Home First is the Manchester and Trafford Local Care Organisations and system partners’ approach to hospital discharge improvement.

A key part of our role in the LCO is to avoid people going in to hospital. If they do need hospital care for a period of time then we work with the hospitals to get them home or back in the community as soon as possible.

We have several approaches to support this work. This includes establishing Manchester and Trafford centralised discharge control rooms which coordinate all hospital discharges. Health and social care staff work together in the control rooms to expedite discharges and solve problems that may delay a patient’s discharge.

A range of other work has been carried out as part of what we called the Resilient Discharge Programme – developing strengths based approaches to discharge.

• You can find a range of Home First Resources on this page including our Resource Guide and staff video
• These are also available on the MFT staff intranet/extranet (look under hospitals/MCS in the LCO section).

Home First video

All hospital staff are encouraged to watch the Home First at MFT video (10 mins) that provides an overview of the Home First approach and useful information and case studies on how to plan for discharge.

Home First back to basics discharge resource guide

The Home First resource guide is an informative training booklet for ward staff. It includes practical steps and advice on strengths-based discharge, guides to pathways, community services and much more. It is based on real work in the hospitals to improve discharge processes.

• Home First Resource Guide [PDF, 770KB]

Other useful resources

Discharge to Access (D2A) Pathways [PPT, 102KB]

National Discharge Leaflets [Word doc, 115KB]

The Alternatives to Admission Guides are a regularly updated single page handy guide to core services that primary care and hospital staff can use to direct patients to other services. Includes contacts for community services, mental health, eye care and VCSE sector. There are guides for each locality:

• North Manchester (NMGH) Alternatives to Admission Dec 2023 [PDF]
• Central Manchester (MRI) Alternatives to Admission Dec 2023 [PDF]
• South Manchester (Wythenshawe) Alternatives to Admission Dec 2023 [PDF]
• Trafford Alternatives to Admission Dec 2023 [PDF].

The guides do not currently include information on the new expanding Hospital at Home services which you can find here for North Manchester Hospital at Home and here for Central Manchester Hospital at Home.

If you find any incorrect information at all in these guides please contact communications@manchesterlco.org

• You can find more information on North Manchester Hospital at Home here
• You can find more information on Central Manchester Hospital at Home here.

South Manchester is following in the next few weeks (Dec 2023/Jan 2024) and plans are also being developed for Trafford residents in 2024.

Pathway 1 – Support to recover at home

Pathway 1 (P1) is for people who need additional short-term support at home. This might include short-term therapy, nursing or medical support to get back to independence. For those with less rehab potential, P1 is also used to trial a package of care in the short-term to assess longer-term needs.

• Patient returns to usual place of residence with some additional support.
• May include short-term therapy, nursing or medical support to get back to independence.
• Also includes a restarting a lapsed existing Package of Care (POC) through the locality discharge control room.
• Pathway 1 is likely to account for around 45% of discharges
• Can include when a new care package required, an increase to existing package or restart of existing package of care that has lapsed due to admission (>48 hours)
• Includes temporary Reablement to maximise independence
• Includes nursing/therapy assessment/intervention.

Once a referral has been sent from the acute hospital control room, teams will work with Reablement services to identify if Reablement or a commissioned package of care is most appropriate and source this care.

The patient will be contacted within the first 1-2 days following discharge to make sure they are home safely and they will be allocated a social worker/social care assessor within 48 hours of returning home to review care needs following hospital discharge.

Above information available to download here:
Pathway 1 [Word doc, 25KB]

Pathway 2 – Rehab or short-term care in a bedded setting

Pathway 2 (P2) is for people who need a period of rehab in a bed based service. Bedded care is only for people who are not safe between care visits in the community. Some people will go to a rehab community bed to recover, reable and rehabilitate. Others might go to an interim bed while home care is sourced, a social issue is resolved, or to assess whether they need a long-term bed.

• Patients transferred to a non-acute bed for a period of rehabilitation before returning home.
• 4% of discharges
• Short-term rehabilitation to maximise potential.
• Bedded assessment for health and/or care needs to return home.

Referral to be completed on a Greater Manchester Supported discharge form by therapy staff with input from wider MDT as required and send to the relevant hospital single point of access email.

Manchester Intermediate care offer is a city wider offer, although control room team will attempt to place a patient if they have a preference this is often not possible.

