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Involving and Supporting Unpaid Carers in Discharge Process

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Involving and Supporting Unpaid Carers in Discharge Process

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Unlike healthcare, social care and support is a chargeable provision. The Social Services and Wellbeing (Wales) Act 2014 provides local authorities with discretion to charge for care and support should they choose to do so.

Where a local authority has undertaken an assessment under the 2014 Act of a person’s social care and support needs and is to provide or commission care to meet identified needs, it can apply a charge. Where a local authority wishes to charge, it must apply the requirements set out in Regulations and a Code of Practice in place under the 2014 Act. This legal framework helps ensure charging, where it occurs, is consistent, fair and affordable to a person by including a number of financial protections. The Regulations and Code of Practice are reviewed on a regular basis. A person and, where relevant their carer, should be informed by their local authority of its charging policy in advance of their agreement to the social care support. Essentially, the charging arrangements:

Set a maximum weekly charge (currently £100 per week – April 2023) that ensures no one pays more than this amount for any form of social care and support provided in their own home, in the community or for a short stay (no more than 8 weeks) at a care home (eg: D2RA Pathway 2).

Require social care and support in the form of reablement to be provided free of charge for up to 6 weeks.

Require that, where a permanent care home placement is needed, a person must be able to retain £50,000 (April 2023) of their capital assets.

Require that partners and families cannot be charged for any form of social care and support a local authority has determined a person as requiring to meet their assessed social care and support needs in full.

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Social Services and Well-being (Wales) Act 2014

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An Act of the National Assembly for Wales to reform social services law; to make provision about improving the well-being outcomes for people who need care and support and carers who need support; to make provision about co-operation and partnership by public authorities with a view to improving the well-being of people; to make provision about complaints relating to social care and palliative care; and for connected purposes.

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Providing safe, timely and effective discharge for every person who attends our hospitals is essential. While it is acknowledged that most hospital discharges are simple in nature, the ageing demographic has resulted in an increasing number of older patients being admitted who require very complex discharge planning and coordination. It is estimated that this cohort of patients can occupy up to 80% of acute hospital inpatient beds at any one time. However, it is not age per se that underpins this challenge rather, it is the increasing prevalence of frailty associated with this population.

Frailty is a long-term condition; it describes a state of health whereby body systems gradually lose their biological, physical, and mental resilience. Best practice for the care of those living with frailty depends on early recognition of changes in social, psychological, and clinical needs that have resulted in a change in physical ability or mental capacity. When this happens, the right anticipatory care and early support can avoid the situation deteriorating into crisis, supported by the effective use of intermediate models of care, including reablement. This approach supports ‘what matters’ most to the population which is to continue to live at home where it is safe for them to do so.

There is currently an imbalance in our health and social care system and missed opportunities for prevention and early intervention in the community are evident. The current health and social care system tends to be weighted towards reactive management. As a result, those living with frailty are more likely to be admitted to hospital, often for avoidable reasons.

This approach, and in particular hospitalisation, can cause a deterioration in frailty and loss of independence resulting from things like exposure to hospital acquired infection, a loss of confidence, and loss of muscle mass (sometimes referred to as deconditioning). The consequence of the latter results in greater requirement for care and support on discharge, the availability and capacity of which remains limited and frequently results in delayed transfer of care back into the community. Delayed patient discharges to the community creates sub optimal flow through the acute hospital environment and places the wider population at risk of being unable to access emergency and planned care when they need it.

The effective and efficient coordination of discharge planning contributes to reducing the inpatient length of stay for patients living with frailty and lowers their exposure to harm. Consequently, reducing length of stay and discharge rates for this population will enhance patient flow throughout the acute hospital.

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This Padlet sets out guidance on Hospital Discharge standards for health, social care, third and independent sector partners in Wales. All partners are expected to adhere to, and deliver, these standards to support safe, timely and efficient discharge of patients either to their own homes or on to the next stages of care.

The principles and processes that help support, safe, timely and effective discharge are set out in the Discharge to Recover then Assess (D2RA) Pathways Guidance. All patients with a decision to admit to hospital should be assessed and provisionally allocated to one of four pathways – 0 to 3. This will identify early in a patient’s admission what level of support and recovery they will need at the point of discharge to best meet their ongoing care needs.

Patients must be placed onto a D2RA Pathway in line with the requirements set out under the “Principles” in the D2RA Pathways Guidance. This will include patients who require any new or increased support at home than they were already receiving before they were admitted. Patients should be provided with a period of rehabilitation, reablement or recovery before a decision is made about their new, long term care needs. Further information on D2RA Pathways can be found on the relevant section of this Padlet.

During a patient’s hospital stay, and particularly prior to discharge, a proportionate assessment of their current needs should be undertaken by a variety of health professionals. This should be in the form of a continuous daily assessment.

The Care Co-ordinator and Trusted Assessor roles will support this process by identifying what is required for the patient going forward and who is responsible for any short-term care needed to aid their further recovery, rehabilitation or reablement and where this is to be provided.

For most patients, a comprehensive assessment of their care needs will be undertaken at the next stage of care. The assessment will identify if a long-term care package at home, or a care home placement, is needed following the completion of a period of recovery-focused intervention.

This assessment must be undertaken in line with the requirements set out in legislation under the Social Services and Well-being (Wales) Act 2014. Wherever possible a person should return home for this period of supported recovery (Home First). This supported recovery could be in the form of a commissioned service or support from family or unpaid carers. Only where unavoidable should a step-down or bedded D2RA Pathway rehabilitation or reablement provision be provided.

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Links with All-Wales Optimal Hospital Patient Flow Framework

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Links with All-Wales Optimal Hospital Patient Flow Framework

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This Guidance must be considered and utilised alongside the Optimal Hospital Patient Flow Framework. Further information is available in the Delivering Optimal Hospital Outcomes and Experiences for People in Hospital operational guidance which has been developed under the Six Goals for Urgent and Emergency Care Programme.

