The Newcastle upon Tyne Hospitals NHS Foundation Trust

Transcription

1 The Newcastle upon Tyne Hospitals NHS Foundation Trust Transfer out of Hospital Policy (formerly Discharge) (For paediatrics see Transfer out of Hospital Policy for Children and Young People) Version No.: 7.0 Effective From: 18 November 2014 Expiry Date: 18 November 2017 Date Ratified: 23 September 2014 Ratified By: Discharge Review Group 1 Introduction The Trust Transfer out of Hospital Policy has been compiled by a multidisciplinary, multi agency group, who collectively represent key agencies, organisations and professions involved in the planning and implementation of the transfer of care of the patient back into the community. This policy underwrites good practice approaches, which are patient, carer and family focused and endorse partnership and collaborative working among various professions, disciplines and agencies involved. The core principles, processes and implementation remain the same for all specialist areas. Service specific variations regarding roles, responsibilities, procedures and pathways will need to be considered within each Directorate. For the majority of patients, transfer out of hospital is simple and uncomplicated. For those patients whose needs are more complex however, there is a need to be confident that policy and procedure ensure that their transfer out of hospital is planned and as uncomplicated as their circumstances allow. Transfer out of hospital planning with clear procedures is an essential component of quality health care for a patient that is transferred from one care environment to another. It can be a major life event for patients, their families and carers and may also have substantial implications for the use of health and social care resources as well as for the voluntary sector and other support services. Many of the wards within the Newcastle upon Tyne Hospitals NHS Foundation Trust provide a tertiary service for patients, it is therefore recognised that transfers of care and transfer out of hospitals will be made to many different clinical commissioning groups (CCG) and Local Authorities. Close liaison and careful planning are essential to ensure a smooth transfer out of hospital for the patient and all concerned with their ongoing care arrangements. This policy is drawn up to meet the requirements of circular Health Care (89) 5 Discharge of Patients from Hospital and (recommendations within) Discharge from Hospital: pathway, policy and practice (Department of Health, 2003). The HC circular recognises that: Page 1 of 33

2 It is the responsibility of Health Authorities and NHS Trusts to implement a safe hospital discharge policy Patients discharged from hospital do so safely to the care of a G.P. (for those patients not registered with a G.P see point 4.5 or seek advice from the Discharge nurse specialist or Trust Social Work Team) Social Services Departments will be involved with patients and carers who require assessment (once consent has been obtained) and support in readiness for transfer out of hospital, together with the provision of Social Care Services as required Clarity of roles and responsibility of professional staff and key agencies and good communication between services is vital The allocation of responsibility to a specific hospital staff member will ensure procedural completion and effective continuity with primary and community staff. NHS and Social Service Departments are required to comply with the regulations and obligations created by the Community Care Delayed Discharges etc. Act 2003, Chapter 5. This Act places duties on the NHS and Local Authorities in England relating to improved communication between Health and Social Care Systems in relation to the transfer out of hospital of patients and also communication between patients and carers. The NHS is required to notify the Local Authorities of any patient s likely needs for community care services and of his/her proposed transfer out of hospital date. The Act introduced a system of reimbursement for delayed transfer out of hospitals. If a patient remains in hospital because the Local Authority is unable to assess or put in place the services that the patient or their carer need for transfer out of hospital to be safe, the Local Authority is then liable to pay the NHS body a charge per day of delay. This duty provides a financial incentive for Local Authorities to promptly address and transfer people from an acute ward to a more appropriate setting as soon as they are ready for transfer out of hospital, and provide an appropriate range of support to facilitate avoiding unnecessary admissions. The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care November 2012 (Revised) (Department of Health April 2013) has defined Continuing Care for the provider. The framework states that Continuing Care is care provided over an extended period of time, to a person aged 18 or over, to meet physical or mental health needs that have arisen as a result of disability, accident or illness. It also defines NHS Continuing Healthcare as a package of continuing care that is arranged and funded solely by the NHS. The actual services provided as part of that package should be seen in the wider context of best practice and service development for each client group. Eligibility for NHS continuing healthcare places no limits on the settings in which the package of support can be offered or on the type of service delivery. Continuing Care Guidelines are available on the Trust Transfer Out of Hospital Directory and include Continuing Care Screening Tools (including Fast-track for End of Life Care). Page 2 of 33