In Manchester the units include:

Crumpsall Vale
North Manchester General Hospital
Delaunays Road
Crumpsall
Manchester
M8 5RB

Buccleuch Lodge Intermediate Care
Elizabeth Slinger Road
Manchester
M20 2XA

Central Manchester Intermediate Care
Delamere Unit
Gorton Parks
121 Taylor Street
Gorton
M18 8DF

For Trafford residents Pathway 2 bedded rehab is provided at

Ascot House
Ascot Avenue
Sale
M33 4GT

Above information available to download here:
Pathway 2 [Word doc, 25KB]

Pathway 3 – People discharged to long-term bed-based care.

Pathway 3 (P3) is often for people who have had a life changing event, have been through other pathways multiple times or are approaching the end of their life and may sadly be likely to quickly decline.

• Pathway 3 is a discharge to a care home for patients who are likely to require long-term bed-based care.
• Patients who have had a life changing event or have been through other pathways multiple times.

Process

• Once the pathway has been identified by the MDT, a member of the hospital integrated discharge team will lead on the completion of the referral utilising the Greater Manchester Supported Discharge Form
• Input may be required from extended members of the MDT to support the assessment and/or Mental capacity if required
• Once complete the referral is sent to the relevant local authority who will lead on the sourcing of a pathway 3 placement
• Referrals should be sent to the relevant hospitals’ single point of access email address.

North Manchester General Hospital – noticetoassess@manchester.gov.uk

Manchester Royal Infirmary- LL.discharge2assessMRI@mft.nhs.uk

WTWA – wythenshawecontactofficer@mft.nhs.uk

Key communication points to consider prior to completion of a pathway 3 referral.

The basic for good practise is to involve patients and their representatives in discharge planning from the earliest opportunity. By keeping them informed throughout the discharge journey and confidently explaining the discharge to assess process further choice issues can be avoided.

• All relevant discharge information leaflets should be provided to patients and their representatives at the earliest opportunity, leaflets form a part of the communication but do not replace regular effective, transparent engage with patients from all members of the MDT.
• A pathway 3 bed is for patients who are likely to require long-term bed-based care who have had a life changing event or have been through other pathways multiple times. It is a temporary move to a discharge to assess bed, based in a care home for a period of up to 28 days, this will likely be one of our contracted D2A beds
• The choice that patients have is to opt out of D2A, if they opt in then this means they agree that the first appropriate placement found will be accepted
• During this time, they will be visited by health and social care workers who will assess them to decide what care they need long-term you will be allocated a social worker within 48 hours of discharge to progress from the temporary plan to a long-term plan
• The temporary bed will be at the first home that has availability and is able to manage the assessed needs, this may be out of the local areas if there are limited beds that can meet specific needs
• Staying in hospital to find a home of choice is not an option because beds in the acute hospital are needed for people who are acutely unwell and the longer you stay in hospital the greater the risk of hospital acquired infections and general deconditioning
• Once they are in a D2A bed the team will work with the patient and family to find a long-term care home which they will be able to choose that suits all the needs
• The D2A bed will be paid for by the local authority until all the long-term assessments are completed (usually less than 28 days)
• Local authorities will try and place in home CQC rated as good – however there are occasions where a home rated as requires improvement may be considered if the local authority is assured through due diligence/improvement work undertaken that the home is suitable.

Above information available to download here:
Pathway 3 [Word doc, 25KB]

Service information on community services

All LCO community services including crisis response and Hospital at Home have pages with referral information on the LCO websites. You can find them here:

• Manchester services
• Trafford services.

Hive is the MFT electronic patient record system and has brought a range of functionality to support effective discharge. This includes Board Round functions that can support effective discharge planning.

All information can be found on the HIVE MFT intranet page here.

The service provides ‘one off’ cleaning in domestic properties that do not meet acceptable health and safety standards. Referrers do need to consider what ongoing support someone may need in managing their hoarding behaviours. Where a property is extremely cluttered due to a long period of hoarding, referrers need to consider if Crisis Clean is right service to support that citizen.