The Framework provides an approach that will improve the hospital stay of people within our care system and be meaningful to staff implementing it. The Framework focuses on ward-based care and preventing a patient’s clinical deconditioning as well as the key principles of using SAFER, Red to Green and D2RA Pathways.

The Framework focuses on the journey of the patient through the healthcare setting and the Discharge Minimum Standards focus on helping that patient, and their family or unpaid carers, on their discharge home or to the next stage of their care.

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Delivering Optimal Outcomes and Experience for People in Hospital

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No-one should be admitted, especially those who are frail, unless their only option for treatment has to be provided in an inpatient bed in an acute hospital, and they fulfil criteria to reside i.e. a person requires acute treatment in a hospital setting. In line with the Six Goals for Urgent and Emergency Care and planned care programmes, an assessment must be made, prior to admitting a person, about the potential for clinically safe alternatives to admission and an assessment of frailty and clinical deconditioning risk in relation to potentially longer admissions.

Most patients will be able to be discharged to their home or usual place of residence without further support, other than that provided by their usual support mechanisms, which might include unpaid carers such as family, friends, and neighbours. The requirement for active reablement, rehabilitation or other therapeutic interventions is still an essential element of the discharge process for these patients and their unpaid carers and must be factored in accordingly.

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Key Tasks, Standards, 
and Expectations of Relevant 
Partner Organisations

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Key Tasks, Standards, 
and Expectations of Relevant 
Partner Organisations

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Health Boards

Health boards must ensure that these standards are adhered to at all levels and that the discharge process they have in place links with the All-Wales Optimal Hospital Patient Flow Framework. Health boards must continue to review and refine their discharge processes and assure themselves that their practices and enabling processes are fit for purpose and resources effectively deployed to deliver the D2RA Pathways.

Ward level (acute and community hospitals):

A clinically led review of all patients will be undertaken at an early morning board round. Any patient not meeting the criteria to reside, i.e. whose acute treatment is completed, will be deemed clinically optimised and ready for discharge, adopting the standards and principles below:

A second, brief afternoon board round (huddle) will agree any further patients not required to be in hospital and therefore able to be discharged. The huddle will also agree tasks that need to be completed to enable early next day discharges (“doing tomorrow’s work today”)

Appropriate representatives from the integrated discharge team (or equivalent), including where possible, any carers officer/coordinator or liaison, should ideally be involved in ward reviews (especially in a community hospital setting to support discharge planning within D2RA Pathway 2), and/or help support effective multi-disciplinary team decision making. This will help with the early identification by the ward multi-disciplinary team of the most appropriate proposed D2RA pathway (and in accordance with the four “what matters to me” questions) that all professionals must be able to answer for every person within their care (the four key questions are set out in the D2RA Pathways Guidance and should be considered on the ward round for patients who may require community support for discharge) and to allow the multi-disciplinary team to undertaken arrangements in good time.

Multi-disciplinary teams should have appropriate representation in order to review patient progress towards being clinically optimised and the possible support needed to facilitate their discharge. This can include, but not be limited to:

1. Consultant

2. Junior Doctors

3. Nursing

4. Therapist – physiotherapy/Occupational Therapy/Speech and language

5. Pharmacists

6. Social workers

7. Bed management/Operational Managers

8. Hospital Administration

Ensure professional and clinical leadership between nursing, medicine and allied health professions for effectively and collaboratively managing decisions.

In order to minimise any delays to recovery and discharge, the Red2Green process must be adopted at all times, and be a key feature of board and ward rounds, with appropriate escalation where delays have not been successfully addressed (both within hospital and externally).

All patients who are not required to be in hospital and are therefore suitable for discharge will be added to the discharge list and allocated to a definitive discharge Pathway. Discharge home today (“home first”) should be the default Pathway.

There must be simple, robust and responsive local processes to enable the definitive pathway decision and rationale to be accurately conveyed from the ward to a discharge co-ordination hub to ensure that safe and appropriate onward care and assessment can be arranged via the appropriate D2RA Pathway – this may be in the form of an accurate and comprehensive D2RA Pathways referral (ideally electronically).

On decision of the definitive discharge pathway, the patient and their family or unpaid carer, existing care providers and any formal supported housing staff must be informed and be provided with details of the decision. At this stage, any key supplemental information should also be shared. Much of this guidance will be accessible through the links within this guidance document. However broader guidance may be necessary depending on the individual’s circumstances and, in these cases, any corresponding guidance should be identified and provided.

In the event that a patient or their unpaid carer is reluctant to accept a reasonable discharge ‘offer’ and/or leave hospital the ‘Reluctant Discharge Protocol’ must be followed sensitively. Further information on reluctant discharge, together with a link to the published guidance, can be found in the Supporting Guidance and Information for Staff section of this document on page 16.

Individuals and their families or unpaid carers must be fully informed of the next steps at all stages of the inpatient stay and involved in the discharge planning process. A sample letter template has been prepared which can be used and should be given to patients that highlights that planning arrangements to discharge that person should already be underway and the reasons for getting a person discharged quickly and safely to support their recovery. The sample template can be found at Annex A – ‘Planning Your Discharge’ letter template. Supporting information for patients, families and unpaid carers that may be used to support this letter can also be found in the relevant section of the guidance on page 22. Each patient’s circumstances may be different so you may need to tailor any supporting information that is provided depending on what may be needed.

The co-ordinator will ensure that all practicalities are addressed, including availability of existing care provider, transport arrangements, medication, discharge communication etc.

Where safe to do so, and if there is capacity, D2RA Pathway 0 patients should be transferred off ward into a discharge lounge as soon as reasonably possible (ideally within 2 hours of the patient being deemed clinically optimised).