3 2 Scope The Transfer out of Hospital Policy applies to all adult patients over the age of 18 years, who are admitted into hospital and whose care is then transferred to community services, GPs, other NHS facilities and adult social and other non NHS providers of 24 hour care. It does not apply to patients seen as an outpatient, or planned day case procedures or paediatric patients (see Transfer out of Hospital Policy for Children and Young people). 3 Aims To ensure efficient and appropriate plans are in place to support the transfer of care to the community or other healthcare providers, for patients admitted to The Newcastle Upon Tyne Hospitals NHS Foundation Trust. The policy sets out, broad principles relating to the transfer of care for patients who have been admitted into hospital, with particular focus on patients with complex ongoing healthcare needs. This policy documents the Trust s expectations from staff and other agencies involved in the transfer of care. 4 Duties (Roles and responsibilities) The Transfer out of Hospital process is a multi-disciplinary, inter-agency progression during which the needs and resources of patients and carers are assessed. Where assessment records highlight that areas of care or service are required, this will be clearly identified, agreed and documented as the responsibility of health and/or social services. This process will involve the patient and carer who are placed central to decision making and who will be informed and communicated about it at all stages. It is crucial that on each occasion the patient and carer are at the centre of a customised pathway and not made to fit into a process. 4.1 The Hospital Consultant and Medical Team Consultants or a nominated deputy are responsible for the overall care of a patient in hospital and are accountable for the discharge of the patient. The Consultant or medical team will, at the earliest appropriate opportunity identify with the patient/carer the outcome of the admission and an anticipated date for transfer out of hospital. In most cases a predicted length of stay will be identified at the first ward round following the admission and will be documented within patients notes. The date of admission will be used as a reference point to inform timescales associated with MDT assessment and planning in preparation for the patient s transfer out of hospital. This will be supported by nursing, social work, and multi-disciplinary assessment reports. It is the responsibility of the Consultant or medical team to determine when a patient is medically fit for transfer out of hospital either via direct contact with the patient or via his/her support of protocols to support nurse led transfer out of hospital. Any continuing health care needs will be identified in line with eligibility criteria as appropriate; other support will have been identified within the MDT assessment processes, and planning will have ensured that these are in place to support the patient s timely transfer out of hospital. Medical Page 3 of 33

4 staff must complete the initial transfer out of hospital letter and prescribe transfer out of hospital medication. A copy of this must be filed in the patient s medical records. 4.2 Ward Sister/Manager (or their deputy) The Ward Sister/Manager has responsibility for ensuring that practice and an effective transfer out of hospital planning process operates within the ward. This responsibility will be delegated to the nurses leading and managing an individual patient s care. The Ward Sister/Manager (or their deputy) will ensure that each patient has a transfer out of hospital care plan in which arrangements for care on transfer will be documented. This will be monitored and evaluated from the admission to the implementation of transfer process. The Ward Sister/Manager (or their deputy) is responsible for ensuring full nursing assessment of the patient and may initiate MDT assessment to determine care needs. He/she will ensure that the patient is at the centre of transfer planning. Patients identified as frail older person on admission to the ward (see Frail Older Persons Tool Appendix 1) should have a care plan developed which reflects the needs of the patient and family to plan for transfer. This will be completed by the nurse leading and managing an individual patient s care. All members of the MDT needed to support the transfer of care out of hospital are identified and involved in the transfer planning as soon as possible. The Ward Sister/Manager (or their deputy) is responsible for ensuring 48 hours notice of transfer is given to the patient, relatives and other care providers of frail older patients. Exceptions to this should be reported through the Trust s Incident Reporting System. The Ward Sister/Manager (or their deputy) is responsible for ensuring a section 2 social work notification of needs is completed and sent to adult social services 72 hours prior to transfer out of hospital (where possible) and a section 5 notification when the transfer out of hospital date identified at least 24 hours prior to transfer out of hospital date. The Ward Sister/Manager (or their deputy) is responsible for completion of transfer checklist hours prior to transfer out of hospital. Should an incident occur during the transfer out of hospital process, staff employed by this Trust are responsible for reporting the incident using the Trust Incident Reporting process. All patients with ongoing care needs should be considered for continuing healthcare funding. A continuing healthcare checklist should be completed if patient is transferring into new 24 hour care setting, has care needs which exceed the normal level of care provided by the local authority or has nursing needs which the community nursing team would be unable to meet. Page 4 of 33

