Hospital Discharge Team
“ To provide high quality person – centred
assessment and support through effective
multi-disciplinary joint working to enable
timely and appropriate discharge planning”
Enquiries to: 01738 473115/Ext 13115
Objectives:
 To assess the patients, as appropriate, for Intermediate
Care Services.
 To support and educate all staff involved with the HDT in
relation to the HDT responsibilities.
 To support the acute ward staff in understanding the
service criteria.
 To act as a link between primary and secondary care.
 Early identification of delayed discharge patients.
Intermediate Care
Our definition:
“A service provided on a short term basis at home or in a
residential setting (usually about 6 weeks) for people who need
some degree of rehab and recuperation. Its aims are to
prevent unnecessary admission to hospital, facilitate early
discharge and prevent premature care home admission.”
(Change Team/Joint Improvement Team 2006)
Roles and Responsibilities
Hospital Discharge Team
The Hospital Discharge Team is an integrated multidisciplinary
team based within PRI. The team consists of Hospital
Discharge Nurses, Mental Health Nurses, Hospital Social
Workers and Occupational Therapists, and they provide a
service to the wards in Perth Royal Infirmary, Ninewells and
Old Age Psychiatry wards in Murray Royal Hospital. All
services are criteria driven and designed to provide the
appropriate care at the appropriate point in the patients journey
of care. The criteria are available in all ward areas in both
hospitals. The team will also provide support and advice with
complex discharge planning.
Hospital Discharge Nurses
The hospital discharge nurses are responsible for assessing
the needs of the patients referred for Community Hospital
Stepdown, Medicine for the Elderly Stepdown within PRI and
Ninewells and Palliative Care beds within the five Perth &
Kinross Community Hospitals.
Hospital Social Workers
The social workers in the team assess the needs of clients in
PRI using information from a variety of sources including
nursing and medical staff, OT’s, physiotherapists, community
workers, relatives and the client themselves. They then aim to
meet identified needs either through a care package in the
individual’s home (or alternative accommodation such as
sheltered housing) or arranging a placement in permanent
care. They also provide advice to clients and carers as
appropriate.
Hospital Mental Health Liaison Nurses
The responsibility of the mental health liaison nurses is to
provide assessment of patients presenting with dementia,
delirium or depression. These patients should be over the age
of 65 years or under if they have a diagnosis of dementia. The
assessment will assist with appropriate discharge planning and
follow up care. This service also provides support and
education to staff groups in relation to mental health.
Hospital Discharge Therapists
The Hospital Discharge therapists are responsible for
assessing and co-ordinating discharge for patients who require
Early Supported Discharge (ESD) to the Intensive Care at
Home Service (ICAHS) for Perth City and other areas where
available.
The Hospital Discharge therapists also provide a rapid
assessment occupational therapy service for A&E and the
admissions/assessment ward in PRI.
Evaluation
The Hospital Discharge Team are evaluated continuously. The
Hospital Discharge Team are happy to receive feedback on
any issue or problem encountered within any of the services.