When a person is considered by clinical teams to be close to the end of life, hospitals should consider issuing palliative care medicines at the point of discharge to support end of life care in their place of choice in sufficient quantity to cover the period until further clinical review. The medicines issued should cover current and foreseeable end of life symptoms on a ‘just in case’ basis. The type of medicines issued should be decided according to clinical need and in discussion between clinicians, the patient and those close to them. The medicines prescribed, rationale and clinical context should be communicated promptly by the hospital to the GP and to other clinicians who are responsible for the patient’s ongoing care, decision making and future prescriptions. These may include district nurses, care home staff, community palliative care teams and community pharmacies, as appropriate.

Identifying an unpaid carer involved with the patient is a vital step in ensuring that a patient’s discharge will run smoothly. Guidance is available for frontline staff on identifying, and engaging with, unpaid carers in the ‘Support for Unpaid Carers’ of this guidance on page 24.

Where no new or amended package of care is required – support the discharge team to put in place any remaining discharge arrangements as timely as possible so that the patient can return home or to their care home promptly.

Where new or amended packages of care are required – support the trusted assessor role, where applicable, to undertake any proportionate assessments and help coordinate any necessary packages of care required so that the patient can return to their home or care home promptly. For further information on trusted assessor please refer to the ‘trusted assessor’ section of this guidance.

Support with making referrals for D2RA Pathway 3 recognising the complexity of some of the patients.

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Provide expert advice and support to the ward teams on the appropriate D2RA Pathways. Act as a key problem-solving contact between hospital and community teams.

Support (where necessary) the nurse in charge of a ward to arrange dedicated ward-based staff to support and manage all patients on D2RA Pathways 0 and 1. This will include:

co-ordinating with transport providers

local voluntary sector and volunteering groups helping to ensure patients are supported (where needed) actively for the first 48 hours after discharge. This should also include support for carers, where required, by appropriate carers services

‘settle in’ support is provided where needed

any community nursing input following discharge.

Provide effective discharge planning for people with no home to go to and ensure that a referral to appropriate housing teams is made.

Where no new or amended package of care is required – support the discharge team to put in place any remaining discharge arrangements as timely as possible so that the patient can return home or to their care home promptly.

Where new or amended packages of care are required – support the trusted assessor role, where applicable, to undertake any proportionate assessments and help coordinate any necessary packages of care required so that the patient can return to their home or care home promptly. For further information on trusted assessor please refer to the ‘trusted assessor’ section of this guidance.

Support with making referrals for D2RA Pathway 3 recognising the complexity of some of the patients.

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Hospital clinical and managerial leadership team

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Hospital clinical and managerial leadership team

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Create safe and comfortable discharge lounge spaces for patients to be transferred to, ensuring enough space for expected numbers of discharges, and as well as ambulatory spaces adding an area for bed bound patients. Ensure the exclusion criteria are narrow and clear in order to not exclude potentially suitable patients. All Pathway 0 and 1 patients are suitable for the discharge lounge.

Maintain timely and high-quality transfer of information to General Practice and other relevant health and care professionals on all patients discharged, including relevant information about any unpaid carers identified.

Senior clinical staff to be available to support ward and discharge staff with appropriate risk-taking and clinical advice arrangements.

Where applicable to the patient, ensure test results are available BEFORE discharge and included in documentation that accompanies the person on discharge. Where virtual wards are used, patients may be discharged prior to certain results being available but a plan to follow up with the patient must be in place.

Effectively deploy available therapies staff to support D2RA Pathway 2 patients in a community hospital setting (especially those requiring rehabilitation) to ensure they receive the optimum outcomes and experiences and help control length of stay and avoid unnecessary discharge delays. This may involve ensuring 7 day working, but also ensuring that the nursing skill mix can deliver a maximising, independence model.

Ensure all patients identified as being in the last days or weeks of their life are rapidly transferred (via a fast-track pathway) to the care of community nursing teams who, along with the integrated discharge team, will be responsible for co-ordinating and facilitating rapid discharge to home (which may be a care home) or a hospice. Community nursing and specialist palliative care teams should have arrangements in place to provide advice, training and support to family and unpaid carers and care and support providers.

Follow the guidance on Continuing NHS Healthcare in line with the detail set in the relevant section below. Further information can be found in the Continuing Healthcare Assessments guidance which includes links to the National Framework.

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Community healthcare teams are expected to take overall responsibility for the safe and effective delivery of the D2RA Pathways, in their areas.

Identify an Executive Lead to oversee the implementation and delivery of the D2RA Pathways model in the acute hospitals in their area.

Deploy staff to co-ordinate and manage the discharge arrangements for all patients on D2RA Pathways. This will include patients being discharged from acute and community hospitals, and other bedded D2RA Pathways facilities.

Have an easily accessible single point of contact (e.g. ‘discharge co-ordination hub’) which will always accept assessments from staff in the hospital and source the care requested in conjunction with local authorities.

Provide a named point of contact to receive and respond to queries from care provider, family members or unpaid carers. This could be the hospital care-co-ordinator and/or Trusted Assessor.

Use multi-disciplinary teams, on the day they are home from hospital, to assess and arrange immediate support for patients on D2RA Pathway 1. Early engagement with any involved unpaid carers should be undertaken prior to the point of discharge to ensure that they are willing and able to provide any agreed care. These arrangements should then be checked and confirmed on the day of discharge.

Facilitate timely provision of equipment to support discharge in order to prevent unnecessary discharge delays.

Ensure patients on D2RA Pathways 1 to 3 are tracked and followed up to assess for long term needs at the end of the period of recovery. When this is in a community setting, as a social care provision, the responsibility for tracking/follow up rests with social services. When in an NHS facility as an NHS provision, the role remains with the NHS in liaison with social services as appropriate.

