Our Services

Integrated Discharge Team

The Integrated Discharge Team was established to provide a multidisciplinary team to support and monitor the discharge process to facilitate safe and timely discharge of all patients within the trust.

The team membership primarily consists of discharge co-ordinators, workers, the Discharge Liaison Team and community matrons, all of whom are experienced nurses, along with hospital social workers. Representatives from other multidisciplinary teams are co-opted as required:

Medical staff/consultant
Ward staff
Therapists
Psychiatric nurses
Other representation from the primary care trust

Our objectives

The fundamental objective of the team is to deliver a co - ordinated, person centered service to avoid unnecessary delay to our patients discharge from hospital.

Referrals are made to the Integrated Discharge Team by ward staff via a single point of referral system.

Each day the Integrated Discharge Team meet at 12.00pm to discuss the allocation of referrals and progress to date regarding individual patients.

The priorities are to:

To promote a team approach to the proactive management of discharge planning for individual patients.
To identify and engage relevant staff groups and family members in contributing proactively to the discharge planning process for individual patients.
To ensure that all discharge planning is undertaken with consideration for dignity and rights and equality and diversity.
To review and monitor action plans where remedial steps are indicated to issues arising from the daily Integrated Discharge Team meetings.

What we do

The team works closely with community services (eg intermediate care teams, district nursing, and community equipment) to facilitate the safe and effective discharge of patients from the hospital to a community setting. Specifically this means facilitating:

An intermediate care discharge as a step-down from hospital care to a community support centre, nursing home or the patient’s own home with an appropriate rehabilitation support package.
A transitional care discharge package for patients who require a longer period of recovery ie more than six weeks, followed by rehabilitation eg patients with a long leg plaster.
A complex health care package for patients with ongoing health care needs with multiple and/ or intensive interventions eg patients with a terminal illness who require palliative care.

The team also undertake a lead role in complex social packages with particular reference to:

Adult protection issues
Carer stress or breakdown that may involve a carer’s assessment.
Unstable home situation that may include cognitive impairment, environmental issues or difficult family dynamics.

More information

If you would like further information or advice from the Integrated Discharge Team, please do not hesitate to contact us, between 9.00am -5.00pm on the following numbers: