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Transition between inpatient hospital settings and community or care home settings for adults with social care needs [NG27]

Measuring the use of this guidance

Recommendation: 1.3.10

Start a comprehensive assessment of older people with complex needs at the point of admission and preferably in a specialist unit for older people.

What was measured: Percentage of acute trusts or local health boards who have a frailty unit (an acute assessment unit focused on the care of frail and older people).
Data collection end: October 2016
52%
Area covered: England
Source: NHS Benchmarking Network. Older People’s Care in Acute Settings Benchmarking Report.

What was measured: Percentage of acute trusts or local health boards who report having a multidisciplinary team response that initiates a comprehensive geriatric assessment within the first hour of admission.
Data collection end: October 2016
26%
Area covered: England
Source: NHS Benchmarking Network. Older People’s Care in Acute Settings Benchmarking Report.


Recommendation: 1.4.3

Ensure clear and timely exchange of patient information: - between healthcare professionals (particularly at the point of any transitions in care) - between healthcare and social care professionals in line with the Health and Social Care Safety and Quality Act 2015.

What was measured: Proportion of people with dementia whose hospital discharge correspondence included a record of their behavioural and psychological symptoms of dementia.
Data collection end: October 2018
44%
Number that met the criteria: 574 / 1299
Area covered: National
Source: Royal College of Psychiatrists. National Audit of Dementia.

What was measured: Proportion of people with dementia discharged from hospital whose discharge plan/summary was sent to their GP/primary care team.
Data collection end: October 2018
94%
Number that met the criteria: 6575 / 6679
Area covered: National
Source: Royal College of Psychiatrists. National Audit of Dementia.


Recommendation: 1.5.1

Make a single health or social care practitioner responsible for coordinating the person's discharge from hospital. Create either designated discharge coordinator posts or make members of the hospital‑ or community-based multidisciplinary team responsible. Select them according to the person's care and support needs. A named replacement should always cover their absence.

What was measured: Percentage of acute trusts or local health boards with dedicated ward discharge co-ordinators.
Data collection end: October 2015
79%
Data collection end: October 2016
70%
Area covered: England
Source: NHS Benchmarking Network. Older People’s Care in Acute Settings Benchmarking Report.

What was measured: Proportion of hospitals which reported having a named person in place to coordinate discharge plans for people with dementia.
Data collection end: October 2018
92%
Number that met the criteria: 179 / 195
Area covered: National
Source: Royal College of Psychiatrists. National Audit of Dementia.

What was measured: Proportion of hospital case notes of people with dementia showing evidence of having a named person in place to coordinate discharge plans.
Data collection end: October 2018
85%
Number that met the criteria: 5950 / 6975
Area covered: National
Source: Royal College of Psychiatrists. National Audit of Dementia.


Recommendation: 1.5.3

Health and social care organisations should agree clear discharge planning protocols.

What was measured: Proportion of acute trusts or local health boards who have a documented supported discharge protocol applied across all wards.
Data collection end: October 2015
86%
Area covered: England
Source: NHS Benchmarking Network. Older People’s Care in Acute Settings Benchmarking Report.

What was measured: Proportion of acute trusts or local health boards who have a documented supported discharge protocol applied across all wards.
Data collection end: October 2016
77%
Area covered: England
Source: NHS Benchmarking Network. Older People’s Care in Acute Settings Benchmarking Report.


Recommendation: 1.5.14

The discharge coordinator should work with the hospital‑ and community‑based multidisciplinary teams and the person receiving care to develop and agree a discharge plan.

What was measured: Proportion of people with dementia discharged from hospital whose case notes contained a single plan/summary for discharge.
Data collection end: October 2018
86%
Number that met the criteria: 5988 / 6975
Area covered: National
Source: Royal College of Psychiatrists. National Audit of Dementia.


Recommendation: 1.5.16

The discharge coordinator should give the plan to the person and all those involved in their ongoing care and support, including families and carers (if the person agrees).

What was measured: Proportion of people with dementia discharged from hospital, or their carers, who received a copy of their discharge plan/summary.
Data collection end: October 2018
88%
Number that met the criteria: 5886 / 6679
Area covered: National
Source: Royal College of Psychiatrists. National Audit of Dementia.


Recommendation: 1.5.31

If the discharge plan involves support from family or carers, the hospital‑based multidisciplinary team should take account of their: - willingness and ability to provide support - circumstances, needs and aspirations - relationship with the person - need for respite.

What was measured: Proportion of people with dementia who were discharged from hospital whose case notes show there was a carer assessment in advance of discharge.
Data collection end: October 2018
69%
Number that met the criteria: 2478 / 3611
Area covered: National
Source: Royal College of Psychiatrists. National Audit of Dementia.


Recommendation: 1.6.1

Ensure that a range of local community health, social care and voluntary sector services is available to support people when they are discharged from hospital. This might include: reablement (to help people re‑learn some of the skills for daily living that they may have lost) other intermediate care services practical support for carers suitable temporary accommodation and support for homeless people.

What was measured: Proportion of older people (65 and over) who were offered reablement services following discharge from hospital.
Data collection end: March 2014
3.3%
Data collection end: March 2015
3.1%
Data collection end: March 2016
2.9%
Data collection end: March 2017
2.7%
Data collection end: March 2018
2.9%
Number that met the criteria: 44757 / 1524615
Area covered: England
Source: Adult Social Care Outcomes Framework, England



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