Unsafe discharge from hospital

[PaintYourDreams]

I hope someone can help me with this one please. My MIL was taken into hospital a few weeks ago and it was a nightmare to get her there. She was very unwell but also extremely hostile to any medical intervention and it was very upsetting all round but once she was there and being treated she's accepted it and doing better but still quite a lot wrong with her that will need ongoing treatment.

The problem is that we've been told by a discharge person (not a nurse, I don't think) that at some point they will discharge her by either us collecting her or them taking her home where they will do a two hour 'assessment' to see if she can cope at home. So the assessment will be done once she has already been taken home. MIL will say yes she can manage fine but she was in a terrible mess and not coping at all when she went into hospital and we think that daily carers and a stairlift are the minimum needed. None of this will be in place if they just bring her back and then decide she doesn't need help. Or if they decide that she can't manage, then she's had all the trauma of being taken home and then taken back to hospital.

So I guess my question is whether this is the normal way that an assessment is done or does this mean that they've effectively decided she is discharged back to her house as it is even though we don't think this is safe.

Sorry about auto incorrects- you can guess what I typed before phone changed it!

So it's ok to talk to discharge team and give context as family, as that's all useful info to be discussed with your mum. . Sometimes the reality of background will indicate if someone has or should be assessed for deteriorating short term memory loss.

In our LA, after having re-enablement care package on discharge for up to 6. Weeks which includes OT (occupational therapy) supper- if needed they assess and refer for longest term care package (which is chargeable, hence my comment about threshold £23,250 for ASD funded care that person pays toward under a financial assessment )

Argh
Longer term care package (ie on going) and support not supper, Sheesh my phone hates me!

@TriciaMcMillan
The idea of D2A is that the bed is held, otherwise it’s just a discharge.

No it isn't, it's to assess patients post discharge to ensure they don't spend time in hospitals unnecessarily. Once they are 'medically optimised' and an acute hospital bed is no longer required they are discharged home/to community rehab/or to a care home where they can be assessed or the next phase of their rehab can begin.

The bed is not held as if the acute site was the suitable place for them to remain (i.e they needed further medical treatment in hospital) they would not have been considered clinically optimised and ready for discharge!

www.local.gov.uk/our-support/our-improvement-offer/care-and-health-improvement/systems-resilience/overall-approach/discharge-to-assess

[quote FelicityBeedle]@TriciaMcMillan
The idea of D2A is that the bed is held, otherwise it’s just a discharge.[/quote]
Sorry, meant to quote @FelicityBeedle in my response above.

@Bonbon21

I cannot emphasise strongly enough that you do NOT say you can visit at weekends. Tell them you are not in a position to provide ANY support whatsoever. This might seem obstructive and uncaring, but if you say you can make a cup of tea for her ,they will expect 3 course dinners 3 times a day!!! They have duty of care, and should not be sendjng her home without an appropriate care plan in place. Stay adamant in this.

This. It's awful basically pulling up the drawbridge and navigating the guilt tripping but there responsibility must stay firmly on their shoulders if you're going to get anywhere.

It's a shit state of affairs.

The discharge co ordinator will have asked your MIL questions about her living arrangements and will hopefully access her whilst in hospital. You need to tell them about your concerns regarding the stairs. They should at least provide a commode. We’ve been in this situation with parents/in laws and it worked out ok. With my father, the carers rang me to set up an appointment to discuss what care he needed, when he was still in hospital, I told them that we didn’t have a discharge date yet, but they had. With regards to equipment try and get this arranged before she leaves hospital as it’s a nightmare trying to get anything additional, if any aids are offered, take them even if she won’t use them, I would at least ask for commode, walking frame, etc, then if she has carers come in, they can sort other things out.

@cptartapp

Be very careful here. I agree, make it very clear there will be no family help. Ignore any guilt tripping. Don't mention going round every weekend, how sustainable (or fair to you) is that anyway? Think long term. As an ex district nurse I saw this scenario play out many a time, usually compounded by patients refusing to pay for care and subsequently in and out of A&E like a revolving door. Unfortunately, it's often only letting things fail and a crisis develop which forces change permanently.

