Reflections on the experiences of patients with complex needs and thoughts on how discharge approaches can be developed

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At Fulfilling Lives South East, we’ve seen how hospital discharges can be a challenging time for patients with multiple and complex needs (‘MCN’). Our client casework has shown us how clients are often discharged to unsuitable accommodation, or to the street in the very worst of cases.  The NHS is a complex system, and in the area of discharge this complexity is compounded by the fact that there is a shared responsibility with Adult Social Care for discharge planning in complex cases.

Hospital discharge – Case example:

S is a female homeless client who had been in hospital for five weeks. She was diagnosed as suffering from endocarditis, with damage to the mitral valve, two thalamic infarcts and two cysts on the brain. At the beginning of week six, despite her being homeless, it was recommended that she be discharged and that she “go home and gain further weight and return after a month to review her health ahead of a referral for heart surgery”.

In April 2021, FLSE and the Brighton Healthwatch Hospital Discharge Project invited organisations from the Voluntary and Community Sector as well as the NHS to discuss how hospital discharge for people experiencing MCN can be improved.  The overarching themes identified were that community mental health support services are stretched and can be difficult for patients to access after hospital discharges but also that hospital discharge means different things to different organisations. We understand that the health, social and third sector are funded and set up quite differently and this runs the risk of services being fragmented which in turn contributes to the difficulties when supporting patients and clients. These difficulties include challenges around information sharing and communication between services and lack of knowledge on where to find the right support depending on referral criteria and thresholds.

At Fulfilling Lives, we have dug deeper into the processes and procedures of hospital discharge and challenged ourselves to articulate what a better hospital discharge system could look like. This involved a focus group of specialist workers who support people with multiple and complex needs, systems change staff and those with lived experiences of hospital inpatient and discharge procedures.  Our key thoughts are outlined below.  

Key Thoughts

Underpinning Principles – We feel that all processes should be informed by the following principles

• Support starts early when planning for hospital discharge with the first paramedic / GP / professional contact. These people help inform the patient’s needs and contexts that should be considered in discharge plans.
• Treatment will be delivered in a Psychologically Informed Environment (‘PIE’) which respects privacy (i.e. no interviews in glass interview rooms) and client ‘agency’ i.e. respects the fact that the client is in the room and isn’t ‘spoken about’ as though they are not.
• Being human   We want the best medical outcomes for clients and understand that this is best supported by recognising the humanity of the client and taking a trauma informed approach to their care and recovery.
• Ensure that the client’s voice is heard early in the process and consistently throughout.
• Hospital discharges for people with multiple complex needs will have clear accountability and oversight within the healthcare system.
• Discharge planning takes patient’s outside circumstances into account and reflects their impact on health – this will require consistent consideration for health determinants not just the presenting clinical healthcare needs.
• Recognition that in-patient treatment, including the impact of medication, can impact on a patient’s ability to make decisions.

Underpinning Behaviours – we believe that certain professionals’ behaviours enable successful hospital discharges.  

• Demonstrating kindness and flexibility is key to providing reassurance to people with MCN who have had multiple negative experiences of support services.
• Creating opportunities for friendly conversation is important to minimize the perception of care being perceived as ‘business like’ or the patient feeling unwanted in the hospital and helps to build trust.  The client will be alert to any signs that they are being judged in a negative way and will be at high risk of self-discharging.
• Be mindful of one’s own stigmatising views and unconscious bias. Be aware that factors such as workplace stress and our own health and wellbeing will have an impact on our work.  Take active steps to maintain your equilibrium and expect the workplace to support your performance through supervision, reflective practice and other means.

Tools – enabling factors that will support positive hospital discharges

• The hospital will keep details of the client’s support network.  This will include details of community-based professionals trusted by the patient to help them communicate with the hospital and likely provide care post-discharge.
• Published policy regarding MCN patients including standards relating to discharge planning.
• Explicit monitoring, and management of hospital discharges for patients with MCN.
• Training in trauma informed care for staff at all levels of the hospital to support effective engagement, communication and support for patients with MCN.
• Mechanisms for feedback that enable feedback from the voices people with lived experiences to be easily captured and learnt from with minimum bureaucracy.
• A strategy to tackle ‘self discharges’ and unplanned exits from hospitals.