If supporting D2RA Pathway 3, ensure effective flow through the pathway within maximum LOS agreements, and ensure necessary CHC/FNC assessments are completed and onward care plans agreed, where possible, within 14 days of admission to the bed.

Maintain the flow of patients from community beds including reablement and rehabilitation packages in care home settings (via D2RA pathway 2), to allow the next sets of patients to be discharged from acute care.

For patients identified as being in the last days or weeks of their life, Community Nursing teams and specialist community Palliative Care teams, will work with the integrated discharge teams, to co-ordinate and facilitate rapid discharge to home, care home or hospice (based upon ‘preferred place of death’) via the fast-track end of life process.

Community Nursing: District Nursing and Community Specialist Nursing will be delivered in line with the National Community Nursing Specification and its implementation milestones to ensure a 7-day 24-hour service provision is provided to meet the needs of the local population and community response times are met.

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It is essential that pharmacy teams are properly integrated in multi-disciplinary teams. Doing so supports efficient patient flow through hospitals, minimises medicines related harm that can occur at transfers of care, and facilitates safe and timely discharge.

Pharmacy services can help to ensure that patients are discharged from hospital in a safe and efficient way and health boards should ensure they are implementing in full the guidance Optimising pharmacy services at hospital discharge published in 2022.

Optimising pharmacy services at hospital discharge sets out five key recommendations and enabling actions.

Discharge planning should start from the day of admission (or pre-admission for elective care).

Pharmacy teams can make a significant contribution to prevent deconditioning by assessment, support and promoting patients’ functional and cognitive ability during hospital stays.

Pharmacy teams should utilise the principles of SAFER and Red2Green to deliver safe and timely discharge.

Reduce discharge prescription and medicines processing time including unnecessary top-up supply of patients’ routine medicines.

Pharmacy services should have dedicated resources to facilitate timely patient discharge.

In addition to mandated measures, health boards should agree standards for the contribution of pharmacy to safe and efficient discharge and regularly measure performance against those standards.

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Optimising pharmacy services at hospital discharge | GOV.WALES

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How pharmacy services can help to ensure that patients are discharged from hospital in a safe and efficient way.

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Actions for Local Authorities:

Identify an Executive Lead for the leadership and delivery of the D2RA Pathways.

Agree a single point of contact arrangement for each health board, to approach when coordinating the discharge of all patients.

Flexibly deploy social worker, social care and occupational therapy staff across hospital and community settings to support patients on relevant D2RA Pathways where such input is identified.

Safeguarding investigations should continue to take place in a hospital setting, wherever essential.

Support real time communication between the hospital and the single point of contact, not just by email. This could be arranged in liaison with the hospital care-co-ordinator and/or Trusted Assessor.

Support communication with the patient, their families and unpaid carers.

Support the development of “trusted” relationships between health boards, adult social care, third sector and provider services, supported by written organisational agreements, to bring together all stakeholders to codesign “trusted assessor” arrangements to support hospital discharge.

Work with their partner local health boards and NHS trusts to agree arrangements across the local health board footprint area for delegating practitioners to undertake assessments for care and support.

Provide capacity to proactively contribute to the timely review of care provision during the D2RA Pathway intervention in order to prevent unnecessary patient delays.

Provide capacity to undertake an appropriate needs assessment should it appear that any involved carers have a need for support.

Ensure there is 7-day working for community health and social care teams.

Support referral of newly identified unpaid carers to the local authority, including for a Carers Needs Assessment, where appropriate.

Joint Actions for Local Authorities and Health Boards:

Close partnership working will be key to the delivery of Hospital Discharge Minimum Standards, Health and Social Care partners must:

Work together and pool staffing to ensure the best use of resources and prioritisation in relation to patients being discharged, respecting appropriate local commissioning routes.

Continue to monitor and review capacity across the system, pooling information from hospital sites, community teams and the National Care and Support Capacity Tool www.carehomes.wales

To minimise the risks associated with multiple contacts for patients, actively seek to implement reciprocal arrangements for delegated tasks between health and social care staff.

Ensure there are robust tracking mechanisms so that care users do not get lost in the system. Monitor all individuals on Pathways 2 and 3 who may be in bedded facilities. The nominated care coordinators will follow up to ensure patients are able to return to their usual place of residence (“home first”) or move to their long-term care home, as soon as possible.

As well as providing support for patients, health boards and local authorities should work closely to identify any new and existing unpaid carers that may be involved with the patient at the earliest opportunity. Early identification of unpaid carers should mean that any support available can be provided in a timely manner and to maximise its impact. Both regional partners should ensure that all unpaid carers made aware of, and any direct support services that the local authority and/or health board can offer.

Coordinate work with local and national voluntary sector organisations to provide services and support to people, including unpaid carers, requiring support around discharge from hospital and subsequent recovery, to help them maximise/ maintain their independence, and keep them as well as possible in the community to help avoid the need for future hospital admissions.

Work together to expand the capacity in domiciliary care, care homes and reablement services in the local area, to also enable sufficient D2RA Pathways capacity.

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Residential Care:

Maintain capacity and identify vacancies that can be used for hospital discharge purposes.

Registered Managers are requested to use the Care & Support Capacity Tool App provided by DEWIS to make vacancy information available to NHS and social care colleagues in real time.

Providers of Care Homes, in partnership with their local Community Health teams, should consider how best to support residents’ health needs, in their familiar environment, wherever possible.

Where Trusted Assessor relationships and arrangements are not already in place, work with the integrated discharge team to implement these rules and processes (See section on ‘Trusted Assessors’ for links to further information).

If supporting D2RA Pathway 3, ensure effective flow through the pathway within maximum LOS agreements, and ensure assessments are completed and onward care plans agreed, where possible, within 14 days of admission to the bed, as well as ensuring care is delivered through a reablement approach where feasible for the patient.

