The discharge hub at Gateshead Health supports patient referrals to be discharged home safely to the community.
During the covid pandemic, the government guidance changed the way hospital discharge worked and the ‘discharge to assess, home first’ approach was introduced to ensure patients were discharged home as a first instance.
According to the Gov.uk website, “under the Discharge to assess, home first approach to hospital discharge, the vast majority of people are expected to go home (to their usual place of residence) following a stay in hospital. The discharge to assess model is built on evidence that the most effective way to support people is to ensure they are discharged safely when they are clinically ready, with timely and appropriate recovery support if needed.”
In July 2022, an RPIW (rapid process improvement workshop) was held for hospital discharge plans (pathways) to support awareness of the discharge processes. Discharge pathways are the plans for what support someone needs to make sure they can go home safely after a hospital stay.
The discharge hub team Claire Hall, Janine Brooks and Andrea Reynolds have explained what their job entails and further insight into the role here at Gateshead Health.
Clare Hall, Discharge liaison sister
I am one of the 6 discharge liaison nurses who are responsible for supporting complex patients on discharge pathways 1-3. These are people who will need some extra support to recover at home, rehabilitation or on going care. I work in collaboration with the social workers, assessing officers and admin officers. We are known as the discharge hub and cover the patients based at the QE Hospital.
As part of the discharge process, we must look at how we will facilitate the safe and timely transfer of patients back into the community. In our role we come across several complex cases, this could be anything from housing, safeguarding, house cleaning and complex social needs.
Another aspect to our role is supporting palliative and end of life patients in the Gateshead area to full fill their last wishes in place of care.
Discharge liaison nurses advise and support wards to signpost to other services in the community, such as Age UK, or Red Cross.
Janine Brookes, social worker
The hospital social work team is based in the Tranwell unit at the QE Hospital and is made up of a team of social workers and assessing officers.
The team carries out trusted assessments to determine the appropriate discharge pathway for patients who no longer need to stay in the hospital.
My usual day includes attending the discharge meeting first thing to discuss current pressures on beds and how many patients are awaiting services on discharge. Any complex cases are also discussed.
The team take referrals from the wards and assess the patient by gathering information from other health professional and speaking to the patient and their families. The team also carries out mental capacity assessments for decision-making around the change of accommodation and care and support needs as well as attending multidisciplinary teams (MDT) on the wards for complex discharges or safeguarding issues. The MDT is a group of health and care staff from different organisations or professions (e.g. GPs, social workers, nurses), that work together to make decisions regarding the treatment of individual patients and service users. The hospital social work team also covers Gateshead patients in other hospitals.
Andrea Reynolds, admin officer
I really enjoy my admin role. It is varied, interesting and always busy and I love the discharge liaison and social work teams I work with. Admins are a team of four workers and we are an approachable team with a “can do” attitude.
Telephone lines are very busy and we take social care queries from relatives, professionals and care providers – often sign-posting calls to appropriate services.
Admin take referrals for all Gateshead residents who are not only in the QE hospital but also in other hospitals. We take social care referrals from discharge liaison nurses and pathway 2 or 3 (the people who are likely to need the most support when they leave hospital) we take directly from the ward and forward to QE duty for social workers to screen.
We act as admin support for Gateshead Council social workers: typing, proofreading, minute taking and compiling staff rotas.