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Hi, everyone. Hopefully you can hear me. Uh Thank you for waiting uh for me. Uh Let me introduce myself quickly. My name is uh an code. Uh Currently I am a lecturer at South Bank, uh London University. But before that, it's quite a newish job for me. Before that I was working as a discharge coordinator, nurse at East Sari Hospital for more than three years. And actually, this is the topic I would like to uh talk about as that's the topic of this uh session. What does it mean uh to be a discharge coordinator. Uh uh What does this job role involve a little bit? I would like to talk about the discharge hospital, discharge processes and pathways and the most typical challenges. Uh obviously, if you have any questions, just please uh pop it into the, into the chat box and hopefully I should see it and then I will try to answer it to my best of knowledge. Um I won't share any slides with you, but I think, you know, we will manage without it. Uh uh it's not too much visual uh effect that uh you know, this joke were involved So I think, you know, as, as, as a chat, it it should be fine. So first of all, I would just like to start with uh with that, that actually when do we discharge coordinators uh step into the patient care as the part of the multidisciplinary team, usually the discharge coordinator, step in uh when the patient who we are going to visit is medically ready to be discharged. Now, what does that mean for the patient to be medically ready to be discharged? From our point of view, from the discharge coordinator's point of view. So they need to be medically fit for discharge. So the doctors need to clarify to us that yes, from their side, the patient is ready to be discharged and it's really important that there shouldn't be any outstanding inpatient investigation examination or, or, or a treatment plan. Uh That would be discharge dependent uh because obviously, then it's a bit too soon for us to start the process. Um So the patient needs to be medically ready to be discharged. And also there there should be a plan, a discharge plan. Uh The discharge plan is established by the the whole multidisciplinary team. This is quite often a misunderstanding quite often when someone hears this role, that discharge coordinator, they think that actually we are deciding what is the discharge plan for the patient? That is not the case, we are coordinating, you know, for the patient so that the discharge plan can happen. But it's actually the whole multidisciplinary team who should decide what is the discharge plan for the patient with the patient. Ideally, and with the family being involved as well, the discharge coordinators coordinators are usually just a handful of people running around the hospital covering usually multiple wards. This is how it works at a hospital as well. Uh But we are usually mostly by background nurses and we are the one who link the patient uh as the part of the multidisciplinary team, we are the one who linked the patient with the community services in the background. There is actually provide the safe discharge for our patients, for example, at East Sa Hospital where I used to work and I can give you that as an example. As I mentioned, the discharge coordinators are on the wards to it down onto the wards. And we are the one who are visiting the patients and the relatives and the multidisciplinary team itself on the huddles, for example, or the multidisciplinary meetings. But also there is an administrative team that are working in the background, mostly on the referrals, receiving emails from the communities, forwarding them to us. And that's how we liaise we communicate. There are usually within the hospital working in the background, community nurses, especially for those patients who need um further community hospital treatment, for example, rehabilitation. So they are working with us as well. They are receiving most often the part of the referrals that we are sending in, then they are screening as well. They are making sure as well that you know, they have all the necessary information that should be forwarded to the community partners. Uh Of course, the social services uh we usually deal with uh adults. So it's mostly the adults, social services teams uh that are involved, especially for example, for patients who need residential or nursing home care after the hospital discharge. But we work together, for example, with such at home when the patient actually can be discharged home, but they just need a little bit of extension, for example, a bit of wound care or IV antibiotic therapy is needed at home. We are working together with Red Cross, for example. So as you see, we charge coordinators, we are dotted on the wards but really a with a quite big um team in the background who are all there uh for the patient to provide as soon as possible and the safest as safest as possible discharge uh for the patient. Uh This is basically our, our goal now uh when we had the, when we had the pandemics, when the pandemic started, it was really stressful for us practically speaking nearly from one day to the other, we had to work in a very different way because suddenly we were facing um um a demand for a much faster uh hospital bed turnover that we used to, you know, achieve before that. So the government introduced extra funding for that uh at around 2020 March spring time. And also, uh what happened is, um, they sort of eased a little bit on the legislation on the Care Act legislation. And we started to work in with that um sort of approach that if the patient needs uh support on the discharge, they cannot just be discharged home. Then, for example, even if it's a care home, let's make a short term uh plan discharge plan from them. And then the long term plan can be actually established in the community. But let's get the patients out from the hospital as soon as possible. Uh So all sorts of paperwork, mental capacity assessments