Crisis Clean Criteria Full Information [Word doc, 37KB]

MCC Adult Social Care Crisis Clean [PPT, 127KB]

Contents

1. Crisis Clean Service Criteria
2. Crisis Clean Service Specification
3. Consent
4. Access to Properties
5. Funding

1. Crisis Clean Service Criteria

In order to access the Crisis Clean Service citizens must meet the following criteria

• Must be over 18 years old
• Must reside in the City of Manchester. The service does not cover other Greater Manchester boroughs
• Must be intending to reside in the property for at least a further 6 months at the time of the referral
• Must be able to give consent or have an advocate or Power of Attorney who can give consent on their behalf

2. Crisis Clean Service Specification

The service provides ‘one off’ cleaning in domestic properties that do not meet acceptable health and safety standards. This includes

• Where an individual is at risk due to the environmental conditions they are living in
• To enable a person to return home to a safe environment; from hospital, residential care or staying with family or friends.
• When health and social care staff or other professionals are unable to go in to provide a service on health and safety grounds.
• Where an individual’s tenancy is ‘at risk’ due to the environmental condition of the property.

Where a property is extremely cluttered due to a long period of hoarding, referrers need to consider if Crisis Clean is right service to support that citizen. Crisis Clean is a ‘one off’ service so referrers do need to consider what ongoing support someone may need in managing their hoarding behaviours.

Crisis Clean will support citizens who hoard but referrers need to be realistic about what can be achieved in a short period of time and be specific about what tasks and outcomes they want from the clean.

If the job will take more than 2 shifts it is too big for us to take on.

Tasks that the Crisis Clean service can support with:

Any tasks that Crisis Clean are to undertake must be specified on the referral form and agreed prior to the clean commencing. This includes:

• General/ deep household cleaning of kitchens, bathrooms, bedrooms and reception rooms
• Removal of unwanted clutter and smaller furniture items, within reason.

Tasks that the Crisis Clean service does NOT support with:

• Any type of decoration, DIY or home improvements
• Clearing of garden areas or garden rubbish
• Removal of large items of furniture or carpets
• Change curtains, wash windows or do any type of laundry
• Defrost fridges or freezers
• Dispose of out-of-date medication
• Full house clearances
• Clearance of individual rooms that are not in use, and do not affect the safety of staff/citizen.

3. Consent

The Crisis Clean service needs to have written agreement to work in citizen’s properties.

Wherever possible this should come from the citizen themselves.

If this is not possible, this must come from someone acting on their behalf. This may be an agreed friend or family member, or it could be someone professionally involved, acting as their advocate.

The Crisis Clean service will normally only dispose of unwanted items when the citizen or their advocate is present to agree what is being removed.

If it is not possible for the citizen or their advocate to be present at the time of the clean, staff will only dispose of items where specific written permission has been given to do this.

4. Access to Properties

It is preferable that either the citizen or their advocate is present in the property while the clean takes place.

If this is not possible, it is up to the referrer to arrange access for the Crisis Clean workers.

The Crisis Clean service do not hold, drop off or pick up keys. Referrers can drop off keys at the Crisis Clean office before 9.00am on the day of the clean but must ensure they pick them up before 4.30pm on the same day as there is no secure storage facilities for keys. This must be agreed prior to the day of the clean.

In the case where Crisis Clean workers cannot again access to a property on the agreed day, the referral will be cancelled.

In the case where Crisis Clean workers cannot gain access to a property on the agreed day, for services where charges apply (see section 5: Funding and Costs) a charge of one hour will still apply plus the cost of any skip hire.

5. Funding and Costs

The Crisis Clean service is funded by Manchester City Council’s Adult Services Division. Due to this there is no additional charge for referrals from teams that sit within this Division.

For referrals from any other services the following charges apply:

Hourly Rate: £45

Skip Hire (if required) £290

No Access Charge: £45 plus any skip hire cost

Funding must be agreed /approved by the budget holder prior to the clean taking place.

Invoices will be issued via SAP once the clean has been completed.

What is Home from Hospital?

Home from Hospital is a voluntary sector service that supports patients leaving hospital who need that extra bit of support to settle back at home. Many patients may have struggled at home prior to admission. Typical issues include homes being unheated, not having utility funding, no food in the property and basic adaptations. Home from Hospital responds to these kind of needs and resettles patients back home with enough support for up to 4 weeks. They provide regular face to face contact and telephone support to respond to issues quickly. Services also include transport on discharge, pet care and more.

