a patient wants to be cared for. For example, if someone is being looked after in the Hospice but would like to be at home at the end of life we will work hard to achieve this.
It is appreciated that sometimes people would, ideally, prefer to stay in the Hospice, or continue to be seen by the Hospice team indefinitely. Unfortunately we are unable to provide ongoing care if a patient’s condition is stable. So, if someone’s condition improves enough for care to be safely provided and monitored elsewhere, then discharge is planned in order to enable other people with specialised palliative care needs to access our services.
What happens during discharge planning?
During discharge planning, the personal circumstances, needs and wishes of each individual are carefully considered, including any recent changes in condition that may influence the level of care and type of follow-up required.
We use the information gained from our assessments to make suggestions about what might help the person to manage as well as possible in his/her preferred place of ongoing care. We might suggest, for example, that carers or district nurses visit regularly after discharge, or that equipment might be needed, or that a Residential or Nursing home may be a more appropriate place of care to meet a person’s specific needs.
If extra care is needed at home, or if residential or nursing home care is required, we also need to think about who will provide funding for this care. The Hospice team can advise on this.
For inpatients, sometimes a visit home with one or more members of the Hospice team, or a ‘trial run’ with an overnight stay, forms part of the assessment.
For day therapy patients who have benefitted from the social aspect of day therapy, sometimes alternative day care can be identified.
In more complex situations, community (and sometimes hospital) teams may be invited to a planning meeting to discuss options and agree discharge plans with the person, their family/carer and Hospice staff.
If a person’s situation changes during discharge planning, then the decision to discharge may be discussed again and deferred if appropriate.
Who is involved in discharge planning?
The Hospice team provide support and information to enable the person, and where appropriate their family or carer, to be closely involved with any decision-making throughout care and at the time of discharge. In other words, we work together to provide arrangements that are suitable for each individual.
Several members of the Hospice team may be involved in supporting discharge planning, such as the nurse, doctor, physiotherapist, occupational therapist and the family support team.
The Hospice team also works closely with other teams in the community and in local hospitals. They often need to be involved in the discharge planning process and after discharge. For example, district nurses may continue to monitor a person’s condition alongside the GP after discharge from a community palliative care nurse specialist, or may continue to offer specific interventions for problems such as lymphoedema, catheter care or wound care.
What happens at the time of discharge?
Any person discharged from Hospice services is given information about who to contact if there are any problems, including a contact number for the Hospice team.
Information is also provided about follow-up arrangements and a discharge letter is sent to update other involved professionals, such as the hospital consultant or specialist nurse, GP, District Nurses and Out of Hours services.
Everyone discharged from the inpatient unit is given a week’s supply of medication to allow enough time to order a repeat prescription from their GP, and an information sheet about medication is provided.
Patients discharged from lymphoedema services are given a supply of hosiery, and the GP is given information about ordering further supplies when needed.
What can be done if a person’s condition changes after discharge?
By working together we hope to meet the needs of each individual, whilst also enabling us to open up our services to as many people as possible.
However, we also know that sometimes people need us again at a future date. If the situation changes and the need arises, an appropriate professional (such as the GP, district nurse or consultant) can refer a person back to Hospice services.