and all these uh uh sort of uh part of the discharge plan. Uh but very important work could actually happen in the communities rather than the patient waiting in the hospital for that. Also, at that time, we simplified the discharge pathways and we established that from now on, we are going to have three main pathways, discharge the patient home, discharge the patient either to an inpatient rehabilitation community hospital, for example, or for a short term placement. Or you know, if, if we know already that it's going to be a long term placement, then obviously with that uh aim we can discharge to a long term placement. Uh but we use one simple referral form for all of these uh the hospital and all the trust invented uh simple patient pathway referral form. The discharge coordinator were responsible for filling that form in based on their assessments. We, we became the trusted assessors and uh we didn't have to uh uh sort of come up with a long term discharge plan. Our aim was just let get the patient to a safe place somewhere in between until the final discharge plan can be established in the community and then they can either go home or to a long term placement. So this document uh was roughly a 454 to 5 page document and it encapsulated all the the pathways. Uh and obviously, it, it just gave sort of like a picture. What does the patient needs, what are the care needs? And we discharge coordinator indicate, indicated the pathway on those referrals and then how, you know, we were uh luckily entering towards the end of the, of the pandemics. Uh then roughly around 2022 July, uh the government then uh sort of uh decided to finish this uh easement on the Care Act. We had the so called COVID funding or discharge to assess funding. Before that during the pandemic, they decided that they are going to withdraw that and we will go back sort of half i to the original way how we used to work before that meant that all the necessary um assessments now need to happen back in the hospital, not in the communities. And actually, the hospital team, multidisciplinary team is responsible to make the long term plan again within the hospital. And we are responsible then to achieve that and put the necessary service in place for our patients. Uh So the discharge to assess funding or COVID funding uh finished. Uh There was a bit of time we had to explain to the patients because obviously, uh it was um nearly couple of years how we, how we work like that. So obviously, patients and their relatives, they learned that there is this short term plan that you know, the government is funding and then the long term plan is going to be established later on now, that has stopped. So it took a while to educate, you know, our patients and our um their, their families as well to get used to again that we need to establish the long term plan in the hospital. Uh So just, just a, a little bit uh going back to the discharge pathways. So when we, when we plan to discharge the our patients, what pathways can we think of? So that has stayed uh as, as it was in the pandemic. So we have three main pathways pathway. One is when we discharge the patients back home, but obviously, they need some support at home, they cannot just return how they, you know, were before they don't need a package of care or community therapy or a re lament. A short term help at home, uh or sometimes they go home on an end of life care and I will get back to this a bit later, but the patient goes back to their usual home. I need some additional support. So pathway two is mostly if we send the patients obviously with their consent uh to inpatient rehabilitation. So to another community hospital where they can have the rehabilitation and depending how far they go with their rehab, then ideally, they can go home either being independent again. Uh And that that would be the best, but sometimes even just to be able to achieve that with the package of care, they can still return home. That that's a great result. Uh in some occasions, pathway two can mean a short term placement and we have some subcategories, some special occasions or special cases rather uh that we deal with. Uh I would just maybe like to highlight two of those. One is if the patient becomes non weight bearing, uh for example, has a big fracture femur fracture, for example, and they cannot wear bait for, let's, let's say six weeks. Uh And because of that, they cannot return home. But we are hoping that after the non weight bearing period and after some period of rehabilitation, ideally, they would be able to return home. So in that case, we can either um find a non weight bearing bed bed for them in the community either in a community hospital or even either in a care home for a short term uh period of time only. So, this is the so called non weight bearing pathway, which can come under the pathway too. And it's just a short term uh bed. What it means. The other example uh of a short term uh usually placement under pathway two is the so called delirium pathway. This is a very complicated pathway, actually, mostly elderly people are affected by this pathway. Um And um it always uh needs a very complex assessments to establish that we are actually sending the patient to the right pathway. Quite often. What happens is due to mostly infections or even even a trauma can cause uh that the patient has delirium. We need to make sure that actually that this delirium has been treated. So we know what was the possible cause and all the necessary treatment the patient has received. And we need to give evidence that actually the delirium is resolving. And once we have all the evidence for that, then we can apply in the community for so called delirium bed, uh which is ideally would be again a short term placement because our hope is that after a certain time that this delirium is going to resolve and the patient can uh regain their cognitive baseline and eventually hopefully they can return home, but it is