Ideas

Ideas for hospital discharge protocols – tangible practices that we feel can inform hospital discharge protocols for patients with MCN

Admission

• Patients with Multiple and Complex Needs (MCN) should have a risk assessment and support plan to improve the prospects of the patient engaging with the full course of treatment and reduce risks of unscheduled discharge.
• The client’s admission paperwork will include the contact details of support staff who can help the patient communicate with the hospital and articulate their views. For patients with MCN, this may include social workers, mental health nurses, GPs, probation workers and members of the voluntary sector. The ward staff are encouraged to help the patient liaise with that support network to ensure that they are included in the whole process.
• The admission will take an overview of their housing situation, pets, family and medication. The client may need help to pack a bag or provide themselves with the things they need for a stay in hospital. 
• In an unplanned admission the multiple and complex needs of the patient will be recorded by the Accident and Emergency team (or earlier where the patient has received an initial assessment by a paramedic) and communicated to ward staff when that patient is admitted to a ward. 
• At admission, or preferably before, there will be an assessment of the patient’s safety and needs.  This assessment will include drug and alcohol use, issues concerning visitors and issues of domestic abuse.            
• We would also recommend informing the patient’s GP of the hospital admission.

As mentioned in the Mental Health Act Review 2021 (Chapter 4), we support the idea of strengthening the patient’s right to refuse and choose treatment.

We would like patients to have:

• greater influence over decisions about their care and treatment,
• their wishes and preferences respected and followed
• the opportunity to challenge their care and treatment if their wishes are not followed. 

FLSE would like to see an ‘advanced choice document’ across all healthcare sectors, physical and mental. With a system in place that communicates between services, information sharing is increased which in turn helps patients to feel more confident and less stigmatised.

We would strongly encourage for the healthcare system to introduce this trauma informed approach.

To read more about how we contributed to the Mental Health Act Review please see our blog post here.

Discharge

• We would strongly suggest that prior to discharge of a person experiencing MCN, Adult Social Care is required to assess the patient’s needs. This would include closer collaboration between discharge coordinators, social workers in hospital and Adult Social Care.
• Ideally, a multi-agency health and complex needs forum is created to discuss more vulnerable patients. This is to make sure that a support system is in place prior to discharge. This includes informing GPs and other non medical support networks of the discharge and we are aware that in Brighton & Hove there is such a forum to discuss patients with complex needs to support their care in the community – this is an approach we support.
• In our experience, patients with MCN being discharged on a Friday is difficult. This is because there is sometimes not enough time to organize and set up support for the weekend and the accommodation they may need, especially when at risk of homelessness.
• The patient’s GP would be notified of the discharge and given the community care/discharge plan.

Monitoring

• There will be a specific record kept of the steps taken to include the patients voice including specific details of what they have done differently to capture innovation.
• Patients with MCN will be recognized throughout the patient record data systems and accountability will sit with an accountable person within the hospital staff team for hospital admission and discharge of those patients with MCN.
• There will be a loop for patients to be able to provide feedback and suggestions to improve interactions.

Hopes for the future hospital discharge system

During the Connectivity Meeting, it was clear that communication between different services (NHS, social care and the Voluntary and Community Sector) is difficult.

We discovered that hospital-based social workers don’t automatically collaborate with community based social workers and information isn’t being shared with other non-medical support networks. We also learnt that the Voluntary and Community Sector services, as well as mental health services, have long waiting lists and that their services are stretched.

The group has also identified that the different systems feel silo-ed and there are few opportunities for collaboration and smooth discharge transitions into the community.

The below was an attempt to map the different services involved in hospital discharge and how these relate to each other. It prompted us to reflect on the commissioning of services to support hospital discharges and how there is an opportunity for commissioners to improve linkages between services and help the support system organise in more joined up and efficient way.

However, the group also suggested that it would be useful to improve communication between hospital, social care and community teams by introducing joined access meetings. These meetings would focus on all aspects (medical and non-medical) of the patient’s support system and that the patient would be able to join this meeting.

Our conclusion is that the hospitals need to review their discharge protocols and develop revised ways to support patients with MCN through the system. This needs to include mechanisms for joint planning with the patient and their closest support networks.

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Author: Michaela Rossmann & Rebecca Rieley