Agree with this completely. When my father in law was due to be discharged from hospital last year, we made it very clear to the hospital team that he couldn't manage at home without help. The hospital made sure that a care package was in place for the first two weeks, which was then assessed and continued in whatever form they thought necessary afterwards. Don't promise that you can do anything, as you might not be able to continue helping weekly etc. Good luck.

@TriciaMcMillan
Apologies, clearly the trust I work in has a very different idea of it. It’s a definite assessment and bed is held for them until they get the go ahead to finish the discharge from the rehab team

[quote FelicityBeedle]@TriciaMcMillan
Apologies, clearly the trust I work in has a very different idea of it. It’s a definite assessment and bed is held for them until they get the go ahead to finish the discharge from the rehab team[/quote]
No need to apologise. That is very unusual and certainly not the recommended policy and approach. Just wanted to ensure the OP is under no illusions re. the bed being available once her MIL is discharged (unless she's in your trust!).

@Mischance I don't know how long it's been since you were a hospital social worker but you are out of date. Assessments for social care now take place AFTER. discharge - it's called "Discharge to Assess".

OP, be very clear that you can't offer any support. Ask the hospital discharge team if your mother qualifies for Reablement. That would provide for up to 6 weeks of care at home whilst the relevant assessments can be made.

My experience pre Covid was: Dad arrived home about 3pm on a Friday; within 30mins an OT arrived followed by a Social Services coordinator. There was then a hectic period of both inspecting the house and firing questions at me simultaneously. Meanwhile the doorbell kept ringing as equipment arrived - zimmer frame for upstairs and downstairs, perching stools, etc. We got him to bed if I remember correctly, but carers arrived to get him up next morning. Requested meals on wheels and they started on the Monday.

In other words, both NHS and Social Services are capable of moving very quickly.

If you go for a stairlift, try reconditioned. Stairlifts are rarely in use much more than a year.

They will have assessed her as medically ready for discharge and assessed any definitive ongoing personal care needs prior to discharge, the in home assessment is quite new and it's to make sure the person being discharged coped in their actual home environment. If your mother has capacity they are under no obligation to speak to you

gogohm
You are right about if the person is judged to have capacity they don't need to speak to you, however deciding on capacity is a moot point.
The test used routinely isn't much use. DF was a retired salesman and a politician. Even when confused he knew who the PM was and a lot of the current affairs stuff, and for about 20 minutes was able to do the chatty old gent bit. The reality was very different, especially when he was tired, and he had brain scans to prove it and he didn't do well on more complex tests.
However he told the social worker I went in daily, and she made all her discharge arrangements accordingly. Never approached me and then argued with me when I said I lived a long way away and had a full time job and kids at school because he had TOLD her I visited and it was in the notes. It got down to " can you read out the phone number you have just used, and do you want to google the dialing code.......And now try puting the town name into Google Maps and plan the route? Which way round the M25 does it suggest?"
She said I was unreasonable and negative when I said I gave him a week at home post discharge. I admit I was wrong, it took 4 days for him to be back in A&E.
Sorry rant over- it still angers me after nearly 10 years.

So - what happens under this new discharge to asses system? Are aids and alterations done before the patient leaves the hospital? Does the OT visit the home before the patient is discharged? Or is it just the government's latest idea for stopping bed-blocking, regardless of the well-being of the patient and their family?

There is no way a proper assessment can be done after discharge - once the hospital bed has gone the patient and their family will have to muddle through as best they can - this is far from acceptable.

My family and I struggled to look after my OH who was discharged with no care over an Easter weekend. He had nil mobility, could not feed himself, was incontinent, was having paranoid delusions, could not do any of his personal care ..... he was discharged and the assess bit came later, then the wait for carers to be organised, then the wait for equipment. I was tearing my hair out, in pain and thoroughly disgusted with the system.

Assess first and then discharge is what you should be fighting for.

@Mischance it really does work. I know as I've worked in a D2A team. Ward based assessments are still carried out as usual, the therapy / SW team will have a good idea of what is needed to ensure safe discharge and get equipment ordered / arrange reablement care packages to start on the day of discharge. Then the D2A team goes in on the day of discharge or morning after to continue the assessment and plan what input is needed from then on.
Sometimes people do need to be readmitted, but that happened even before D2A. As long as the right teams and processes are in place, the system works well.