5 4.3 Wellbeing Care and Learning Directorate / Adult social care NHS and Community Care Act 1990 When implemented in 1993, this act gave new responsibilities to Social Service Departments which impact on the transfer out of hospital processes. These include: Undertaking needs assessment of people referred for community care services and meeting those needs of people (within agreed criteria) Assessing, arranging and commissioning packages of care. Adult social care Services responsibilities also include: Inclusion of families and carers in the assessment process Support and advice, relating to safe transfer out of hospital Working with colleagues in relation to the implementation of Interagency Safeguarding Adults Policy & Procedure Arrangement of home based services from an approved range of service providers Care management in which complex domiciliary services are required or residential/nursing home care is needed Contribution to care programme arrangements for people with mental health problems Participation in multi-disciplinary team assessments Care Packages/Re-Referral/Increased Aftercare Support When a person is admitted to hospital, Adult Social care Services will suspend care packages and will normally hold on to these existing services for a period of up to 21 days. If a patient is admitted for a more prolonged length of stay and the MDT feel that their functioning remains the same, a new care package will need to be commissioned before transfer out of hospital. If in the opinion of the MDT the patient does not require re-assessment of existing services; requests to Adult Services/Care at Home Services to restart care packages will usually require 48hours notice, however Adult Services will endeavour to do this as soon as possible. No patient will be transferred out of hospital to their home prior to the re-instatement of an established or planned new care package without the awareness and agreement of patient, carer and Social Services New Assessments Identifying the need for social work assessment as soon as possible is important. However a social work assessment cannot be completed until the patient has undergone treatment or is at least progressing towards recovery. Untimely or inappropriate referrals to the Social Work Page 5 of 33

6 Department only serves to reduce their ability to complete work on imminent transfer out of hospitals or to respond to urgent requests. Adult Social work will complete an initial assessment within 72 hours of receiving a section 2 notification of need, and will arrange appropriate services within 48 hours of receiving of a section 5 (transfer out of hospital) notification. If Section 2s or 5s arrive after 2pm they will be counted as arriving at 9am on the next working day. When the recommendation of the MDT is for 24 hour care placement (except Nursing care - see CHC) a social worker will make an initial assessment and if they agree with MDT will seek authority from placement avoidance clinic. Adult services will arrange a placement care plan and liaise with family and care homes to facilitate transfer out of hospital as soon as possible within the 21 day choice directive Community care (Delayed discharges etc.) Act 2003 The Delayed discharges Act defines the responsibility of Local Authorities to prevent delays in transferring patient care out of hospital. It sets out a charging mechanism when local authority is the sole reason for the delay in transferring care. Note the charging mechanism only applies to patients in acute beds, but we would accept that the spirit of timely transfer out of hospital would also extend to non-acute beds (though there is no liability for reimbursement for any delayed transfer out of hospitals from non-acute care beds). Definition of Delayed Transfer out of Hospital A patient will only be identified as being a delayed transfer of care in the context of the Community Care (Delayed Discharges etc.) Act 2003 when we have not been able to make available a Community Care Service which has been identified as essential to enable a safe transfer or the assessment of social care needs has not been completed. The period of delayed transfer out of hospital as defined within the Act will end on the day that Adult Social Care have completed the assessment of social care need and the identified community care services have been provided to enable the transfer out of hospital of the patient from the acute bed. The Hospital is required to make two notifications to the relevant Adult Care/Adult Social Services Department in order to trigger a claim for reimbursement. 1. The first notification under section 2 of the Act gives notice of the patient s possible need for services on transfer out of hospital. Following this notification, Adult Social Care will have a minimum period of 72 hours, including the day where the notification has been issued (excluding Saturdays, Sundays and Bank Holidays), to carry out an assessment and provide services. A section 5 will also need to be issued. Page 6 of 33