quite difficult discharge coordinator always are a little bit anxious when you know the multidisciplinary team suggests a delirium pathway and the pathway three uh the third pathway, what we have is uh placements, residential uh care homes or nursing home placements, uh long term placements uh and also placements on end of life pathway. And now mentioning the end of life pathway, I would just like to clarify what does that mean in acute hospital settings? When we speak about end of life, usually we, we mean the last days uh when actually the patient is entering the last phase of their lives, this is a bit different from our perspective. End of life pathway in community means that uh the prognosis is unfortunately poor. So most likely the patient uh life expectancy is um less than three months, but currently, they are stable enough to leave the hospital and either go home with the needed support or in if we are talking about pathway three, that is actually going to a nursing home if they need uh a 24 hour care uh in order to meet their needs. Uh So this is the end of life pathway in community different than what is usually end of life care plan in acute hospital setting. Um Little bit about the funding. So who is paying for all this support, isn't it? Uh That, that is quite often a a very relevant question and it comes from the patients and from the next ofs as well because obviously they would like to know. So the patients can be self funders, self funders if uh they are above a certain threshold, which is established legally, uh roughly at the moment uh in SA and Sussex area that is at around 23,500 lbs. So if they are above this threshold, then they would be most likely funding themselves uh the the support but the market disciplinary team is suggesting them um if they don't have the, the, the funding themselves, then obviously, the support that is needed can be funded by social services. When we apply for the support, we actually indicate that on the referral, uh what our understanding is based on, on the communication with the patient and the next of kins, if they are going to be self funders or uh they would apply for uh funding support as well. So social services can obviously, if they are eligible uh help them fully or even partially. And uh the support that is needed can be actually uh funded by the health services as well. For example, inpatient rehabilitation, if that is needed on the discharge from the acute hospital setting, then that is funded by the health services by from the health budget. And uh for very complex health needs or, or for patients who are on their end of life pathway within the communities. It's usually the continuing health care who is going to be funding their care. Now a little bit uh just few sentences if, if you don't mind. I'm just going to talk about uh how do we discharge coordinator as trusted, trusted assessors operate between the hospital wards and between the communities, community services. So what happens is when the patient is medically ready to be discharged? And now we know what does that mean? From our perspective. If something is outstanding, then we kindly will ask the help from the doctors or the physiotherapist or occupational therapist or nurses uh to, to help us out. And once we see that actually the patient is not medically ready, then we can proceed. So once the patient is uh medically ready to be discharged, and once the multidisciplinary team with the patient and their families established, what is the discharge plan? Obviously, we, we can help as well. Then the discharge coordinator uh does their own assessment. That's why we call us uh as trusted assessors. And we complete the referral form including all the necessary information uh that is going to be sent into the discharge hub within the discharge hub. Uh Obviously, the the administrative uh staff is going to deal with um with the uh with, with, you know, where to forward this referral and what response they get back. They will, you know, obviously forward that to the discharge coordinators as well if needed. But once the discharge hub has the referral, it goes according to the pathway uh to the relevant community services. And obviously, they are going to screen this referral to make sure that they, they are starting to search for the right support for the right carers or for the right, if, if it's a social services referral for the right residential home or nursing home, uh or they are searching for the right community hospital. Once the right support is in place then from the communities, they are going to get back to us to discharge coordinators and then we are going to start to organize the discharge with the ward together. Cause in that process, the whole multidisciplinary team is involved and not just the discharge coordinators obviously. So what are the main challenges? And this is kind of the last part of my presentation uh during the discharge process. Uh We need to make sure to actually start the process as soon as possible. Uh saying that the patient needs to be medically ready to be discharged. But sometimes there are some really, really complex cases when it's good to keep an eye on them, you know, well in advance. And if there is any background work that we can do, we can start in advance so that we don't have delays because of that. Uh if the patient already has a care package in place or the patient already came from a residential care home or a nursing home, then we need to make sure that actually on the discharge, if there is even no no change in the care needs, they don't need any extra support. We need to make sure that actually that support which we think that is in place. It is actually in place. So we need to contact the care agencies. We need to liaise with the with the care homes that they are ready to take these patients back. Also, we need to be very mindful if there is any safeguarding in place. Uh we cannot discharge back to the same place with the