Providers and referral contacts

There are 3 providers of Home from Hospital services across MFT for residents of Manchester and Trafford:

• Manchester Care and Repair (North Manchester General Hospital – all pathways supported)
• Age UK Manchester (MRI and Wythenshawe Hospital – all pathways supported)
• Royal Voluntary Service (MRI only – pathway 0 supported only).

Full information of what is available on each site – including referral contacts and provision available – here:
Home from Hospital Winter 2023 [PDF, 381KB]

Discharge for patients with palliative and end of life care needs

Discharge planning for patients with palliative and end of life care needs can be complex. Additional measures should be taken to ensure all aspects of care are considered in the context of the patient’s condition, current phase of illness and in anticipation of deterioration.

This document will outline some of the key elements to consider when planning a discharge for a person with palliative and end of life care needs and will refer to useful resources that may be required for discharge.

NHS Fast Track for NHS Continuing Care

When a patient has a primary health care need arising from a rapidly deteriorating condition and an increased level of dependency, then they can be fast tracked for NHS Continuing Healthcare (a package of care or 24 hour nursing care home, arranged and funded by the NHS).

Completing the fast track assessment tool ensures that these individuals have continuing healthcare funding approved without delay, enabling them to be supported in their preferred place of care as quickly as possible without encountering any delays.

A referral to the hospital discharge planning team will be required to complete the necessary assessment and application for a fast track NHS continuing care funded discharge.

Rapid Discharge at the End of Life

This is a process to support the safe and timely discharge of patients who are thought to be actively dying in the last hours to days of life to their preferred place of death in the community. Part of this process typically involves applying for fast track NHS continuing healthcare funding, although the care may not be readily available at the point of discharge. In such an event, this should be clearly communicated to the patient where possible and to those closest to the patient.

A prompt referral to the hospital discharge planning team should be made as soon as it is determined that a patient requires a rapid discharge to die to their preferred place of death.

As rapid discharges are for patients recognised to be in the last hours or days of life, there is a risk that the patient may die whilst the discharge is being planned, during the transfer or shortly after arriving at their preferred destination. This risk should be clearly and sensitively communicated with the patient where possible and those closest to the patient, with a discussion on what would happen in that instance.

ReSPECT form

The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is a document that outlines personalised recommendations for a person’s goals of care and ceiling of treatment (including resuscitation) in a future emergency in which they are unable to make or express choices. It is created following discussions between the person and/or persons they’ve identified as important to them and their healthcare professionals.

It is valid in both hospital and community settings. If a patient is admitted to hospital with a ReSPECT form or uDNACPR form, a copy of this should be scanned in to HIVE and the original returned to the patient. Whilst in hospital a new version should be created in HIVE detailing the existing information and decisions, inclusive of any additional information or decisions made whilst an inpatient. At the point of discharge the ReSPECT form should be printed and this copy should then be signed by a doctor of an appropriate grade and discharged with the patient.

Statement of Intent

The aim of this document is to prevent the unnecessary attendance of the police in circumstances where a death has been anticipated (and does not need referral to coroner), but occurs at a time when the patient’s regular GP has not seen the patient in the last 14 days or is not immediately available to issue a Medical Certificate Cause of Death (MCCD).

If a patient is discharged home supported by the rapid discharge process, expected to die, and does not need referral to the coroner, the GP should review the patient as soon after discharge as possible to issue this.

A ‘bridging statement of intent’ can be issued in the meantime by an MFT doctor declaring they will be available as a medical practitioner to issue a medical certificate cause of death until such a time the GP has reviewed the patient and completed a Statement of intent. On occasions this may not be possible if there is not a medical practitioner available to issue the MCCD and therefore this should be highlighted to the patient’s community healthcare team including the GP prior to discharge to ensure a GP visit can be arranged as soon as possible.

TTO and Anticipatory Medications

Prior to discharging patients with longer term palliative care needs and those patients being supported with a fast track or rapid discharge at the end of life, it is important to review medications in the context of the persons condition and current phase of illness. Patients with palliative care needs should have their medications reviewed regularly to prevent polypharmacy and to ensure their medication regime remains appropriate for their needs. Any decision to modify or discontinue medications should be discussed where possible with the patient.

When a patient is recognised to be in the final hours or days of life it is important to review their medication regime and consider discontinuing non-essential medications and make plans for suitable alternatives for those medications considered essential, even when the oral route may no longer be reliable.