Round here getting any item of equipment takes weeks - what happens under this new system? Does the patient stay in hospital, or do they get discharged without the necessary care and equipment in place, as my OH did?

What happens when the care put in does not work? - I know all about this from bitter experience. Plenty of people come round with bits of paper and assess what is needed - but is it forthcoming? - no. Not without a fight. I was there to fight for my OH - what happens to those who have no-one?

Where is there choice for the individual? Should they just have anyone, however unsuitable, going into their home? - we had one carer who was giving my OH serious heart-stopping (literally) drugs when my back was turned - OH would have died if I had not seen what was happening and intervened.

Often the care that was thought to be needed is insufficient - we certainly found this. So - whilst awaiting what is needed family (if you are lucky enough to have one) found ways of muddling through. My DDs were washing my OH, changing his catheter and other personal care, because no carers had been sent - none of this is appropriate.

We were promised 6 weeks of care when he returned home, which was rescinded the day before he was discharged as the agency SSD use could not provide the level of care he needed (2 carers 4 times a day) and were not prepared to use a different agency - so, he was assessed as needing this high level of care, but because they could not find carers from their chosen agency we, as family, were left to muddle through. I had a serious back problem, my family needed to be at work and were taking time off.

It took about 6 weeks to get a standing aid - in the meantime we were lugging him about as best we could to wash him, change his pads, relieve his pressure areas etc. He was promised a tracking hoist - we waited and waited, then I rang up again - they had not ordered it!

I could go on - and on. It was a living nightmare and his dignity was last on the list. And as for our well-being - forget it.

This may sound like a rant - as indeed it is - but until you have been in this hell, you have no idea what is really going on.

There is an important principal here: care in place, THEN discharge.

Some years ago I was employed to run a research project into hospital discharge, and that principal was at the heart of it. Whatever home assessments were done happened with the hospital bed still retained; and some of those assessments were overnight. But the bed stayed.

This government has always taken short cuts with care - it is not good enough.

Their much-heralded care reforms are simply about money - no mention of quality! Surprise, surprise.

@Mischance I'm genuinely sorry that you had the experience you had, but that doesn't mean that D2A is wrong or ineffective.
Equipment essential for discharge is given for discharge. Otherwise that discharge would be unsafe.
Care essential for discharge is also set up ready for discharge. Even if someone wasn't under D2A they wouldn't meet the carers that SS had sorted out for them prior to going home.
There will always be equipment that is not essential for discharge that the person may need to wait for once at home. As long as they can be cared for safely once at home.
Where I work, for example, a ceiling track hoist is a major adaptation and would take about a year to get put in place. As would a stairlift.
These pathways are set up so that people spend less time in hospital. Longer hospital stays have poorer outcomes especially for older people. So even though you had a really bad experience, in the vast majority of cases home is the best place for someone to be.

@Mischance reading your post has helped me so much. I felt such a failure when my mum was sent home from hospital after a perforated ulcer in 2019. She has severe osteoarthritis, no connection with her illness at all, and with a vile discharge nurse and her denial of the support she needed we ended up collecting her from the ward and then we were left to put her in the car - which took an hour - and the same when we got home.

The only concession was that we had the care package in place. But mum made a supreme effort and would dress and take herself into the living room every morning before they arrived and so they stopped coming.

Meanwhile it took two people to get her to the bathroom and on and off the toilet. One of the carers arranged for OT to come. OT floated in and promised us the world. She was so lovely. She came back later that day with a commode, a frame for the toilet and arranged for the loan of a small wheelchair to get mum from the armchair to the bathroom and said she would be in a week's time. When she didn't turn up I phoned the number she had given me and it turned out she was on holiday for a fortnight. We never saw her again!

Thanks to the support here I knew what to say when she was taken into hospital last year. My husband and I withdrew all personal care and said that she had to be self mobilising and able to take herself to and from the toilet. That was when the dementia became obvious. She really did not understand how to move her body anymore.

Even reading this thread makes me feel panicked. Hopefully if someone reads our posts and understands that they have to fight for care and support it will be worth it.

You need to explicitly say that if she is claiming that she can cope alone then that is clear evidence that she lacks capacity to make that judgement. Tell them that whatever she claims to the contrary she does not have reliable support from neighbours and family.

