The Integrated Discharge Team (IDT) is an integrated multi-disciplinary team of social care professionals, nurses, and discharge trackers who triage patients and provide them with information on accessing services aiming to support their discharge from hospital.
This may include:
- rehabilitation to be provided in a person’s home or in a care home environment
- care support as part of a re-ablement care package or domiciliary care
- provision of nursing and complex healthcare to support the discharge from hospital to their own home, a care home environment or assessment of an alternative suitable discharge destination.
All referrals are sent by the hospital staff caring for the patient on the ward via the IDT Gateway.
What happens after referral?
- The IDT team will screen the referrals and decide on a suitable pathway for the patient.
- For some patients the pathway is clear and we process that referral to the team who will pick up those needs at the point of discharge (Short Term Assessment and Rehabilitation – STAR – and Home First).
- If a patient is suitable for a T2A bed the team speak to the person and gain consent, a Transfer of Care (ToC) form is completed will be sent to the most suitable care home provider for consideration. The team then advise the ward regarding the discharge process.
- If the provider feels they cannot meet the needs of a patient then the transfer of care is sent back to IDT. It will then be sent to the next provider for consideration and the ward are updated.
- The team also complete assessments in hospital for people who need to remain an inpatient to support discharge.
- The team also process and send referrals to the correct locality for “out of area” patients having treatment within the hospital.
What happens whilst under the care of the IDT team?
- The IDT team attend ward board rounds and support the ward team with an understanding of community services which can support discharge.
- Triage and process referrals to Single Point of Access and Referral to Community Services Integrated Gateway Team (SPARCS).
- Attend and update the hospital on planned discharge as part of bed management and support ward staff with discharges.
- Meet with individuals and gain consent to moves out of the hospital to Care Environments, complete ToCs and support with the transfer of patients from the hospital to these settings.
- Complete health or social care assessments to process and support access to domiciliary care and Continuing Health Care (CHC) funded support.
- Where longer term placements are necessary, options will be discussed with the patient and their family to facilitate the move to a suitable discharge destination.
Who is suitable for referral?
- Patients who are not managing well with their current package of care and require assessment to establish what their new needs are.
- Patients who have had numerous hospital admissions and are felt to be vulnerable or frail.
- Patients requiring stabilisation and recovery from an episode of ill-health or due to their hospitalisation, for targeted person-centred care, support and therapies to enable them to return home or to an alternative setting.
- Patients who are in hospital and have been assessed as medically optimised but who may not yet be at a functional level for discharge home. These patients will require on-going therapy and social work input in order to establish a baseline for discharge planning. Patients who need assessment of their health care needs to support hospital discharges.
Who is unsuitable for referral?
- Patients who are too acutely unwell to establish if they have health and / or social care needs.
- Patients that do not have health and or social care needs.
- Patients who do not consent to the referral but have the capacity to understand the purpose of the referral.
The IDT is a shared service of Wirral University Teaching Hospital NHS Foundation Trust and Wirral Community Health and Care NHS Foundation Trust.