same services until the safeguarding is closed. So we discharge coordinator though these discharges are usually just pathway zeros. So uh there is no change in the care needs. We could just discharge back the patients uh into the same environment where from where they are coming from. But because of these two issues to make sure that that service is actually still in place and that there is no safeguarding in place. We usually uh try to assist the the the ward, especially the charge nurses, the nurses in charge to make sure that the discharge is going to be safe. Now if um if there is a change in the care need. Hello, Anita. Uh Hi, I can hear you. Can you hear is everything ok. Can you hear that? I am? Ok. Ok. Ok. Yeah, that's fine. I carry on then. So um the other um mm key element is uh during the discharge process to establish actually the the correct discharge plan uh with the patient, we need to establish if the patient uh has mental capacity to make the decision for themselves. So when we, when we plan the discharge, uh we always plan with the patient. And if the patient has capacity quite often, uh or quite often it can happen, let's put it like that, that we because we are all caring people, you know, within the within the hospital environment, we would like the best and the safest discharge for our patient. But sometimes we can face that actually, the patient does not want that support on their discharge. We would like to provide a package of care or we even think that the safest place actually would be in a care home. But the patient says, but I I don't feel like I need that I will be just fine. So in these cases, I I'm sure that, you know, everyone who works in a hospital comes across with these difficult situations. It's a very key element uh in the discharge process. If the patient has mental capacity, not there is no such as general mental capacity, it's always, you know, a task specific or topic specific. The mental capacity is in this case, if the patient has mental capacity regards the discharge plan and actually the patients are allowed to make unwed decisions. But what we really need to make sure just to explain all the risks if they are not willing to follow our advice or guidance, and we need to make sure that actually they can weigh up their, their risks. And the other thing is it's really important to involve the families if the patient who has capacity is in agreement is in agreement to do, to do that. So when we do the discharge planning process, it's with the patient, especially if the patient has capacity with the with the families, uh because they know the best their relatives as well and they can quite often can support us if we have some questions which you know, which we cannot agree on with the patient. Um If the patient lacks capacity, regards the discharge plan and the discharge destination, then obviously, it is the next of kin who we should involve. Now, in this kind of situation, it's very important to establish if the next of kin has um power of attorney, if they have the legal right to represent the patient, if they have the legal right. And obviously, uh we are going to take into consideration what, but it's their wishes, but we sometimes even can come across with a very difficult situation. When actually we feel that the next of kin who has the power of attorney is actually not representing the best interest of the patient. In these cases, we have multiple meetings just to make sure that what is the reason, maybe it's just the miscommunication lack of an information. So we need to put that extra time and extra effort into the discharge process to make sure that we are really representing all of us the best interest of the patient. And if needed, social services can be included as well. Um Once we actually, you know, we we have the discharge plan, uh it is the best interest of the patient, the patient is in agreement and everyone is in agreement, then we can actually go ahead with the discharge, but there can be some tricky elements in that bit as well. When we think we are already in the finish, there can be some challenges. So we need to make sure that all the equipment is in place. Sometimes the patient needs oxygen, extra equipment, hoists, hospital bed mattresses with the mattresses, we need to provide the pump as well. So lots of things, we need to make sure that it is in place and nurses can be very busy. Discharge, coordinators can help to clarify this. But obviously working together with the occupational therapist, physiotherapist nurses, all of us. So that just shows how much of a team work is a hospital discharge. Er really we need to make sure that the TTS are done. This is quite often one thing that you know, we delay the discharge, especially if the patient has blister packs. Sometimes it takes a day or two, even for the pharmacy to organize the dish, uh the blister packs. So these are the things that we need to capture well, in advance not to lose precious days, time hours uh during the discharges. Um We need to make sure that if the patient goes to community, we have the needed COVID tests if they require to do so. Uh We need to make sure that the correct transport is booked. Uh And we need to bear in mind that the transport usually has some windows. So just give you an example if we know that the patient's package of care starts at tea time, uh not at lunch time and not in the morning. So then we we aim to get home the patient after the lunch time, but obviously before the tea time. So if we know that that it it can take up to two hours for the transport to to come and collect our patient and bring home. Then obviously, we need to take that into consideration when we book the transport. So even the the lovely ward clerks needs to be partner with us and need to know these fine details in order to achieve a successful discharge because it's quite uncomfortable for all of us and on waste of other people's time when actually the carers went