Domiciliary Care:

Work closely with health and adult social care contract leads to maximise existing capacity, and identify additional capacity if required, to support hospital discharge.

For those providers actively supporting D2RA Pathway 1, ensure effective flow through the pathway within maximum LOS agreements, and ensure assessments are completed and onward care plans agreed within agreed timelines to prevent avoidable delays in the pathway.

For those providers actively supporting D2RA Pathway 1, ensure that the care is delivered via an ‘enabling’ model to promote independence and recovery, and titrate care provision through weekly review. There must be formal reviews at 2 and 4 weeks for those patients still in the pathway, to enable decisions and procurement of longer-term care arrangements.

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Non-Emergency Patient Transport Services (NEPTS) are a critical resource in moving non-emergency patients from one care setting to a more appropriate setting on another site. In Wales all non-emergency transport is co-ordinated through the Welsh Ambulance Services NHS Trust (WAST).

WAST, NEPTS, independent and voluntary sector providers, are expected to provide support to enable the transfer of patients as part of the discharge process and to support transfers and discharge as a priority in order to maintain flow and maximise patient safety.

Organisations need to consider implementing mechanisms to inform WAST as escalation and additional capacity is utilised. This may involve alternative transport options and could include:

Local Authority owned or contracted vehicles if available

Volunteer cars

Voluntary sector resources

Taxi services.

NEPTS must work with/facilitate inpatient wards to ensure discharge transport bookings are made the day before discharge (reflecting they should be planned discharges). Exceptions will be for acute assessment/short stay wards/units, where the need for some same day discharges will also be supported and enabled.

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Many systems already work with the voluntary sector to facilitate swift and safe discharges. The sector can support this by:

Providing a continued focus on safety and positive experiences for patients on D2RA Pathway 1, enabling patients and unpaid carers to feel supported at home. They can also help reticent patients feel much more comfortable about being discharged.

Providing a range of practical support to facilitate discharge within D2RA Pathway 1, including transport home and equipment such as key safes.

Supporting discharged patients with home settling services to maintain wellbeing in the community (e.g. safety checks and essential food shopping), Pathway 1.

Supporting unpaid carers, including those who are carers for the first time, with information, advice and practical support, and referring for or delivering a Carers Needs Assessment as appropriate.

Providing ongoing community-based support to support emotional wellbeing, such as wellbeing daily phone calls and companionship to patients and unpaid carers, Pathway 1.

Engaging with NHS providers (particularly integrated discharge teams) to provide solutions to operational discharge challenges, freeing-up clinical staff for other activities – focusing on the patients on D2RA Pathway 0.

Utilising embedded local voluntary organisations in all D2RA Pathways and enhance with input from large voluntary organisations.

Coordinating support between voluntary organisations and existing volunteers within NHS providers.

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Discharge to Recover then Assess 
(D2RA) Pathways

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Discharge to Recover then Assess 
(D2RA) Pathways

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Patients must be placed onto a D2RA Pathway in line with the requirements set out under the Principles in the D2RA Pathways Guidance which can be found in the pdf above.

The D2RA Pathways model requires that patients should have a period of active reablement/rehabilitation intervention, preferably at home (D2RA Pathway 1) or in a bedded facility (D2RA Pathways 2 & 3) before an assessment of long-term need is made. Home First Principles must be applied.

No patient will normally be discharged to a new, long term care home placement from an acute hospital bed. A period of bedded reablement (D2RA Pathway 2) must precede any assessment for long term care, unless it is clear that the patient is unable to meaningfully engage in rehabilitation/reablement.

Through D2RA pathway 3, those discharged will have such complex needs that they are likely to require 24-hour bedded care on an ongoing basis following an assessment of their long-term care needs outside of an acute hospital setting. However, some patients may have their ongoing care needs meaningfully assessed after a period of reablement outside an acute hospital setting. Once the decision is made that a long-term care home placement is required, arrangements will need to be made to move the person to their permanent care home placement. If the care home of their choice is not able to take them at that point, they may need to go to an alternative care home as an interim placement.

All interim placements must be closely reviewed by the responsible local authority, in line with legislation in place under the Social Services and Well-being (Wales) Act 2014. An interim placement must not lead to a lower priority for a permanent placement than those in NHS beds which may be perceived to be under greater pressure.

If the person is awaiting a domiciliary care package to support a return home, a level of reablement intervention must be maintained to prevent deconditioning and loss of the skills recovered through the period of reablement. Any unpaid carers supporting the patient should, if appropriate, also be involved in this reablement support. This can assist with patient compliance and engagement with the reablement as well as ensure that both patient and carer are best prepared for their transition back to their home or usual place of residence.

Based on the Optimising Hospital Patient Flow Framework criteria, acute and community hospitals must discharge all patients as soon as they are deemed clinically optimised to do so. For D2RA Pathway 0 patients, transfer from the ward should happen on the same day of that decision being made, either straight home or to a designated discharge lounge. Discharge from a discharge lounge should happen as soon after that as possible.

For D2RA Pathways 1-3, patients must leave hospital within 48 hours (maximum) of being declared clinically optimised to do so.

Hospitals must work in partnership with local partners to maximise the provision of D2RA Pathway capacity and processes to support good homecare for patients and support safe, sustainable discharges.

Acute and community hospitals must keep a list of all those suitable for discharge and report on the number of patients on the list who have left the hospital through the daily situation report. This reporting should ideally be managed via the discharge co-ordination hub.

All bedded facilities must be commissioned for the purpose of recovery prior to an assessment of the person’s needs. Although most older people will do best returning to their own homes, some will require a space for recuperation and building personal resilience prior to return home. The main purpose of the bedded facility, whether in a care home or a community hospital, should be to support people to return home. Without this focus there is little prospect of D2RA Pathway 2 delivering desired outcomes and short-term placements are likely to become permanent.

