The National Institute for Health and Care Excellence (NICE) has issued new guidance on how to create closer communication between health and social care teams, including GPs, in order to stop the ‘revolving door of care’ for adults in hospital with social care needs.
The NICE guidance also advises how to create closer communication between health and social care teams. This includes GPs and other relevant practitioners who are responsible for transferring people to hospital (including care home managers) sharing all appropriate information with the hospital when a person with social care needs is admitted.
It recommends that out-of-hours GPs responsible for transferring people into hospital should ensure that the admitting team is given all available relevant information, including advance care plans, behavioural issues (triggers to certain behaviours), communication needs, communication passport, current medicines, hospital passport, housing status, named carers, and next of kin, other profiles containing important information about the person's needs and wishes and their preferred places of care.
In line with this, hospitals need to appoint a single discharge coordinator, who would be the main point of contact for the patient/their family/other health professionals, sharing updates on the person’s health and working with the hospital and community-based teams to agree a discharge plan.
After discharge, the hospital-based doctor responsible for the person's care should ensure that the discharge summary is made available to the person's GP within 24 hours, and a GP or community-based nurse should phone or visit people at risk of readmission 24–72 hours after they leave hospital, the guidance said.
However, NICE also called for more data on the effectiveness of models of multiagency working, and how GPs can support transitions from hospital to the community for this population.
According to the latest information from the National Audit Office, one million people were readmitted to hospital as an emergency within 30 days of discharge in 2012-13, costing the NHS £2.4 billion.
Tony Hunter, chief executive of the Social Care Institute for Excellence (SCIE), said: “It’s really good that the guideline focuses on what should happen in hospital, from admission onwards and throughout someone’s stay, so that their discharge isn’t rushed or unplanned. We’re keen to encourage good collaboration between health and social care and people’s experience of transition between hospital and home is a key indicator on how well integration is working.”
See the full guidance here