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Discharge to assess pathway (D2A)

This page explains the care and support services available through the the discharge to assess pathway at Rutland County Council. 

 ‘For older people in particular, we know that longer stays in hospital can lead to worse health outcomes and can increase their long-term support needs. Wherever possible, people should be supported to return to their home for assessment, with alternative pathways for people who cannot go straight home.’
NHS England Publications Gateway Reference 05871

What is Discharge to Assess?

Returning home with pathway 1

Reablement service Micare team

Pathway 2 – Inpatient rehabilitation

Discharged with pathway 2

Pathway 3 - complex needs

Discharged with pathway 3

What happens to the information I share with you?

What can I do if I am unhappy with decisions made about my care and support?

What is Discharge to Assess (D2A)?

During your hospital admission the clinical practitioners will identify which D2A pathway will support your discharge when medically fit.

There are 4 pathways:

Pathway 0 Fully independent

  • Patient returns to their usual place of residence (Including care homes)
  • Fully independent – no further support required
  • Restart former package of care with no changes
  • Has pre-existing community services in place

Pathway 1 Interim care and support

  • Patient returns to usual place of residency with interim support
  • New package of Care or increase in existing package of care
  • Temporary reablement to maximise independence
  • Assessment and some additional care/support (Including therapy, equipment, nursing and domiciliary care)
  • Patient is safe between care calls and overnight

Returning home with pathway 1

D2A pathway 1 provides a 72 hour assessment period for a team of professionals to assess your support needs once home following a hospital discharge.

  • You will be provided with up to 4 calls a day of free care for the 72-hour assessment period, with our Mi Care domiciliary team.
  • A member of our Mi Care team will meet you at home to complete a first visit, agree your support needs, including the number of calls per day to help you safely settle in at home.

Assessment period

During the first 72 hours your current support needs will be assessed by our hospital discharge and therapy teams, to establish the correct services to meet your current level of support, short-term and longer-term needs.

This includes:

  • Short-term Reablement Services
  • Safetynet – a chargeable service (Means tested) while arranging a package of care, formulating a care plan and completing a financial assessment.
  • Package of care and short-term therapy support
  • Package of Care

Therapy Assessment:

  • You will receive a holistic assessment by one of our therapists within 48 hours of your discharge home to assess if our short–term reablement service would enable you to return to your former level of independence, reduce, or delay the need for on-going care.
  • The assessment will also include any equipment or minor adaptations such as a grab rail, that will support you in your recovery.

Support needs assessment:

  • A Social Worker will carry out an assessment to identify which of our services is right for you.
  • We might ask whether any of the other professionals involved in your care are to be involved, for example a community nurse.

Multi-disciplinary approach:

  • By the end of the 72-hour assessment period, our team of professionals will have a clearer idea of the appropriate service to support your current and longer-term need
  • If Reablement is assessed as the most appropriate service, the team will identify how long you will likely need to be with the reablement service which can be anything from a day to a maximum of 6 weeks. We find that on average it is between 2 to 4 weeks
  • If you have been assessed as needing on-going care, a means test will be completed.

Package of Care:

If you are entitled to services provided by social care, you have two choices:

  1. You can have home care from an independent care agency that Rutland County Council work with.
  2. You can have a Direct Payment to pay someone of your choice to help you.

If you are not eligible for services provided by social care, you will be offered advice and information to help you privately purchase any services you may want or need.

Reablement Service - MiCare Team

CQC Registration

We are registered with the Care Quality Commission - the independent regulator of health and social care in England.

You can see our latest inspection report online.

Our staff are trained in helping you in your home environment to try and regain your confidence and independence in daily activities

What is meant by Reablement?

Reablement is an intensive home care service providing trained support staff who attend your home from 1 to 4 times a day, to help you work towards getting your independence back after a period of ill health.

This is one of the services you may be offered following the initial 72 hour assessment period as part of the discharge to assess pathway.

The service aims to support you to regain your independence to remain living safely at home, managing your day to day activities, such as washing, dressing, preparing meals and managing your medication.