The D2RA Pathways model can only be achieved through close partnership working. Local discharge co-ordination hubs will work together closely and on a daily basis to: Review provision of reablement and rehabilitation to deliver the requirements of the D2RA Pathways (bedded or own home).

Minimise the risks associated with multiple contacts for patients, and actively seek to implement reciprocal arrangements for delegated tasks between health and social care staff (ie: optimising trusted assessments frameworks).

Ensure there are robust tracking mechanisms so that care users do not get lost in the system.

Coordinate with local third sector organisations providing support for patients and unpaid carers.

There needs to be clear accountability and escalation mechanisms at each stage of the D2RA Pathways process in each locality, to identify and problem solve any avoidable delays

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Assessments must be undertaken in line with the requirements set out in the National Framework for Continuing NHS Healthcare in the most appropriate location in relation to the D2RA pathway the person is on. Wherever possible these should not be completed in the acute setting (unless they fulfil any exemption as set out under the D2RA Pathways criteria – see D2RA Pathways Guidance in the relevant section on page 16). The current Framework issued in March 2022 can be accessed via the link above.

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National framework for Continuing NHS Healthcare | GOV.WALES

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Guidance on the principles and processes of Continuing NHS Healthcare (CHC).

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The role of the care co-ordinator is pivotal in the discharge process. Whilst the nurse in charge of each ward is responsible for the overall co-ordination of effective discharge planning, a care co-ordinator is responsible for overseeing the discharge plan for each patient they are responsible for. This includes the assessment, communication and active management of the discharge process, including explaining that transfer to a more appropriate care setting, including a care home, is anticipated if the person has ongoing, more complex, long-term care and support needs.

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A trusted assessment involves a trusted assessor – someone acting on behalf of and with the permission of multiple organisations – carrying out an assessment of health and/or social care needs in a variety of health or social care settings. The aim is to avoid unnecessary duplication and delays to discharge.

Guidance, together with a supporting toolkit, has been prepared on the trusted assessor role. This sets out key principles, functions and responsibilities and contains a set of examples, as well as a trusted assessor implementation checklist. This guidance can be found by clicking on the link above.

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The Six Goals, co-designed by clinical and professional leads, span the urgent and emergency care pathway and reflect the priorities in the Programme for Government 2021-2026 to provide effective, high quality and sustainable healthcare as close to home as possible, and to improve service access and integration.

These goals represent the outcomes we expect for people who need to access urgent and emergency care. Successful delivery of the goals should enable optimal experience and outcomes for local populations and staff.

The Six Goals for Urgent and Emergency Care National Programme has been established to support Local Health Boards and their partners to transform and improve delivery of urgent and emergency care services to the people in Wales.

In 2022, Welsh Government published the Six Goals for Urgent and Emergency Care Policy Handbook, setting out the priorities for urgent and emergency care to ensure that patients get the right care, in the right place, first time.

The handbook contains a series of quality statements for each of the Six Goals, to describe in detail the outcomes and standards individuals should expect when they may need urgent or emergency care.

The Six Goals for Urgent and Emergency Care Portfolio Management Office (PMO) supports delivery of the Programme, working closely with Welsh Government, Local Health Boards, NHS Trusts and partner organisations. The PMO ensures the connectivity and flow of information between Goal Leads and enabling workstreams, and is accountable to the Six Goals Programme Board.

To contact the PMO, you can email the Six Goals mailbox - ABB.SixGoalsUEC@wales.nhs.uk

The Six Goals Programme Board has endorsed a number of key projects for 2024/25. Year three of the Six Goals Programme will continue to provide effective, high quality and sustainable healthcare as close to home as possible, and to improve service access and integration.

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The Six Goals Programme oversees delivery of the six policy goals that span the urgent and emergency care pathway.

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A reluctant discharge is where a person has been assessed as no longer in need of care or treatment in the hospital setting they currently occupy. They will either have been assessed as able to transfer onto the next appropriate stage in their episode of care, e.g. from an acute bed to a rehabilitation/reablement bed in an alternative setting, or that they no longer require any form of inpatient care. These individuals will have been assessed as clinically optimised for discharge and have been reviewed in relation to their ongoing needs, with safe and appropriate arrangements confirmed as in place where required.

Guidance on Reluctant Discharge has been produced. It should only be considered where all other avenues to ensure care is provided in the most appropriate setting have been considered and not been possible for a range of reasons.

In all circumstances when implementing the guidance, the focus should be on the individual, understanding what matters to them and on ensuring their needs are met safely and appropriately.

The process refers to the principles to be adopted, allowing for local systems and arrangements to be shaped in a way that provides local/regional partners with the most effective operational process for local implementation.

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The Management of Reluctant Discharge_Transfer of Care to a More Appropriate Care Setting - Guidance

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D2RA Pathway Step-down to Recover 
(SD2R) – National Minimum Standards 
(D2RA Pathway ‘bridging’)

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D2RA Pathway Step-down to Recover 
(SD2R) – National Minimum Standards 
(D2RA Pathway ‘bridging’)

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Where recovery and assessment at home is not currently possible, a short-term, time limited stay based on individual needs, in a D2RA Pathways Step Down to Recover facility, is the next step on the pathway home, with review and transfer to D2RA Pathway 1 wherever and as soon as possible. A timely planned return home is the desired outcome. These beds are often referred to as D2RA Pathway ‘bridging beds’.

The stay in the D2RA Pathways step-down bed for people whose care and support requirements at home are not available must still add value to the individual by providing reablement, thus potentially requiring less care and support to be commissioned to discharge home.

There is an expectation that work is underway to ensure that care and support will be available following the stay in the D2RA Pathways step-down bed.

