Planning safe discharge from hospital—the importance of interprofessional collaboration and communication

Abstract

This paper was the outcome of a 1-month research project undertaken by social workers in an acute general hospital. The project examined the effectiveness of the hospital referral system—ward staff to social workers, viewing referrals as indicators of need for assessment. Seventeen per cent of the patients admitted were referred to the social workers. They were mostly elderly men and women, likely to be living alone, and with an above average hospital stay of 11 days.

The reasons for referral are compared with the assessment outcomes of problems and need for services. Sixty-one per cent of the referred patients returned home. Eighty per cent wm safely discharged or transferred at the appropriate time and 20% experienced delays in discharge. The reasons for delay were mainly due to NHS systems and patient health care needs.

Patients and carers should be part of the assessment and care-planning process. Hospital social workers should be on site as part of the interdisciplinary care process. A discharge scheme needs to be planned and available for very frail and 'at risk' patients. A formal policy is needed to support working practices. Recommendations are made with regard to policy and practice.

Key Words:

• Assessment
• delayed discharge
• hospital discharge
• indicators of need