Transfer of Care Hub

As we continue to improve the processes around safe discharge from hospital, we have created a Transfer of Care Hub leaflet which gives advice to patients and their families and carers on the options available to support their discharge and them when they return home. 

The leaflet is available on the Document Management System here.

Photographed: (L-R) John Menton (Homeless team), Tony Cavanagh (Sefton Senior Social Work Practitioner), Gemma Disley (Trusted assessor), Ryan Gilbody (General Service Manager), Angela Evans (Discharge Matron), Jane Williams (Nursing Lead - Integrated Discharge and TOCH), Sheila Kelly (Liverpool Social worker), Helen Mannion (Mersey care Therapy Discharge Matron), Chloe Pybis – Crowley (Admin)

Photographed: (L-R) Lynne Cannell (Head of Operations - DMOPS, Endocrinology and Diabetes), Mathew Hood (Assistant Director of Nursing for the Department of Geriatric Medicine and Diabetes and Endocrinology), Raj Nagra (Frailty Coordinator), Simon Coyle (Physiotherapist), Sarah Nock (Social Worker), Helen Privett-Cook (Palliative Care Clinical Services Manager).

Here are some useful terms for you to understand more about the discharge process and the options available in the community.

This will help you to start planning for discharge, from admission and apply a strength based approach to patient care. Discharge to Assess (D2A) and ‘pathways’ – the different options that we have when it comes to the amount of support a patient might need once out of hospital.

You might also hear these referred to as P Zero, P1, P2 and P3

From Tuesday 4 November, the electronic discharge summary (eDS) template in ADT dashboard will be updated to improve clarity, completeness and data quality.

Key changes include:

• Expanded “Changes in Medication” section to capture the rationale for new, amended or discontinued drugs.
• Revised section order to support a more logical clinical flow.
• New mandatory fields for AKI, blood transfusion, and relevant investigations.
• New in-line prompts and guidance to assist clinicians in providing the most relevant information.

We ask that senior clinical staff support junior team members as they adapt to the new format, and encourage good practice in writing clear, high-quality discharge summaries — helping ensure safe and effective transitions of care into the community.

For further guidance or to report any issues, please contact paul.hine@liverpoolft.nhs.uk

Parallel planning involves a team of complex discharged nurses, social workers and colleagues from Mersey Care assessing patients on admission to hospital to identify needs that can be managed whilst the patient continues to have their acute episode of care, and help to facilitate discharge home.

This is a change from historic discharge planning which would routinely happen once the patient no longer had criteria to reside, and means that plans can be made quickly and efficiently.

The assessment that is undertaken on the assessment units will continue whilst the patient receives their treatment in hospital and will be monitored by the transfer of care hub, I'm through the ward and board rounds.