All individuals transferred onto this care pathway will require a discharge plan with clear goals, a reablement/recovery plan, including a clear exit strategy (plan for the person to return to their own home), including an estimated date of discharge.

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Step Down to Recover (SD2R)_National Minimum Service Standards_18 Sept 23 (E)

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Through the use of Discharge to Recover then Assess we want to ensure that a patient’s onward care needs are identified early in their pathway. This will allow discharge teams to begin to make the necessary connections, with the right support services, ahead of discharge. An important factor in determining the right level of support a person may need will be their level of independence. By considering these factors early in a person’s discharge planning we can ensure that patients, their families and unpaid carers have the right level of support they need.

British Red Cross Five Part Independence Checklist

The British Red Cross have developed a 5 part independence checklist that sets out some of the key factors that could impact on a person’s independence.

This checklist is aimed as a guide for staff and multi disciplinary teams working with the patient to help inform and support the discharge process. Meeting each point is not a requirement for discharge nor should it act as a barrier in preventing timely and appropriate discharge. However, staff may wish to refer to the checklist to consider aspects of a patient’s level of independence and consider any additional arrangements that might support the discharge process for that individual. For example, engagement with third sector/voluntary organisations, as set out on page 15, can assist people and their family/unpaid carer by providing direct support or help in accessing on-going support services.

The Checklist includes:

Practical independence (for example, suitable home environment and adaptations).

Social independence (for example, risk of loneliness and social isolation, if they have meaningful connections and support networks).

Psychological independence (for example, how they are feeling about going home, dealing with stress associated with injury).

Physical independence (for example, washing, getting dressed, making tea) and mobility (for example, need for a short-term wheelchair loan).

Financial independence (for example, ability to cope with financial burdens).

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Homelessness is where a person lacks accommodation or where their tenure is not secure. Rough sleeping is the most visible and acute end of the homelessness spectrum, but homelessness includes anyone who has no accommodation, cannot gain access to their accommodation or where it is not reasonable for them to continue to occupy accommodation.

Homelessness, or the risk of it, can have a devastating impact on individuals and families, affecting their physical and mental health and well-being, isolating them from their local communities and negatively impacting society.

It is well recognised that housing alone cannot prevent homelessness and all public services and the third sector in Wales have an important role in collaborating and working in an integrated way to prevent homelessness.

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Community equipment and adaptation services provide specialist responses which enable people to live safely and independently as possible. This can support people to avoid admission and remain in their own home. It may be an essential part of enabling timely discharge and implementation of home first and D2RA Pathways.

The provision of assistive equipment, adaptations and technology will also help reduce the need for double handed care packages, reducing delays in discharge because of avoidable requests for social care support.

Assistive equipment and technology may be a part of enabling discharge on Pathway 0, but it is highly likely to be essential in supporting on Pathways 1-3. It may also be required to support people following reablement provision for the long term as they move out of the D2RA Pathways. Every health board and local authority will have in place a community equipment service, ideally an integrated service, which delivers timely and safe equipment/ technology.

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Adaptations which enable and support discharge, particularly minor adaptations, must be planned for as early as possible during admission as part of the recovery plan. The SAFER Guidance can be found here.

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SAFER - National Minimum Standards for the Application of SAFER, RED2GREEN and D2RA

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This guidance covers the hospital discharge process more generally, however there may be situations where external factors override some or all of the sections within this guidance and may require health boards and supporting partners to adopt different practices in order to safely support patients. These factors may occur nationally or may be localised and isolated.

In these circumstances it is expected that the health board will make staff aware that new guidance is in place and staff should refer to, adopt and follow any overriding guidance. The duration of time that any overriding guidance will be followed will also be communicated.

Supporting guidance on infection, prevention and control practices in respect of covid and other respiratory infections is available for health and social care – links are provided below – this discharge guidance should be read and considered in parallel to these.

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A carer is anyone who cares, unpaid, for a friend or family member who due to illness, disability, a mental health need or an addiction cannot cope without their support.

Unpaid carers in Wales have legal rights which are set out under the Social Services and Well-being (Wales) Act 2014 carer is defined as: “a person who provides or intends to provide care for an adult or disabled child.”

A carer can be an adult, a child or young person. Children have additional rights, including under the UNCRC and the 2014 Act, and children and young people may have different needs to support their development than adult carers.

People who are caring, or intending to care for someone, such as those who are supporting a family member or friend being discharged from hospital who needs care as they recover or on an ongoing basis, have the right to:

Access information, advice and assistance.

Be assessed if it appears they have a need for support, and to have all eligible needs met. is clear that a person must be “willing and able” to provide care. The extent to which a carer is able to provide care and willing to do so is assessed as part of the formal statutory Carers Needs Assessment but the 2014 Act makes clear that all professionals encountering people who need care and support are responsible for proportional assessments of a carer’s needs.

Exercise voice and control and be fully involved in decisions that affect them.

Access advocacy to support involvement in decisions.

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Social care guide to controlling acute respiratory infections [HTML] | GOV.WALES

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This advice covers personal protective equipment (PPE), testing, isolation and visiting guidelines.

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Winter respiratory framework 2024 to 2025 (WHC/2024/037) | GOV.WALES

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Our plans for the NHS, social care and communities for managing respiratory viruses.

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There are many D2RA Pathways and considerations in providing the right adaptation. Referrals to local services must be anticipated and undertaken as soon as practicable. Every health board must ensure that integrated discharge teams know how to arrange adaptations that are essential to enable an individual to be discharged. These are most likely to be identified under D2RA Pathways 1-3. Referral processes must be simplified and streamlined for all ward staff needing to make timely referrals.

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All potential need for assistive equipment to enable discharge must be identified as early as possible as part of the planning for optimal hospital care and discharge.

The key principles underpinning equipment and technology provision:

The safety and well-being of individuals is paramount.