7 2. The second notification under section 5 of the Act gives at least 24 hours notice of the day on which it is proposed that the patient be transferred out of hospital. Reimbursement liability commences at 11am on the day after the minimum period (excluding Saturdays, Sundays, and Bank Holidays) highlighted on the section 2 or the day after the proposed transfer out of hospital date section 5, whichever is the later. Where a section 2 or 5 is no longer appropriate (see criteria for withdrawal) then nursing staff will withdraw the notice. Wards must ensure that all delayed transfer out of hospitals are reported to the Emergency Care Facilitator on extension Continuing Healthcare Assessment If the transfer out of hospital is for nursing care then the checklist would be completed by the MDT. Adult Services would complete their assessment with nurse assessors as either an inpatient or in the care home (see appendix 3). Whilst this goes to CHC panel for a decision, adult services would arrange the transfer out of hospital into nursing care pending this decision. The 21 day choice directive still applies. For transfer out of hospitals into the community there are 2 pathways: 1) Fast track referrals for people with end of life and complex needs should be completed by ward staff. The Fast Track documentation when complete should be faxed to the CHC assessment team for the area in which the GP is registered. A CHC Case Manager will be allocated who will arrange transfer out of hospital. This is not undertaken by Adult Social Services. 2) Transfer out of hospital to home with ongoing care needs requires completion of a checklist. Adult Services would commission services initially pending CHC panel decision, as long as the cost of the care package had received appropriate Adult Service authorisation. Where the package of care exceeds local authority budget patients should remain in hospital until CHC assessment is complete. 4.4 The Role of Continuing Health Care Nurse Assessors The Continuing Health Care Nurse Assessor s work in partnership with social services and MDTs carrying out assessments to establish eligibility for NHS funded care. They will advise and support individuals, their families and MDTs through the assessment process and ensure awareness of the reviewing process. Should there be a dispute to the outcome of criteria application, the nurse assessors will support the individuals concerned through a local resolution process of re-assessment by the team and/or assessment by a nurse assessor from another CCG. Continuing Health Care Nurse Assessors will provide training and support for ward staff in completion of CHC checklists. Page 7 of 33

8 4.5 The General Practitioner (GP) and Clinical Commissioning Group (CCG) For patients who are admitted to hospital the general practitioner should be contacted for information regarding any circumstances, which may impact on the patient s hospital care and transfer out of hospital plan including important details concerning carers. Patients who are transferred out of hospital should return to the care of a GP who will be responsible for communicating within the primary healthcare team. If the patient is not registered with a GP they may be allocated to a GP practice near to the address they are to be transfer out of hospital to (contact the Clinical Commissioning Group local to the patient s transfer out of hospital address), or they may register temporarily with the GP of the person they are staying with. Patients requiring support from community nursing service must be registered with a GP. 4.6 Role of the Community Nursing team The community nursing team may have information about patient s home circumstances which would aid hospital discharge planning. For those patients whose community nurse is involved in their care, pertinent information may be sought via telephone. The community nurses must be involved in the planning of patient with complex nursing care needs prior to transferring back to the community. All patients requiring community nurse support must have a transfer out of hospital care plan. For frail, older persons or patients with complex needs this should be a complex transfer out of hospital care plan which should accompany the patient on transfer. All other patients should have a noncomplex transfer out of hospital care plan completed. All patients discharged on insulin which the District Nurses are expected to supervise or administer need to ensure insulin is prescribed and the prescription accompanies patient on discharge. Patients who require community nurse input must be referred by telephone at least 24 hours prior to transfer where possible. Telephone referral should follow the SBAR principles. Some areas you may consider are detailed below Situation Name of nurse referring Name of ward referring Reason for referral Background Patients normal condition Dressing regime Continence/Catheter care Reason for admission Any risks or alerts for community staff to be aware of Page 8 of 33

9 Any communication support required or relevant disabilities- eg learning disability Assessment Wound grade Mobility Mental state Nutrition score (MUST score) BP/Pulse/Temp if applicable Recommendations When visits are required Date catheter change due Duration of treatment Patient should be given a adequate supply of dressings: If discharge to Care Home: 7 days supply If transferred to another hospital, no dressings need to be supplied, unless specified by Tissue Viability If discharged to own home: 3 days or more if discharged over the weekend or Bank Holidays If required, 7 days of continence products will be supplied if the patient is discharged home. If transferred to another hospital, no continence equipment needs to be supplied, unless specified by the continence service. Patients transferred to the care of the District Nursing team for administration of intravenous antibiotics (IVAB) should be registered with a GP. The patient must also be able to recognise line or medication complications and be able to summon assistance if required. If the patient is unable to identify potential complications then another responsible adult, who can, must live in the house. The patient must be referred to the District Nursing administration base on A member of the team will contact the ward and discuss the patient with the named nurse. If the patient is accepted into the service a member of the team will inform the named nurse. The patient must be transferred to the care of the District Nursing with a 7 day supply of all equipment such as dressing packs, syringes, needles etc. The patient must also be supplied with the full course of IVAB, posiflush and heparin solution. The patient must be discharged from the ward with the prescription sheet. The ward should provide a contact number for the District Nursing team/patient to call if complications arise. The patient should always be provided with instructions regarding monitoring of treatment such as bloods and who will be responsible for monitoring the results and any review dates. 4.7 The Role of a Community Matron The Community Matron proactively manages high risk patients with complex long term conditions by providing a case management approach to anticipate, Page 9 of 33

