Definition of a Delayed Transfer
A delayed transfer of care from acute or non-acute (including community and mental health) care occurs when a patient is ready to depart from such care and is still occupying a bed.
A patient is ready for transfer when:
A clinical decision has been made that patient is ready for transfer AND
A multi-disciplinary team decision has been made that patient is ready for transfer AND
The patient is safe to discharge/transfer.
A multi-disciplinary team should be made up of people from different professions, including social workers where appropriate, with the skills and expertise to address the patient’s on-going health and social care needs. If there is any concern that a delay has been caused by the actions or inactions of a Local Authority, they should be represented in the team. The way that the team is organised and functions is fundamental to timely discharge and to the patient’s wellbeing.
Where delays occur for people of no fixed abode, the crucial issue is to identify the local authority responsible for providing them with care and support services. For example, if they are admitted to hospital from a public place then that place should be used to identify the responsible local authority. For asylum seekers or other patients from overseas, they should be listed under the local authority in which they currently reside. It is the responsibility of the local authority to decide whether they are eligible for social services.
To help manage patient flow more effectively, some NHS organisations collect data on the number of patients for whom a clinical decision has been made that they are ready to transfer. A number of terms are used, including ‘medically fit for discharge’ ‘clinically optimised’ or ‘medically optimised’. It is important to remember that ‘medically optimised’ is not the same as a delayed transfer of care.
The determination that a patient is medically optimised is from a medical perspective only, and is a decision made by the consultant or team who are responsible for the patient. The patient has not had a multi-disciplinary team decision at this point and may need further therapy or social care in-put prior to such a decision being made, so is not a reportable delay.
‘Medical optimisation’ is the point at which care and assessment can safely be continued in a non-acute setting. It is a decision that balances the acute care requirements of the patient, the typical desire of individuals to return to their home environment at the earliest opportunity, the potential harm associated with staying in hospital and the needs of other more acutely ill patients. Too often, early discharge is seen as ‘freeing up a bed’ rather than acting in a patient’s best interests to move them swiftly to a safer, more familiar environment that will encourage supported self-management, speedy recuperation and recovery, and have them feel better.
All staff must understand that there is recognition that patients may still have on-going care and assessment needs (e.g. therapy or social care assessment), but that these needs can and should be met in the community.
Wokingham Borough Council has entered into an agreement with local Clinical Commissioning Groups and hospitals, under the Better Care Fund scheme, to minimise the potential for delayed discharges through local schemes such as “hospital at home”, step-down beds in nursing care and a more integrated intermediate care/re-ablement service.