Discharge to Assess

Discharge to Assess (DTA) is a dynamic and multi-skilled team consisting of nurses, social workers, occupational therapists, physiotherapists, community care workers and support workers. Our purpose is to support a safe and timely hospital discharge of people who are medically fit, and no longer need hospital care, to a place more suitable to the person’s needs. Assessments and care provision can then be tailored to support people to regain strengths and skills so that they can live as independently as possible.

The DTA model aims to support better outcomes for people leaving hospital by:

Reducing the time people spend in hospital when they no longer need acute care preventing hospital acquired infections and ‘deconditioning’ (the loss of strength and independence)
Assessing people in a more appropriate environment than the hospital giving a more accurate indication of their strengths and needs
Providing multidisciplinary reablement and rehabilitation plans, and if necessary short term care and support, to help people gain and re-gain independence, preventing or reducing need for longer term care.
The model also enables the urgent care system to prioritise acute hospital care for those people who need it.

The DTA team work in partnership with individuals and families to identify their own needs and goals, recognising that person-centred care planning is key to the person accomplishing the outcomes they want to achieve.

They also closely work with other services as part of the ‘Urgent Care System’. The Integrated Hospital Discharge Team based at Derriford Hospital and made up of discharge case managers, social workers and nurses identify people who have onward care needs and then make necessary arrangements for discharge to one of the two pathways within the DTA service; Home First and Bedded Pathway.

Home First is the default pathway for people leaving hospital and should be the first consideration for everyone. People who are discharged home under Home First will be assessed within 2 hours by a member of the DTA multidisciplinary team who will work with them to identify the type of care, support or rehabilitation that they need to meet the outcomes they want to achieve.

Where people are unable to go home immediately they will be discharged to the Bedded Pathway. This means they will be placed in a residential or nursing care home where they will be assessed by a member of the DTA multidisciplinary team within 48 hours. The DTA team will work with the person to identify the type of care, support or rehabilitation they need to meet the outcomes they want to achieve including, wherever possible, a return home.

Longer term needs will be assessed following a period of intermediate care.