10 co-ordinate and link health and social care. The identified patients may be high intensity users of unplanned secondary care and the role aims to: Improve the quality of life and care of the patient. Help prevent future inappropriate emergency hospital admissions. Enable patients admitted to hospital to return home quicker. The Community Matron acts as a key worker for the patient and maintains responsibility for the management of care and service provision across the primary/secondary care interface, preventing unnecessary hospital admission and facilitating hospital discharge. 5 Definitions CHC: Continuing health Care. NHS continuing healthcare is the name given to a package of care that is arranged and funded solely by the NHS for individuals who are not in hospital but have complex ongoing healthcare needs. HCAI: health care acquired infections are infections that are acquired as a result of healthcare interventions. CCG: Clinical Commissioning Groups are groups of GPs responsible for designing local health services in England. 6 Transfer out of Hospital Process 6.1 Aims and objectives of planned transfer out of hospital Transfer out of hospital planning should start on admission with completion of a full case history, taken from the patient and carer to ensure the patient/carer is at the centre of the transfer out of hospital planning process. The patient and carer should be fully involved and informed at each stage with particular attention given to those patients with sensory, mental health, learning or language disabilities. Deaf or with communication needs and patients identified as frail older person. Patients beliefs, wishes and culture must also be considered when planning their transfer out of hospital. Patients should be transferred out of hospital to a safe and adequate environment or accepted risks should be highlighted with the patient and discussions recorded. All patients should be considered as having mental capacity regarding transfer out of hospital destinations. If there are concerns regarding a person s mental capacity to make specific decisions a Mental Capacity assessment must be completed. See Mental Capacity Act 2005 (including the Deprivation of Liberty Amendment 2009) It is important that the patient s condition is continually reassessed by a MDT and referrals to other agencies be actioned as soon as practicable to facilitate a smooth transfer by ensuring all health and community care facilities and services are arranged to meet the patients needs. This will provide continuity of care between hospital and agreed care environment and vice versa by effective communication and seamless service transition. Page 10 of 33

11 The patient will be fully involved in planning for his/her transfer out of hospital (where possible) and will be kept informed of any change affecting agreed plans. With the patient s agreement, relatives and carers will be fully involved in both transfer out of hospital process and arrangements. Their contribution to aftercare and support will be both acknowledged and recorded. Appendix 2 shows the range of services that can be involved in the transfer out of hospital process. 6.2 Sequential task list for planning and managing patient transfer out of hospital Identify the named nurse (for that shift) Discuss care with the patient/ relative/carer and document discussions and outcomes in the patient notes If social care needs are identified complete section 2 notification to social worker and /or therapists with the consent of the patient Receive assessments (medical, nursing, allied professionals), bear in mind the need for Continuing Care assessment where indicated Convene multi-disciplinary case discussion Agree follow up and agree community care arrangements. Agree transfer out of hospital date Arrange transport as outlined in section 6.4 Obtain equipment ensuring any equipment which is essential to support transfer out of hospital of the patient is available on the day of transfer out of hospital at the latest Obtain patient s drugs and ensure patient understands their drug regime If the patient is being transfer out of hospital with self-injecting medication obtain and issue a disposable sharps box (see section 6.7 for more information). Advise patients to visit the GP and/or Practice Nurse if treatment is required following transfer out of hospital Confirm transfer out of hospital date, arrangements etc. with patient/relatives and carer and inform GP Return patients property Confirm patient/carer/relatives understanding of arrangements Transfer out of hospital patient with all required information leaflets e.g. Leaving Hospital leaflet and the transfer out of hospital letter and outpatient appointments and discharge care plan. Information about any relevant support groups in the community. On wards where Nurse Led Transfer out of hospital is in practice staff must follow locally agreed protocols and guidelines. It is the responsibility of staff on these wards to review protocols and always work within their scope of practice. 6.3 Active and Day Case Admissions Arrangements for transfer out of hospital should be determined prior to admission based on the anticipated outcome of the procedure. Considerable information can be provided by the patient, carer, GP, CCG or Social Services Page 11 of 33