Reablement is a short-term service with an average duration of 2 to 4 weeks, but can be up as little as a few days or up to 6 weeks when necessary.

Please note that sometimes people are unable to regain full independence, but if you can do more for yourself, this will help maintain your general health and wellbeing.

If you are likely to require on-going care support, but may be able to regain independence in some areas of daily living, you may be offered Reablement to help reduce the numbers of care calls per day.

Do I have to pay for the Reablement Service?

The service is funded and free of any financial charge to you while you are receiving reablement support. This may be as little as one day, a couple of weeks or up to a maximum of six weeks.

What does the Reablement Service do?

A member of our therapy team will visit you at home following your hospital discharge, to work in partnership to identify and agree how we can support you to work towards achieving greater independence.

This includes:

  • Minor equipment provision & adaptations
  • Setting reablement goals

Together we will agree how Mi Care staff will support you to achieve your chosen goals during your reablement period.  Your goals will be recorded in your Reablement Plan, monitored weekly, and adapted to help you progress to gain maximum benefit from the service.

All staff will respect your views and listen to what you have to say.

What are 'Reablement Goals'?

Reablement Goals can include being able to:

  • Prepare basic and ready meals independently

  • Prepare hot and cold drinks independently

  • Manage your own medication

  • Strip wash, bath or shower independently depending on your level of mobility

  • Dress independently

  • Manage your shopping

  • Improve mobility indoors and outdoors

What kind of care and support do the Reablement Team offer?

Everything we do is designed to help you reach your optimum independence in activities of daily living.

Support workers will visit on a regular basis to help you get back on your feet.

Mi Care will provide you with an approximate time for your support worker to attend, allowing some flexibility for traffic delays. We aim to be with you as close to the call time as possible.

If you know in advance that you won’t need a visit, please let us know as soon as possible, to help with our planning.

Where minor equipment has been identified and agreed to support independence and maintain safety, we can arrange for this to be delivered to you on loan, or discuss your options for purchasing privately, or through a Direct Payment.

When does Reablement Support finish?

The service calls will reduce when:

In consultation with you, calls will be reduced as you achieve individual goals and regain independence, thereby gradually reducing the service/number of calls per day.

The service will end completely when:

  • You have achieved all reablement goals.
  • You have made consistent progress with your goals but have come to the end of the 6 weeks and have some on-going support needs.

This will be discussed with you throughout the service, as we review your progress regularly, update your reablement goals accordingly, and where appropriate plan on-going support needs prior to reablement ending.

  • You have been identified as needing on-going care provision. This can be at any point in the reablement service.

Where on-going care has been identified, a member of our hospital and discharge team will support you through the process of arranging care.

  • You are not engaging with the service
  • You no longer require the service

How is ongoing support arranged?

A financial assessment will be completed to establish if you have a financial contribution to make towards your care costs.

  • A social worker or care manager will complete a needs assessment and work with you to agree your care plan and what your package of care will include.
  • Your social worker or care manager will support you to arrange ongoing care including our in-house brokerage service where appropriate.
  • If you are assessed as self-funding your care and support, our social worker will talk you through the options available to you.

If a care agency is not immediately available to take over your care and support at the end of your reablement service, you will be offered ‘Safetynet’ services, to bridge the care until a care agency is able to start working with you.

What is Safetynet?

Safetynet is a chargeable bridging service through Rutland County Council and Mi Care to support a smooth transition onto a package of care.

  • This may be offered following the 72-hour assessment period where on-going care needs and long-term services have been identified as the most appropriate next action, or your current package of care needs increasing.
  • Equally this may be offered following a period of reablement while waiting for a care provider to start delivering your package of care or leaving hospital and waiting for your former care agency to be able to re-start your care.
  • Once you move to the ‘Safetynet’ service, you will be charged at the same rate as if you were receiving services from a care provider.
  • Safetynet is a very short-term service while care is arranged, and once an agency has been sourced you will transition across to your new care agency.

When might therapy be offered alongside a package of care?