In addition to prescribing and supplying a patient’s regular regime of medications it is important to prescribe medications that may be required to treat any symptoms a patient may experience in the last hours – days of their life. They are given via the subcutaneous route and will need prescribing on the patient’s TTO.   In addition to the supply of these medications, the direction to administer form should be completed to enable district nurses to administer them in the community setting.

These medications need to be prescribed on an individual basis following an appropriate assessment.

Patients requiring a syringe pump to support their symptom management should have these medications prescribed and supplied on their take home medication regime and the appropriate direction to administer form completed for the district nurses to be able to administer the infusion.

Prior to discharge, the syringe pump should be replenished to ensure the infusion does not run out before the district nurses are able to visit. When the district nurses visit the patient, they should replenish the syringe pump and change to a community device. Arrangements should be made to return the pump to the discharging hospital as per the local agreement.

Equipment

All patients with palliative care needs, and those having a rapid discharge home at the end of life should have equipment needed for discharge in place prior to discharge, unless otherwise discussed and agreed with the patient and those important to them; this may include practical equipment such as mobility aids, but may also include oxygen, suction machines and nebulisers.

Communication and Referrals

All patients with palliative care needs, and those having a rapid discharge home at the end of life should, with permission, be referred to the district nursing team; this supports the transition of care and ensures patients and those important to them are supported following a hospital admission.

All patients with palliative care needs, and those having a rapid discharge home at the end of life should have contact numbers for community teams they may need after discharge, particularly out of hours such as district nurses and GP. Ensure the patient and/or those important to them have these numbers.

All patients with palliative care needs, and those having a rapid discharge home at the end of life should have a discharge summary that reflects the events of the inpatient episode, their phase of illness, and any recommended follow up for the GP to note. If the patient is going home supported by a rapid discharge at the end of life, then the clinical team looking after the patient should phone the GP within working hours ahead of the discharge to ensure a visit can be planned as close to the discharge as possible.

Download the Palliative Care Discharge Policy [Word doc, 33KB]

For patients who live outside the Manchester and Trafford areas, early contact should be made with their relevant locality as soon as possible to plan discharge and make arrangements. 

GM locality discharge contact details

PTL Charter – Sept 2023 [PPT, 197KB]

Transfer of Care Hub [PPT, 90KB]

Glossary of Terms

Discharge to Assess (D2A)

An approach to intermediate care in which people are discharged from hospital as soon as medically ready so that long-term assessment can take place at or close to home instead of waiting to have that assessment while still in hospital.

Expected Discharge Date (EDD)

This is the date the patient leaves the hospital this should be moved as necessary to align with the clinical and discharge progress information. This should be recorded on HIVE

Criteria to Reside

Every person on every general ward should be reviewed on a twice-daily ward round to determine the following and recorded on HIVE. If the answer to each question is ‘no’, active consideration for discharge to a less acute setting must be made:

• requiring ITU or HDU care?
• requiring oxygen therapy/NIV?
• requiring intravenous fluids?
• NEWS2 greater than 3? (Clinical judgement required in persons with AF and/or chronic respiratory disease)
• diminished level of consciousness where recovery realistic?
• acute functional impairment in excess of home/community care provision?
• last hours of life?
• requiring intravenous medication > b.d. (including analgesia)?
• undergone lower limb surgery within 48 hours?
• undergone thorax-abdominal or pelvic surgery with 72 hours?
• within 24 hours of an invasive procedure? (With attendant risk of acute life- threatening deterioration)

Clinical exceptions will occur but must be warranted and justified. Recording the rationale will assist meaningful, time efficient review.

Strengths based approach.

A strengths-based approach focuses on an individuals’ strengths (including personal strengths and social and community networks) and not on their deficits. Strengths-based practice is holistic and multidisciplinary and works with the individual to promote their wellbeing.

It is an approach to working with a person that focuses on what they or their support network can do rather than approaching it from the perspective of what they cannot do.

Download Glossary of Terms [Word doc, 152KB]

The District Nursing service delivers holistic quality assured nursing care to those aged 18 and over living in Manchester to ensure that patients and their carers are able to maximise their independence and to remain at home whenever possible.

City Wide District Nursing

North Manchester District Nursing

Central District Nursing

South Manchester District Nursing