Do not specify that you will be visiting every weekend, indeed you need to explicitly state the opposite - that whilst you will try to visit as often as you can you cannot commit to being there every weekend and there will sometimes be 2 or 3 weeks between your visits. This is important so as to ensure that the care plan put in place covers weekend support too, and will mean that when you do visit you will be able to direct your time to much better effect to help make a positive difference, rather than just picking up the daily grind so that the paid carers don't have to come in that day.

There will always be equipment that is not essential for discharge that the person may need to wait for once at home. As long as they can be cared for safely once at home

So who does that caring in the absence of the care awaited? And who assesses whether that care is safe? - for the patient and for those providing the care.

Was it right that I, as someone with a slipped disc, had to muddle through to my detriment (and danger) and that of my OH?

There is no way that a system that dumps patients at home without the full care and equipment necessary can be right. The government wants you to believe this because it can then tick the bed-blocking box and say they have done something about it. You are serving a corrupt system.

Hospital discharge was my "specialist subject" for many years and the principles will not have changed: if there is no proper care in place, the patient stays where they are until it is, or is offered a community hospital place in the interim. I know bed-blocking is a problem, but professionals on the ground are duty bound to put the safety of the patient and their family ahead of political considerations. Just because the government does not properly fund the NHS and social care there is no reason for any social worker or OT to be complicit in unsafe discharges. They are pawns in a game that destroys their professional judgement and leaves vulnerable people at risk.

So I agree with some of the PPs on here

Re enablement 'teams often set up care package and assess as they go in a multi disciplinary community team with OTs nurses and assessing reablement carers with the quick equipment in place - if essential such as profile hospital bed, air mattresses, slide sheets, mobile hoist, bed levers, commode, frame, perching stools etc
The longer separations such as ceiling track hoist, stair lifts bathroom adaptations to wet room or downstairs bathroom facilities on DFG can take far longer but manageable whilst that is processed. YoU don't want someone in hospital losing more skills and muscle strength , becoming disirientated, when home may be better for them. It is important that you ensure the discharge team hear what is realistic that main carer (spouse partner) or family are actually able to do - if anything- rather than a wishful thinking hope from the client.

Assessments for social care now take place AFTER. discharge - it's called "Discharge to Assess".

I'm a social worker - our initial assessments complex ones led by S/w and simple ones are mostly led by mdt discharge teams and all take place before discharge, we osentify that someone needs carers , how often, and equipment prior to discharge but that they may also improve on rehab from physio at home, if they have rehab potential. So we organise and mostly have a re-ablement team including MDT going in with care package and OTs and equipment etc - and it is an ongoing assessment as care needs may change and reduce with rehab that is part of the Discharge to Assess (D2A) process . It's called intermediate care by some areas. It's for up to 6 weeks then a decision is made for ongoing longer term care and at what level usually with a trail taper down if needed or an increase. Then we have a 12 week (but chargeable so financially assessed) further specialist contract with our main carer provider who can further "right size" (up or down) the care package carer support if suitable.

We also make use of D2A beds after hospital of up to 6 weeks funded (Non chargeable to client ) at block funded beds at local nursing homes with mdt reablement team going in those for people who have had major health crises - such as broken hips and THRs, strokes or other major health issues that it is not yet clear to client or to MDT whether they will ultimately need placement or lots of work and rehab and large care package to get them home. Years ago People used to move from acute hospitals to stay in the community hospitals for that rehab but lost skills whilst they waited and were away from home in unfamiliar ward environments.

So , our LA is very good at D2A. I appreciate it may work differently in different LAs (County councils) but here it works fairly well as good as or better than previous systems when we had far more beds. I see better results and suppprt to keep people at home. But of course it can always go wrong or not work out as planned due to unforeseen circumstances / deteriorations or other reasons.

I do find it really upsetting to read when someone describes become left and forgotten and how bad their discharge went.

Often this is because they were discharged without good plans in place or bypassed the social care system somehow and community teams are then dealing with "unsafe discharge " that family have rung in about. We then are trying urgently to organise care and urgent equipment via local mdt CCTs. We have some specialist rapid response teams (they are different in each different CCG and GP patch area! As my patch falls across catchment of several acute hospitals, OPMH hospitals, some specialist hospitals and GP Practice groups that have signed up to different Health project services )