Julie Dublin, Senior Transformation Manager, gave an update on the hospital discharge process and outlined the Tower Hamlets Together Board’s key priorities for municipal year 2024-25. Ms Dublin noted that hospital discharge varies depending on the individual's condition upon entering the hospital, how they are when departing the hospital and where they will be going.

Ms Dublin noted that the report only deals with adult discharges, then outlined the 4 discharge pathways a patient goes through when approaching their final day in hospital:

?        Pathway 0 refers to a patient discharged to home or a usual place and who does not have any a patient discharged to a home or a usual place who does have new or additional health or care needs.

?        Pathway 2 refers to a patient discharged to a community bed-based setting who has dedicated support for new or additional health or care needs, in the short term to aid in recovery and/or live independently. This also relates to someone who may require longer term care.

?        Pathway 3 refers to a patient discharged to a new residential or nursing home setting who may also require long term residential or nursing home care.

Members were informed that Pathways 2 and 3 require more complex care packages, equipment and support or may also require a residential bed. Details of the discharge framework were noted. This framework, compiled  by stakeholders including Tower Hamlets Council, the Royal London NHS Trust, the East London Foundation Trust (ELFT) and the ICB, sets out six key priorities the discharge service adheres to:

1.     Address risk- adverse decision-making and over provision of homecare in pathway 1.

2.     Improve knowledge of discharge to assess (D2A) process for patient, families and carers.

3.     Improve engagement with families/carers.

4.     Address complex discharge issues earlier in the planning process.

5.     Streamline and accelerate the process for reviewing high-cost packages of care.

6.     Encourage better use of the reablement service, reducing inappropriate referrals, promote goal-focused therapeutic input in reablement.

Members were informed of the multidisciplinary team approach to discharging patients and collaboration required by brokerage staff, the acute hospital and community health services, alongside the reablement and rehabilitation services and the adult social care teams.

The ‘Transfer of Care Hub’, formerly known as the Integrated Discharge Hub, supports people about to be discharged from hospital to the most appropriate place, is not without challenges. Most notably the lack of suitable places within the borough.  This has meant that some patients are housed outside Tower Hamlets, which can cause concern for family members. Members were informed that a lack of equipment has also caused challenges.

Accessible equipment available in more swiftly greatly has improved the  discharging process. There have been instances where a patient refuses discharge due to housing issues and the choice policy has been implemented to facilitate a patient's discharge.

Ms Dublin then outlined the current activities being undertaken in line with the key priorities for a more streamlined service. This included the implementation of the optimal-handed care project at the Royal London Hospital and improving discharges through EHCC step-down beds.

Further work is required, including analysis of the priorities produced by the Integrated Discharge Hub and NHS England to ensure all requirements are met and all departments work together. A progress report will be provided to the sub-committee in six months’ time.

Following questions from the sub-committee, Julie Dublin, Councillor Gulam Kibria Choudhury and Georgia Chimbani, Director, Adult Social Care;

•         Explained that homeless patients requiring discharge are usually placed with the Homeless Pathways team if they are not known to the borough, who will aim to identify their former place of resident and use the referral escalation process for them to be returned in that area for assistance by that local authority. Homeless patients who have ties to the borough are discharged and temporary accommodation is provided with assistance from the Housing team. Gloria House is also available for approximately 42 days for homeless patients to stay.

•         Clarified that the Transfer of Care Hub is a multidisciplinary team, consisting of representatives from specialist care providers, ASC staff, community services and hospital departments. Discussions on the service are conducted weekly at escalation calls, and information sharing on the best methods of treatment for patient discharge are considered.

•         Confirmed that the programs aim to ensure that the correct patient assessment and integrated care planning for discharge is continually implemented and the collaboration and trust between health and social care professionals, NHS staff and the patient remains.

•         Explained that the discharge process involves a patient assessment to determines any ongoing needs. If a package of care is required, a review will be conducted and adjusted as necessary and may also include occupational therapists or adaptations.

•         Acknowledged that housing adaptations can be complex due to some Landlords not willing to undertake modifications required, although there are means to escalate in these instances and many Landlords do comply.

•         Clarified the various means of discharge depending on the patients requirements, including Re-ablement, step down beds when required and extra care sheltered. Consideration will be made to other ways of housing patients with varying levels of support.

•         Noted that patients who require transportation when being discharged from hospital will have this arranged as part of their exit plan. One day delays can occur due to heavy traffic, or a requirement for a carer to accompany the driver. The majority of discharge date takes place on the day as planned. Consideration will be made to improving the delays.

•         Explained that vulnerable individuals who require assistance but live alone are usually placed with a social worker, who works alongside the Transfer of Care Hub, to establish the level of support and package of care required. A home care provider will also be involved to ensure they work with the patient.

•         Noted that the timeline for patients package of care is dependent on the patient’s level of complexity. Advanced discharge planning can begin whilst in hospital and collaboration with a social worker.  Some packages can be arranged within a day, if the patient is known and or minor changes are required.

•         Clarified that methods to reverse delays in nursing and care home placements include giving care providers times scales to undertake assessments. Consideration is also be given to using a trusted assessor model on behalf of multiple care homes, to ensure patients are received based on that assessment.

The Health and Adults Sub-Committee RESOLVED;

1.     That a progress report on the Hospital Discharge Service to be provided to the sub-committee by July 2025.

2.     That the presentation be noted.