Implementing a successful transition of care from hospital to home needs careful planning. The aim of this planning is to ensure that the child’s care is continuous and the parents receive the support and education that enables them to provide safe care without undue stress. The aim should be to have the first discharge meeting as soon as possible to plan for the child's discharge from hospital.
NHS Lothian (2009) identified the principles of good discharge planning and these include:
Children & young people and their parents or carers must be fully and actively involved in discharge assessment, planning and decision-making.
Assessment and planning should consider the whole child and not just healthcare needs.
Ward staff should identify on admission any child or family with additional needs and any key contacts that help coordinate care at home. This may be the child’s Named Person and/or Lead Professional (GIRFEC), community or specialist children’s nurse, or other professional. The key contacts should be informed of the child’s admission by the next working day.
Children and families should have their homecare needs assessed on or before admission, or as soon as possible after recognition of an ongoing care need. Early identification of complex discharges is vital in avoiding discharge delay.
Responsibility for initiating and coordinating discharge planning lies at ward level, for those with more complex needs ward staff need to work in partnership with other professionals.
Each child will have an identified member of hospital staff responsible for coordinating discharge planning.This may be a named nurse, specialist nurse or other clearly identified individual.
There should be evidence of the ‘Child’s Plan’ with actions, outcomes, timescales and responsibility, Named Person and Lead Professional