12 if sought prior to or immediately on admission. (Pre-admission assessment will identify potential transfer out of hospital needs as a component of holistic assessment). 6.4 Transportation The presumption should be that patients will make their own arrangements for transport home using the support of relatives, friends and carers or taxis (not paid for by the Trust). Staff should encourage patients to make their own arrangements, which will allow transfer out of hospital by 11:00hrs to support effective management of bed capacity. Where a patient has no means of transport or requires an ambulance, arrangements can be made, as follows: Early planning is recommended. Book online before 10:00 on the day prior to transfer or telephone bookings can be made on the day prior to transfer and will be classed as a late booking. Out of area ambulances must be booked 48hrs in advance. When booking an ambulance choose a time when you are confident that the prescription, discharge letter and anything necessary for discharge will be ready for the patient to leave the ward. If the patient is not ready at the requested time the ambulance will be cancelled and cannot be guaranteed to be booked again for the same day. Be sure to order the correct mobility i.e. stretcher, wheelchair, or 2-man. Don t forget to add any special requirements for oxygen etc. A 2-man crew will take a patient on oxygen. A nurse must escort a patient with a drip or infusion pump with a paramedic crew Same day transfers out of hospitals (by ambulance) are not guaranteed. It is easier to book the ambulance the day before and cancel if the transfer out of hospital does not go ahead. 6.5 Transfer out of Hospital to another Hospital This occurs at the request of the Consultant and by the referral and acceptance of the patient by the receiving hospital Consultant. Full nurse handover is to be given to the receiving ward and documented in the patients notes. The patients family and carers must be kept fully aware of any plans for transfer out of hospital/transfer to another hospital. 6.6 Documentation to accompany patient on transfer out of hospital The patient must be transferred out of hospital with full information regarding their hospital admission and any ongoing healthcare needs; disabilities and communication needs and treatment including transfer out of hospital diagnosis, complications, medical or social issues outstanding at transfer out of hospital, transfer out of hospital medications and follow-up arrangements. A formal transfer out of hospital summary letter will be sent to the patient s GP within 48 hours of the patient s transfer out of hospital. If a patient is Page 12 of 33

13 transferred out of hospital to an address other than his or her own, the patient s GP should be informed of this. If the address is outside the patient s GP practice area, the patient should register with another doctor, whose practice covers that area, as a permanent or temporary resident. Patients who are being transferred to the care of the community nurse or other NHS or social care setting must have a simple /complex transfer out of hospital care plan provided on transfer out of hospital. 6.7 Provision of Sharps Boxes If the patient is to be transfer out of hospital with self-injecting medication obtain and issue a disposable sharps box. The type/colour of sharps box supplied will depend on the type of medication the patient is on. If the drug is cytotoxic or cytostatic then the sharps box must have a purple lid, otherwise a sharps box with a yellow lid can be used for all other drugs. The patient should be instructed on how to safely use, store and securely close the sharps box. Sharps boxes should be kept safe when not in use and stored away from children or pets. When the patient has finished their course of medication or the sharps box becomes full they should lock the box down and take it to their GP for disposal. 6.8 Patient Groups A significant number of people require special care when planning transfer out of hospital arrangements, and this group of patients can be identified as having Complex transfer out of hospital needs (this includes patients identified a frail older person). Refer to flow chart (Appendix 3) for additional guidance Identifying Patients with Complex transfer out of hospital needs Risk must be considered by all professionals, with their patients and relatives/carers as part of the transfer out of hospital planning process. A shared understanding of what is an acceptable risk will reduce conflict at all stages of the transfer out of hospital process. All involved in the transfer out of hospital planning process must balance the risks of transfer out of hospital against the risk of the person remaining in hospital. Particular care must be taken to assess and plan for the transfer out of hospital of certain groups of people including: Those who live alone (of any age) Those who are identified as frail older person (see appendix 1) Those who live with a carer or are carers themselves Those who may have difficulty coping Homeless people of any age, those living in poor housing or physically isolated or inaccessible conditions Those patients with a long term condition which requires frequent admission to hospital or those who have had an extended hospital stay Patients with a complex care package involving social services Page 13 of 33

