All hospital discharges are on a ‘discharge to assess’ model.

This means that a Care Act assessment will not be completed while in hospital but after discharge has taken place.

The current process within Camden ASC is that when an adult is admitted to hospital, in most cases, the Integrated Discharge Team will lead and co-ordinate the discharge. This includes identifying carers and referral for carer assessment.

Once the discharge from hospital has taken place, the Neighbourhoods Team will resume their responsibilities for completing an annual review of care, including carer’s needs.

If a person is admitted to a hospital that is out of borough and the person does not have an allocated social worker in the Neighbourhood Team, they will be allocated to one of the out of borough social workers within that hospital team.

There are 4 pathways for patient discharge as outlined below:

Note: Fast Track and Hospices pathways are funded by NHS Continuing Healthcare (CHC) and fall outside of the below pathway model. A person requiring CHC funded care is discharged to the NHS.

Pathway 0 – Person might benefit from social prescribing and connecting with services in the community and voluntary sector, but does not require care or support from ASC

Pathway 1 – Person is discharged with a home reablement package or restarts/increases existing care package, with input from their carer. The carer’s needs is also assessed.

Pathway 2 – Person requires additional rehab or inpatient reablement in a 24 hour bedded setting. Usually, this would be St Pancras Rehabilitation Unit (SPRU) or Henderson Court Reablement flats

Pathway 3 – Person requires 24 hour interim care in a residential/care or nursing home immediately after hospital discharge

All in-borough hospitals, Royal Free, UCL hospital and SPRU have a daily Multi Disciplinary Team meetings including SWs to decide which pathway a person should be discharged on.

Discharge of people that have MH as a primary need

The above pathways 0 to 3 tend to apply to people in hospital with a physical need.

Where people are in hospital with a primary mental health need, their existing allocated worker (MH Team) supports the discharge process, with guidance from the Hospital Discharge Team.

Attached is a map showing a sequence of steps and decisions from when a person is due to be discharged, to when a placement review is carried out,.