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Going home – the discharge pathway

Jane Newland and Andrew Tinsley, Case Managers at the North West Regional Spinal Injuries Centre describe the discharge process from the view of a Healthcare Professional.

The North West Regional Spinal Injuries Centre receives patients with new spinal cord injuries (SCI) from local hospitals and trauma centres across the North West.

Our mission is “to provide every opportunity for individuals to achieve their maximum potential in order to adopt the lifestyle of their choice within the extent of their ability.”

Upon admission patients are allocated a Case Manager to provide support and information to the patient and family, maintain an overview of rehabilitation and arrange a safe and timely discharge.

The Centre has 43 (acute and rehab) in-patient beds and eight community outreach beds.  We support people from a wide variety of backgrounds, social circumstances and levels of SCI including high levels and ventilator dependent people.

Our discharge pathway states that an environmental visit should be arranged to the potential discharge destination within first two weeks of admission, to assess suitability and identify any barriers.  Following the visit we meet with the patient and the Occupational Therapist to discuss outcome of the assessment and explore all options.  This brings its own challenges as what we often report as suitable for short-term needs is not always appropriate in the patient’s mind.

Our Occupational Therapist will refer and liaise with Community Occupational Therapist to arrange adaptations to the property.  Depending on accessibility and level of adaptation needed this can take longer than the admission and often Social Services will not start works until the patient has returned home.  In this instance patients can consider temporary solutions such as downstairs living, confined living or short term interim placement.

In some circumstances, patients are admitted as homeless or unable to return to their property, in which case they are deemed as unintentionally homeless.  We can offer support by liaising with local homeless teams and completion of re-housing applications.  Challenges arise when patients do not wish to return to their own area but have no connection to another, or have no identification to make the application or are reluctant to searching a broader area.  We are able to provide letters of support and information on individual housing needs, to support priority banding.  As well as working with local housing associations we reach out to any charitable organisations such as ASPIRE and My Space.

As a Centre, we are largely dependent on the services in each area.  We encourage patients to take responsibility and work together as a team to plan short-term and long-term housing needs.  For those who are able to access their property in some way, we encourage weekend leave to identify any barriers that can be incorporated into their rehab programme and be able to spend time with family and friends.

As discharge approaches, we provide individualised signposting, which includes contacts and information available in their own area to facilitate reintegration back to community.  We understand this is an anxious time for SCI patients and their loved ones and not having a suitable place to be discharge to can add to this stress.  We are here to help and are happy to provide any information to reduce this anxiety, so we need to talk about it and address it at an early stage.