Internationally, there has been a move towards trying to enable older people to remain in their own homes or in the community for as long as possible (Day et al 2009). In the UK, this goal is underpinned by the NHS and Community Care Act (DoH 1990). Meanwhile, with the rise in hospital admissions ongoing, pressure has been applied from the Department of Health to shorten the length of hospital stay (Bauer et al 2009). The Community Care (Delayed Discharges, etc.) Act (DoH 2003) assigned time scales within which local authorities should work to achieve discharge from hospital to avoid financial penalty. Connolly et al (2009) found that between 2004 and 2006, there were increases in both elective and emergency admissions to hospital, with a decline in the average length of stay in hospital of 7.4% in 2004/5 and a further 6.4% in 2005/6. In addition, the number of delayed discharges fell from 6.3% in 2001 to 2.1% in 2006.

In this context, discharge planning, which has always presented a challenge to health and social care teams, has become ever more difficult. A plethora of reports from the Audit Commission and the Department of Health have identified discharge planning as being problematic – recently, the Healthcare Commission identified that hospital discharge ranked fifth in the top ten of complaints that they received (Healthcare Commission 2007). In 2010, the Department of Health published yet another guide to assist both organisations and individual professionals in their discharge planning.

Referring back to Ivy’s case history above, it is easy to see why discharge planning presents problems. For example:

• The organisations with an interest in Ivy’s discharge might include the discharging hospital, the local provider of community health services, the local department of social services, local social care organisations who might be commissioned to provide care and Ivy’s family.

• The professionals and other individuals who might be involved in Ivy’s discharge could include:

• The hospital: consultant, named nurse, physiotherapist, occupational therapist, speech and language therapist, discharge liaison nurse, bed manager.

• The local provider of community health services: community matron, district nursing team, any profession identified above offering follow-up treatment.

• The local department of social services: social worker, budget holder for care.

• The local social care organisation: social care manager, community care assistants.

• Ivy’s family: Ivy, Ivy’s daughter, other family members.

The individuals concerned could have widely varying goals in relation to her discharge from hospital. Some examples are the following:

• Ivy: might be torn between a desire to return home as soon as possible, a concern that her daughter will not be put under too much strain in supporting her and a desire not to see all her resources disappear in charges for community services.

• Ivy’s daughter: might have similar concerns to Ivy, although it is possible that her priorities will be different as she may be keen not to be identified as ‘the carer’.

• Discharging hospital bed manager: for an appropriate discharge to be organised as soon as possible after Ivy has been identified as ‘medically fit for discharge’.

• Social services budget holder: that plans are in place to ensure that Ivy achieves the maximum level of independence possible; that as many of Ivy’s needs as possible are met by family members rather than formal services; and that the support offered by formal services is proportionate to the needs of Ivy and her daughter.

Having just identified four people with an interest in Ivy’s discharge from hospital, it is clear that different people have different goals for a discharge – and, sometimes, individuals have more than one goal – and that these goals sometimes contradict each other. It is very important that there should be one nurse or small team of nurses looking after this patient to be the central communication person/team for managing her discharge from hospital in an effective manner as well as being the best possible experience for Ivy and her family. This of course will be dependent on many factors, including who is present when she is finally discharged from hospital.

The next two sections will consider this good practice in discharge planning in two possible contexts – discharge to the community and her own home and to a long-term care environment.

Planning discharge to community settings

There is a wealth of literature identifying good practice in discharge planning. Most recently, the Department of Health (2010) outlined ten steps for discharge planning to enable professionals to achieve ‘the best outcomes for patients, carers, practitioners, the organisation and its partners’ (DoH 2010:5). These are shown in Table 14.1.

Table 14.1 The ten steps for effective discharge planning

1	Start planning for discharge or transfer before or on admission
2	Identify whether the patient has simple or complex discharge and transfer planning needs, involving the patient and carer in your decision
3	Develop a clinical management plan for every patient within 24 hours of admission
4	Co-ordinate the discharge or transfer of care process through effective leadership and handover of responsibilities at ward level
5	Set an expected date of discharge or transfer within 24–48 hours of admission, and discuss with the patient and carer
6	Review the clinical management plan with the patient each day, take any necessary action and update progress towards the discharge or transfer date
7	Involve patients and carers so that they can make informed decisions and choices that deliver a personalised care pathway and maximise their independence
8	Plan discharges and transfers to take place over 7 days to deliver continuity of care for the patient
9	Use a discharge checklist 24–48 hours prior to transfer
10	Make decisions to discharge and transfer patients each day