Multi-disciplinary / multi-agency discharge teams

Coordinated discharge planning based on joint assessment processes and protocols and on shared and agreed responsibilities promotes effective discharge and positive outcomes for patients.

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Some things that people have told us about what works and how to overcome the challenges

  • focus on decision-making in the right place making it a principle that assessment for long-term care should not take place in hospital
  • overcoming possible bottlenecks by not sending simple discharges to the integrated team
  • involving voluntary and community sector organisations with self-funders who may not want to talk to adult social care.