The Discharge to Assess model works on the principle of making sure patients do not stay in hospital for any longer than they need to. Patients are discharged as soon as their acute medical treatment is complete and all assessments are followed up within the community, after discharge. These assessments will be based around the patient's level of function, environment and care needs to ensure they remain as independent as possible at home.
The Discharge to Assess model focuses on a home first principle and is comprised of three different discharge pathways, with all referrals accepted from any hospital and processed by the Integrated Discharge Team (IDT).
IDT - is an integrated team comprising of the CNWL Community teams, the hospital discharge teams and social services, that facilitate Discharge to Assess pathways. Camden Central Access Team is our single point of access that supports all hospital discharges and signposts appropriately for Camden patients.
Pathway 1 (this team) – for patients going home from hospital. This pathway is operated in conjunction with Camden Adult Social Care with any therapy assessment that is required for the patient undertaken by this team following patients hospital discharge.
Pathway 2 - discharge for patients to an alternative location that isn't home, for a short-term period for rehabilitation and reablement before returning home. This pathway is operated by St Pancras Rehabilitation Unit. For patients stepping down to a short-stay reablement flat, or interim residential home this is operated in conjunction with Camden Adult Social Care.
Pathway 3 – for patients being transferred to long-term care such as a residential care home or nursing home. This pathway is delivered by Camden Adult Social Care and where required is in conjunction with the Camden Continuing Care team.
In Camden, Discharge to Assess (Pathway 1) is an integrated health and social care community service which provides therapy and/or care for adults in Camden going home from hospital. The team consists of occupational therapists, physiotherapists, social workers, therapy assistants and support workers. The service offers short-term intensive therapeutic intervention and care for up to five days.
Under Pathway 1 patients are safely discharged home where functional and care assessments can take place. Not only is this setting more appropriate as the environment is familiar to the individual, but it gives us a sense of functional capability. It also prevents decisions about long-term care being made in crisis and gives insight into how patients cope and gives the professional an accurate assessment.
Assessments that take place in the home environment include:
- Functional assessments
- Environmental assessments
- Medication review
- Care needs assessment with rapid access to reablement care, if required.
At the end of assessment the team will support the transition to long-term support (if required) as well as develop care plans with patients, and where appropriate their carers, to help alleviate the risk of crisis.
Therapists will also make sure referrals for ongoing therapy input are made prior to discharge from the pathway.
The service is for adults over the age of 18 who live in Camden and currently in an inpatient hospital bed.
The service is not suitable for people who are medically unstable, have received a new diagnosis of a stroke or where mental health is the main presenting problem.
The identification of patients is done by acute hospitals. A simple referral form is completed and sent to camdenreferrals.cnwl@nhs.net.
The service is available from 8am to 8pm, seven days a week.
The discharging hospital should make arrangements to transport patient home from hospital.