A summary of the Department of Health’s guidance Ready to go? Planning the discharge and the transfer of patients from hospital and intermediate care
This guide has been supported by
RCN PUBLISHING ESSENTIAL GUIDE
Written by Hazel Heath, independent nurse consultant for older people, Deborah Sturdy, nurse adviser older people at the Department of Health, and Amanda Cheesley, service manager intermediate care, South Gloucestershire Primary Care Trust
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Introduction Department of Health guidance The ten operating principles Person-centred care and patient empowerment Ready to go? The ten steps Improving your practice References
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Introduction Being admitted to hospital can be frightening. In addition to the physical ill-health or trauma that triggered admission, hospital environments can be daunting and confusing, particularly for people who are ill, frail or vulnerable. Patients have consistently reported feeling ‘anxious, insignificant and powerless’ (Department of Health (DH) 2010). Care transfer is an essential part of care management in any setting and it bestows responsibilities on organisations, systems and individuals. Smooth and effective care transfer ensures that health and social care systems are proactive in supporting individuals, their families and carers. It also ensures that resources are used effectively. Timely care transfer requires clinicians and others to plan, inform and negotiate to ensure a smooth transition for individuals and their families. Underpinning this is the need for early identification of discharge/transfer dates including pre-admission planning, effective communication between individuals and across settings, good clinical management plans and the alignment of services to ensure continuity of care. Although nursing roles are distinct in different services, the role of the nurse in liaising with patients, families and colleagues is central in achieving smooth transitions of care across service interfaces. The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives (Nursing and Midwifery Council 2008) highlights the responsibility of nurses to: Listen to people in their care and respond to their needs and preferences. Share with people in a way they can understand the information they want and need to know about their health and care. Share information with colleagues and keep them informed. Work effectively as part of a team. Ensure that patient consent is gained before intervention. Act as advocate for patients. Ready to go? Department of Health (England) guidance The DH has issued comprehensive guidance on planning the discharge and transfer of patients from hospital and intermediate care (DH 2010). Accompanying the guidance is a package of resources that can be adapted for local needs. This essential guide aims to offer practitioners ideas to help support improvements in how they manage hospital discharge of individuals and transfer of care between settings. Service examples are also provided. The ten operating principles Start early to anticipate problems, plan for discharge and agree an expected discharge date. A person-centred approach treats individuals with dignity and respect and meets their diverse or unique needs to secure the best outcomes possible.
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