As discussed in section 2.3, early assessment of discharge needs and the involvement of patients and carers are important in discharge planning. Discharge planning should be divided into three parts: pre-discharge, actual discharge and post-discharge.

5.1 Pre-discharge

For many stroke patients and their carers the transition between the protective environment of the hospital to independence at home can be an overwhelming and challenging experience.

The pre-discharge process should involve the patient and carer(s), the primary care team, social services and allied health professionals (AHPs). It should take account of the domestic circumstances of the patient, or if the patient lives in residential or sheltered care, the facilities available there.

A nominated key worker should be identified at this time.

Essential alterations to the patient’s home should be completed and necessary aids installed prior to discharge.

5.1.1 PRE-DISCHARGE HOME VISITS

Pre-discharge home visits are often considered a vital part of the discharge planning process.¹⁶¹ Evidence level 4

Pre-discharge home visits performed by various members of the multidisciplinary team aim to give staff (hospital and community), stroke patients and carers the opportunity to identify actual and likely problems, as well as to address any other needs that the stroke patient/ carer may have. Evidence level 4

The UK College of Occupational Therapists defines a home visit as a visit to the home of a hospital inpatient which involves an occupational therapist in accompanying the consumer to assess his/ her ability to function independently within the home environment or to assess the potential for the consumer to be as independent as possible with the support of carers.¹⁶² Evidence level 4

To date there is no evidence to inform the practice of pre-discharge home-visit assessments. Evidence level 4

Pre-discharge home visits should be available for patients that require them.

5.2 Discharge

5.2.1 DISCHARGE PLANNING AND TRANSFER OF CARE

Discharge planning should be documented in a discharge document (example shown in Annex 2). Discharge documents may be paper or electronic (e.g. in Electronic Clinical Communications Implementation (ECCI) format).

The following information should be accurately and legibly displayed in the discharge documents:

• Diagnosis(es)
• Investigations and results
• Medication and duration of treatment if applicable
• Levels of achievement, ability and recovery
• Team care plan
• Further investigations needed at primary care level with dates
• Further investigations needed at hospital and dates
• Further hospital attendance with dates
• Transport arrangements
• The trust name, trust telephone number, ward name or number, ward telephone number, consultant’s name, named nurse and key worker
• The date of admission and discharge.

Consideration should be given to such information being retained by the patient as a patient-held record, to allow all members of the primary care team, AHPs and care agencies to clearly see what the care plan for the patient should be. The wishes of the patient in respect of the confidentiality of this record should be paramount. There is evidence that patient-held records may enhance the patient’s understanding and involvement in their care.¹⁶³ There is also evidence to show that discharge planning increases patient satisfaction.¹⁶⁴ Evidence level 1+,4

The discharge document should have a minimum font size of 12 or larger as appropriate for those with visual impairment. Medical terminology given to patients or their carers should be in plain English, and discussed with the patient. The form must be signed by the staff member giving the information, and by the patient or their relative/ carer. Any information that has been given to the patient or their carer(s) should be included in the information given to the General Practitioner (GP).

At the time of discharge, the discharge document should be sent to all the relevant agencies and teams.

5.3 Post-discharge

Post-discharge, the members of the primary care team, AHPs, care agencies and the patient and carer(s), should continue to assess the progress of the patient. In the event that there is cause for concern, the key worker is responsible for the appropriate referral of the patient to the correct team member or agency for assessment or treatment of the problem. This may include referral for re-admission to hospital. Voluntary services or charities (e.g. CHSS) provide a variety of different support schemes including stroke clubs, day care and respite (see section 7.5).

5.3.1 RETURNING TO WORK

Patients planning to return to work should speak to the rehabilitation team who can advise them on such issues as when to return, how to gradually increase hours in order to cope with fatigue and what kinds of duties would be most and least suitable in the first instance.

The team may be able to help the patient to negotiate with employers or occupational health departments. Help is also available from disability employment advisers at local job centres and from learning support departments at some local colleges. In addition some areas have specialist organisations offering employment support (see section 7.5).