The discharge planning team is operating 08:00 – 20:00 7 days a week. This is in line with the NHS directive to support all discharges from hospital within hours of being declared medically fit. We are still making progress with our patients with complex needs and who require support when they leave hospital, and last week we discharged 62% within 24 hours of their clinically fit date. This is an improvement from 38% discharged prior to the changes in the way we are now working as a system.

We are continuing to make positive steps forward in achieving minimal delays when discharging our complex patients.

However, we still need your help with ensuring that we are receiving all the referrals required to support our patients with complex needs on discharge, and realising simple discharges as soon as possible.

  • Please ensure that your ward area is using the new Letter A and Letter B. All patients require these. Letter A to be given on Admission; Letter B to be given when approaching their clinically fit date.
  • Ensure that on admission the MDT gains a collateral history, which includes set up at home / care home.
  • All patients who have a care package or are from a care home must have a Discharge Notification completed. This informs the discharge team that this patient is receiving support in the community, and is vital in ensuring that either the Local Authority or the NHS (who may be paying for their care) are aware that they have been admitted to hospital.
  • Board rounds are essential, and following Red 2 Green / SAFER, will help with clinically fit date setting; minimising delays in patients hospital journey and overall improving patient experience.
  • If a patient is likely to require support when they leave hospital, refer early and talk to the patient and/or patients named representative and discharge planning.
  • TTOs and discharge summaries need to be written in real time, and if needed, involve pharmacy as soon as possible.
  • If a patient is going home (simple or complex discharge), please check they have access to their property and they have access to food/drink. There have been recent discharges where patients have been discharged without any food at home, and no access to shops, etc. due to current restrictions. If the patient requires support with a food parcel/shopping, please contact the discharge planning team or check our Connect Page for information of voluntary agencies.
  • Ward sister/nurse in charge to ensure patient transport is booked or patient family/carer are advised to collect patient at the earliest opportunity to help facilitate the 2 hour deadline.

Please contact the discharge planning team on x586951 or at dpsnduty@addenbrookes.nhs.uk for support or further information or consult the discharge planning page on Connect.