Stage 5: discharge and transferring care

Chronic heart failure in adults: diagnosis and management

1.1.5 People with heart failure should generally be discharged from hospital only when their clinical condition is stable and the management plan is optimised. Timing of discharge should take into account the wishes of the person and their family or carer, and the level of care and support that can be provided in the community.
1.9.1 Offer people with heart failure a personalised, evidence based cardiac rehabilitation programme, unless their condition is unstable.

1.1.6 Home hazard and safety intervention.
1.1.6.1 Older people who have received treatment in hospital following a fall should be offered a home hazard assessment and safety intervention/modifications by a suitably trained healthcare professional. Normally this should be part of discharge planning and be carried out within a timescale agreed by the patient or carer and appropriate members of the health care team.
1.1.6.2 Home hazard assessment is shown to be effective only in conjunction with follow up and intervention, not in isolation.

1.1.1 Ensure that intermediate care practitioners: develop goals in a collaborative way that optimises independence and wellbeing adopt a person-centred approach, taking into account cultural differences and preferences.
1.1.2 At all stages of assessment and delivery, ensure good communication between intermediate care practitioners and: other agencies people using the service and their families and carers.
1.1.3 Intermediate care practitioners should: work in partnership with the person to find out what they want to achieve and understand what motivates them to focus on the person's own strengths and help them realise their potential to regain independence build the person's knowledge, skills, resilience and confidence learn to observe and guide and not automatically intervene, even when the person is struggling to perform an activity, such as dressing themselves or preparing a snack support positive risk-taking.
1.7 Transition from intermediate care.

1.5.2 Ensure staff in contact with older people are aware of the importance of maintaining and improving their independence and mental wellbeing.
1.5.3 Ensure staff in contact with older people can identify those most at risk of a decline in their independence and mental wellbeing. This includes being aware that certain life events or circumstances are more likely to increase the risk of decline. For example, older people whose partner has died in the past 2 years are at risk. Others at risk include those who: are carers, live alone and have little opportunity to socialise, have recently separated or divorced, have recently retired, were unemployed in later life, have low income, have recently experienced or developed a health problem, have had to give up driving, Have an age related disability, are aged 80 or older.

1.1 Ensuring care is person centred.
1.1.1 Ensure services support the aspirations, goals and priorities of each person, rather than providing 'one size fits all' services.
1.1.2 Ensure support focuses on what people can or would like to do to maintain their independence, not only on what they cannot do. Recognise: that people have preferences, aspirations and potential throughout their lives and that people with cognitive impairment and those living alone might be at higher risk of having unmet social care‑related quality of life needs or worse psychological outcomes.

1.2 Medicines-related communication systems when moving from one care setting to another.
1.5 Self-management plans.
1.8.2 Organisations should involve a pharmacist with relevant clinical knowledge and skills when making strategic decisions about medicines use or when developing care pathways that involve medicines use.

1.1 Overarching principles of care and support during transition.
1.5.25 Ensure that older people with identified social care needs are offered early supported discharge with a home care and rehabilitation package.
1.5.26 Consider early supported discharge with a home care and rehabilitation package provided by a community based multidisciplinary team for adults with identified social care needs.