Following the 72 hour discharge to assess assessment period, you may be offered a package of care with short-term therapy support alongside.

  • This may be offered when reablement is not the most appropriate service to meet your requirements, but therapy input may be able to improve your well-being or quality of life.

Therapy visits will be arranged with you to work on smaller goals over a duration of a few weeks.

Pathway 2 – Inpatient rehabilitation

  • Patient is transferred to a non-acute bed and received rehabilitation and assessment until able to safely return home
  • Short term bedded rehabilitation with or without reablement and assessment
  • Unsafe to be at home overnight/between care calls

Includes Specialist rehabilitation

  • Non-weight bearing pathway where you are discharged from hospital either into a residential setting or your own home with a package of care funded by health for the duration of your non-weight bearing status.

Discharged with Pathway 2

When you are discharged from hospital using pathway 2 the hospital ward will send your referral to our Hospital Discharge Team for triage.

  • You will receive a holistic assessment by our Social Workers and/or our integrated In-Reach Nurses to identify your discharge needs, which will be discussed with you and your family/main carer.
  • This may include arranging placement or a package of Care, funded by health for the duration of your non-weight bearing period.
  • You will have a weekly review by a Social worker and/or an In Reach nurse and continue on the non-weight bearing pathway until the hospital team have reviewed and ended your non weight bearing period.
  • Once your non-weight bearing period ends you will be offered the most appropriate service to meet your on-going needs:

Either:

  1. Reablement to support you to become more independent and reduce or delay the need for an on-going care.

  1. An ongoing package of care if appropriate with a financial assessment to assess eligibility for council funded care with or without therapy input depending on assessment outcome.

Pathway 3 – Complex needs

  • Patient is transferred to a new long term bed, assessment bed or usual residence and receives the complex support and/or assessment for their needs.
  • Complex/significant health and/or social needs in usual residency or significant change requiring new placement.
  • Longer term placement
  • Life changing health care needs
  • Complex end of life or mental health needs.
  • Complex housing and homeless needs
  • Live in care or more than QDS POC with multi professional input

Discharged  with Pathway 3

When you are discharged from hospital using pathway 3 your referral from the ward will be sent to our hospital discharge team for triage. You will receive a holistic assessment and the recommended discharge destination will be discussed with you, your family, and/or main carer.

You may be offered a package of care or an assessment bed on a short-term basis funded by health for the duration of your assessment period. This is to enable further out of hospital assessments to be completed to:

  • Identify ongoing care needs
  • Offer a period of recuperation/recovery

This can be placement in a 24 hour care setting, or your own home if safe to do so, and often includes the completion of a Continuing health care (CHC) checklist once you are medically stable.

You will have a weekly review by your In-Reach nurse and/or Social worker

Where appropriate a Decision Support Tool (DST) will be completed by Continuing Health Care to identify on-going health and social care needs. Once this has been completed and the outcome is known you may be offered:

  1. Long-term placement
  2. A package of Care funded by health, or social care following financial means test or both where there are identified health and social care needs.

If you are above the financial threshold for Social care funding, you will need to contribute towards, or pay in full the cost of your package of care that meets your social care needs.

Further information can be accessed with the following links:

www.nhs.uk

 www.gov.uk

What happens to the information I share with you?

All information given will be treated sensitively and confidentially.

However it is sometimes helpful to share relevant information with other health and social care colleagues.

If you do not want this to happen please let us know.

What can I do if I am unhappy with decisions made about my care and support?

We welcome feedback that assists us to provide an outstanding service. If we are not meeting your needs or expectations we would encourage you to let us know.

If you feel able to, please talk through your concerns with the people directly involved and see if you can resolve the issue together.

If you are unhappy with a decision that has been made about your care and support, you may be able to appeal against the decision.

Contact the Council on 01572 722 577 or email us using enquries@rutland.gov.uk to find out if you are able to appeal.

If you are still unhappy, you can make a complaint to Rutland County Council. Making a complaint will not adversely affect the care and support services you receive or how you are treated by us.

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