out to the house to attend, you know, our patients, but the patient is still in the hospital because there is a delay in the transportation. So that is again, something that we need to bear in mind. Uh We need to make sure that you know, uh there is electricity in the house that there is going to be food for our patients. We need to make sure that all the community referrals have been done as well. For example, for the district nurses for wound care or for insulin, very important that once we discharge the patient, we need to and if they are diabetic and they are insulin dependent, we need to be very certain that actually at the right time, the district nurse is going to go out and give the insulin and not to face the sad situation that you know, if the district nurse is late because the refer I went to them late and they just appeared the next day, they will find an unconscious patient, isn't it? So that that would be just horrible. Um So as you see, there are lots of elements of the hospital discharge and it's really a team work. So discharge coordinators have the experience where can we go wrong and they will really try to, to kindly remind that and ask support from the other MDT members as well, the therapist, the nurses, the doctors, the pharmacist, the ward clerk, the transportation. So we are all in in this game uh together and because that's the only way that we can, you know, succeed. Um uh But you know, if we work as a team that then, then you know, we will, we will, we will get our patients home safe and sound as soon as possible. Obviously, in the media, everyone can hear that, you know, uh we have, you know, more some problems, you know, to find the community services. There is a delay in finding home carers. There is a delay in community hospitals for the rehab beds and people can wait unfortunately, even weeks for care homes because there is just simply not enough in the communities. Uh Hopefully that will, you know, change or improve. Uh There's not too much that discharge coordinators can do about that, but at least from the hospital side to start the process when we can start it. And when actually we have the community service to discharge as soon as possible, the patient in a safe way, that's basically what you know, we can help as discharge coordinator just very briefly. And then I am I am more or less finishing this session. There are some very interesting patient groups that sometimes we deal with. Uh maybe I'm just going to uh mention you three groups, one is homeless patients when there is nowhere to discharge the patient because they don't have homes. Uh If the patient does not have care needs quite often, we are called to homeless patients. But if they actually don't have care needs, so they are independent, they don't need help with washing and dressing or they don't have any health needs, they don't need, I don't know, insulin to be given to them. Then that is actually purely a housing issue. So what we can help with is to do a so called duty to refer to the local authority to the council. And actually, the patient can be discharged. If they are independent, then they can be discharged. They can be informed what is their counselor that they can turn to? But they don't necessarily need to wait in the hospital for that. Obviously, if the patient, the homeless patient has care needs, that's a different pathway, then we usually refer this patient to social services and then we will try to find them some interim in place until the the the real problem, the housing problem would be, you know, addressed. Uh Sometimes you come across patients with uh uninhabitable homes. Uh So, you know, from ambulance services, we we receive the safeguarding concerns that actually the home is just um you know, it's not suitable and not safe for them to go home. In some cases, we can again apply for social services for some support regard the deep clean. Uh But the patient obviously needs to consent to that. And it's not necessarily always the social services who will found it. In some cases, it's going to be the patient themselves who will need to find it, but we can help a little bit with that as well. And uh the, the third group may be uh as a as an interesting group is the overseas patients if they need support on their discharge. Obviously, every hospital has overseas department. So we need to liaise with them. Uh, what have we can offer. Yeah. So that was, uh, pretty much what I was thinking to share with you. Um, I hope, uh, it gave a bit of impression what a discharge coordinator does and how complex it is. Um, it's a very interesting job role. I really enjoy to do it for more than three years. Um And um, obviously, if any questions then yeah, please just let me know. But if no other questions, then I will, I will thank you for the attention and I will say goodbye. Hi, Anika. Thank you so much for your talk. It was very, very informative, to be honest, we have, you know, a lot of times we don't really get to know what discharge coordinates, how, you know, the training they've gone through what they do day to day, what you know, pathway to way to even means. So this was, this was really helpful. Thank you very much. I'm sorry for the initial tech difficulties as well. But thank you for giving us this talk and I hope you have a lovely time. We'll send out the certificates later and we'll upload this on metal if this is ok for you. Absolutely. Fine, so much. Do you have any slides as well that we can put up? Have unfortunately, I tried to upload it but uh it didn't go through, but I can send it to you. Yes. Absolutely. I'll just pop my email on the chart and I will, you can just send it to me and I am very happy to upload it if that helps. Yes, that's absolutely fine. And then obviously, you know, if someone would like to, you know, have you or contact me, I am, I'm more than happy to help. Thank you so much. It's all very helpful. Have a lovely day. Thank you and you. bye bye bye bye.