14 Terminally ill patients Persons with a disability including those transfer out of hospital from long stay hospitals to return to the community and those who are Deaf or have a sensory impairment Patients known to the mental health services Those who may be confused, forgetful or prone to wandering, at risk of self-harm from falling and self-neglect (Getting it right for people with dementia, DoH July 2003) Those who have been recently bereaved moved home or have a change in care circumstances Unable to comply with medication regimes The main carer for another dependant person or who would rely on a child or young person for care Patients who have frequent admissions to hospital Persons with learning disability People at risk of abuse Displaced persons Patients with communication difficulties Transfer out of hospital of Frail Older Person All patients who are identified as frail older person by the Trust Frail Older Person Tool (Appendix 1) must have a comprehensive MDT assessment of their needs and their transfer out of hospital should be commenced, planned and co-ordinated by a named member of the ward staff well before discharge. Patient, family and carers need to be central to the transfer out of hospital planning process. Education may need to be provided for carers, e.g. equipment use. Non acute NHS care and social partners should be included in transfer out of hospital discussions at an early stage to ensure a smooth transition of care on transfer out of hospital. The transfer out of hospital co-ordinator or the person planning the transfer out of hospital should discuss appropriate place of transfer out of hospital and support needs with patients and carers, wherever possible. A complex transfer out of hospital care plan (see appendix 6) should be commenced on admission and reviewed frequently by the MDT. The patient, and, if appropriate those close to them should always be given information about their care and treatment, as well as given access to their transfer out of hospital care plan. Carers and family should be given sufficient notice of transfer out of hospital, so they have enough time to make the necessary arrangements. There should be a minimum of 48 hours notice given to patient s family, non-acute NHS and social partners of the proposed Page 14 of 33

15 date for transfer out of hospital (unless this is not in the patients best interest). Transfer out of hospitals should occur before 8 pm if possible unless this is agreed with the patient or carer. The Trust Board should be made aware of any incidents of transfer out of hospital taking place after midnight or when carers / family receive less than 24 hours notice of transfer out of hospital. A Datix incident form should be completed. All frail older people will be offered a referral to adult social care for assessment of need. Family and carers will be offered a referral to adult social services for carer assessment. To ensure adequate support is available on transfer out of hospital for patients and their carers information about support on transfer out of hospital should be given to the patients and /or carer. Patient, family/carer (with patient s consent), GP, community nurses, carer managers, home managers will receive a complex transfer out of hospital care plan to support their ongoing transfer out of hospital needs. All frail older persons should have the transfer out of hospitals handover document (see appendix 8) completed and sent to GPs, district nurses, care home/carers where appropriate Transfer of care to Residential / Nursing Home Care (supported by the Choice Directive Policy) All patients transferring to care home setting will be classified as frail older person and follow the guidelines stated above. If the patient is a new resident to the care home the manager should be invited on to the ward to assess the patient to ensure they can meet the patient s needs. This should normally be within 48 hours of a request and a date for discharge agreed. When patient is returning to the same care home, the ward nurse should give the care home the opportunity to reassess the patient prior to transfer out of hospital. If the classification of care is changed e.g. Residential to Nursing a full social work assessment is required and a CHC checklist complete before transferring back to the care home. A verbal Nurse to Nurse handover should be completed and documented and a complex transfer document should be complete and sent with the patient to the care home. Page 15 of 33

16 Patients with nursing needs who are being transferred to a residential care home will need referral to the community nursing team Transfer out of hospital for patients with Hospital and Healthcare Acquired Infection (H.C.A.I s) Special measures need to be taken when transferring out of hospital a patient who has a healthcare acquired infection or is in source isolation. Staff must refer to the appropriate policy for the management of these patients according to the reason for isolation. If the patient is in source isolation the cubicle/areas must be terminally cleaned on patient discharge as per the Decontamination of the Patient Environment (including Terminal & Deep Cleaning) Policy. The Infection Prevention and Control Team should be contacted for advice regarding the transfer out of hospital of these patients if necessary End of life care if the patient is being discharged to home for End of life care The NICE guidance Improving Supportive and Palliative Care for Adults with Cancer in 2004 recommends that people who have an incurable illness should be allowed to make the choices relating to end of life care including where to die. Ward staff should make a referral to the Hospital Specialist Palliative Care Team if they require help and support in the discharge process utilising their expertise in local networking to achieve a rapid discharge. Advise on discharge medication Liaise with patients family and carers Liaise with district nursing service Liaise with ambulance services Ward staff should: Confirm with GP that patient has expressed a wish to die at home Confirm with D/N current plan of treatment Contact community central admin and inform that this is a patient for Rapid Discharge for end of life care (Mon-Fri pm : Out of Hours ) Referral to appropriate MDT members re: equipment/resources, and check in place Book ambulance-category 1 discharge DNACPR original form completed signed and travels with the patient Discharge drugs (7 day supply) with prescribing sheet completed by an F2 Doctor (or above) Discuss medications with carers Page 16 of 33