Community equipment services should be person centred providing a flexible response to need which promotes the independence of the individual.

Users have expertise about the challenges they face on a daily basis and must be partners in assessment decisions and choice of equipment.

Equipment provision is underpinned by timely and clear clinical decision making.

Access to assistive and rehabilitation equipment must be quickly (same day where needed) and easily facilitated. Utilising mutual aid with neighbouring areas or redeployment of community-based staff if required.

Effective processes must be established to ensure speedy response and provision even when equipment is provided across borders and where the individual is being discharged to the home of a relative outside of their normal Local Authority of residence.

It is expected that in order to facilitate timely provision of equipment Regional Partnership Boards, local partners and Integrated Community Equipment Services should work with and support Trusted Assessors to help minimise delays and avoid duplicated assessments.

Partner agencies and community equipment services must use the Occupational Therapy Advisory Forum Cross Border Guidelines to operationalise these processes. The guidelines can be used as the basis of negotiation between individual agencies who provide equipment across local borders, including where adults with additional learning needs reside outside of its borders or where there is joint residency across borders. The guidelines do not cover wheelchairs, or any other equipment provided via Welsh Health Specialised Services Committee (WHSSC). The guidelines can be provided via local occupational therapy services.

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delivers services through 7 local health boards and 3 NHS trusts. Local health boards are responsible for planning and delivering NHS services in their areas and include reducing health inequalities across their population and commissioning services from other organisations to meet the needs of their residents. This includes the provision of appropriate care and support for people experiencing homelessness.

Consideration of people experiencing homelessness prior to discharge.

People at risk of homelessness use more acute hospital services and emergency care than the general population. When admitted to a hospital, the length of stay is usually much longer because of multiple unmet needs. People experiencing homelessness have far worse health and social care outcomes than the general population. According to the Office for National Statistics The average age of death for the homeless population is around 30 years lower than for the general population.

Discharge from hospital can exacerbate vulnerability and frailty for those who are homeless, at risk of homelessness or those for whom a hospital admission increases the likelihood of them becoming homeless (due to current accommodation no longer being suitable for example).

As with any other potential onward care needs, hospital ward staff must try to establish actual/ potential homelessness status of an individual as near to the point of hospital admission as possible to ensure timely referrals to local authority homelessness prevention services and where appropriate, multidisciplinary services. This will enable appropriate care and provision at the right time, thereby improving outcomes for people experiencing homelessness on discharge from hospital and avoiding re-admission.

The shift in focus, to planning for discharge at the earliest stage, means that support in any form (social care, health, housing, etc.) should be in place and ready for that individual when their treatment has completed, before they are ready for discharge.

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NHS Wales delivers services through 7 local health boards and 3 NHS trusts.

Local health boards are responsible for planning and delivering NHS services in their areas. These health services include:

They are also responsible for:

improving physical and mental health outcomes

promoting wellbeing

reducing health inequalities across their population

commissioning services from other organisations to meet the needs of their residents

NHS trusts look after public health, ambulance services as well as cancer and blood services.

There are also a number of related organisations that support NHS Wales.

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An overview of NHS local health boards and trusts and related NHS organisations.

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Ending homelessness in Wales action plan: update summer 2023 | GOV.WALES

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A report on our progress to end homelessness over the next five years.

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Overview | Integrated health and social care for people experiencing homelessness | Guidance | NICE

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This guideline covers providing integrated health and social care services for people experiencing homelessness. It aims to improve access to and engagement with health and social care, and ensure care is coordinated across different services

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Topics include:

NICE guidance says housing status should be recorded, but how, and what should be recorded in each setting? Latest developments from ED and mental health database development - hear about all the work we have been doing nationally.

What lobbying would members like us to get involved in? Opportunities around the next NHS long term plan, Mental Health Act & Health and Care Act needing new guidance for ICSs.

Update from Alex Bax, Pathway CEO
Event Recording

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Faculty for Homeless and Inclusion Health General Meeting – Pathway

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Frailty among the homeless population comparable to that of 89-year-olds in the general population

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Premature frailty, geriatric conditions and multimorbidity among people experiencing homelessness: a cross-sectional observational study in a London hostel. Housing care and support. People experiencing homelessness are some of the most disadvantaged within our society. Homelessness is associated with extremely poor health outcomes with mortality rates 3-6 times those of the general population.

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Office for Health Improvement and Disparities

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Working definition of trauma-informed practice

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Trauma-informed approaches have become increasingly cited in policy and adopted in practice as a means for reducing the negative impact of trauma experiences and supporting mental and physical health outcomes. They build on evidence developed over several decades. However, there has been a lack of c…

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Each hospital will have its own Carer Support service, which will either be a member of the hospital staff or staff from a local carer organisation who is connected to the hospital. Discharge staff should know how to refer unpaid carers who are identified when a patient is admitted and/or discharged from hospital to the Carer Support Service.

Further information about joint working between health boards and the carer support service can be found by clicking the link above.

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Unpaid carers can also access support from local carer organisations, such as Carers Trust Network Partners. You can find your local service by clicking the link above.

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All unpaid carers have the right to request a statutory Carers Needs Assessment to assess their right to support from their local authority to undertake their caring responsibilities.

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All hospitals should have information available for unpaid carers. Carers Wales ‘Coming out of Hospital – A Guide for Carers’ can be found here.

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Support and guidance for healthcare professionals encountering unpaid carers through the hospital discharge process can be found here.

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Annex A:

‘Planning Your Discharge’ letter template.

Annex B:

Social Care Charging and Financial Assessment Arrangements Guide

Annex C1:

Choice of Care Home Accommodation Following a Hospital Stay

Annex C2:

Patient Information – Moving to a Care Home Following a Hospital Stay: Including Information about Care Home Choice