17 Inform Palliative Care team (if appropriate) Community staff should: Community central admin to contact Team Leader Team Leader will complete the initial assessment Hospital and Community Nurse to agree time of discharge, care package and equipment needed including medication Community Nurse to visit patient within 1 hour of discharge and inform Out of Hours of the patient Transfer out of hospital of persons of no fixed abode. For persons who declare at admission that they are of no fixed abode (NFA). It is best if the patient can go to stay with a friend or relative when ready for transfer. This possibility should be explored as soon after admission as possible and the patient encouraged to help resolve the problem of their transfer destination. If this is not possible establish their last address and reasons they are unable to return to that address. Patients need to have a connection to an area to receive rehousing support and hostel accommodation. A connection is usually made because they have any of following: Lived in that area for 6 out of the previous 12 months or 3 out of the past 5 years Have a close family member live in that area for more than 5 years. Employed in the area. Contact the Housing advice centre (HAC tel at Pilgrim Street in Newcastle) for advice. HAC will assess the persons need and assist with finding emergency accommodation. This referral should be made 48 hours in advance of discharge where possible. Opening hours 10:00 12:00 and 13:00 16:00, Monday, Tuesday, Thursday and Friday and 13:00 16:00 only on Wednesday. The office is closed at the weekend. Phone calls only from :00 and 13:00 to 16:30 On the day of discharge it is essential that the person attends for interview at HAC as soon at the office opens. For patients transferring out of hospital outside of these hours the on call duty officer for social services on and the Patient Services Coordinator has a list of hostels which may be contacted. The Hospital Discharge and Homeless prevention protocol is available on the Trust intranet. Sometimes patients are unable to return to their previous accommodation because it is unsuitable to meet their current needs. A referral through to Your Homes Newcastle should be made as a priority as soon as it becomes apparent that alternative accommodation will be Page 17 of 33

18 required. Before the tenancy is given up, consideration should be made to establish if, with the support of carers, the patient could return to their existing property temporarily until rehoused. If patients need to be rehoused referral should be made to Adult Social Care to consider temporary respite care. Patients who have suitable accommodation but wish to be rehoused should be referred to Adult Social Care and Your Homes Newcastle but encouraged to return to their property. Patients who are assessed as MDT fit for discharge and have suitable accommodation cannot remain in hospital until they are rehoused. Please contact the Discharge Nurse Specialist on Dect for advice and support. NB it is not good practice to discharge persons when they have no discharge destination People seeking refuge and asylum, and displaced persons Asylum seekers, refugees and displaced persons often have very complex situations and therefore each person s discharge must be dealt with according to individual need and circumstance. Information and advice can be sought from several areas if it becomes apparent that discharge may be difficult. Social work at each site has a social worker with a special interest in these areas and will advise accordingly (advice can be sought from any site in the absence of their colleague). Other persons to contact are; the Discharge Liaison Facilitator DECT 48900, The North Eastern Refugee Service on and The Community Relations Officer who is based at the Police Station on Westgate Road Patients who decide to stay home at a home visit An assessment must be made of the risks of the patient remaining at home and their competency to make that decision. If it is felt the patient is not competent to make that decision the Senior Manager must be contacted and an action plan agreed. The ward sister/consultant and bed manager must be informed. The G.P and any health /social services involved with the patient must be informed. Family/carers may be contacted to help persuade the patient to return. It should be ensured the patient has any equipment and medication. If the patient cannot be persuaded to return to the ward they should be asked to sign a self-discharge form (or a written disclaimer).if the patient refuses this must be documented in the patients medical record by the staff member leading the home visit. Page 18 of 33

19 All conversations must be clearly recorded and the incident reported on return to the Trust Patients taking Own Discharge against Medical Advice When a patient is determined to discharge him or herself from Hospital, against medical advice the nurse must summon the Doctor and try to dissuade the patient. If the patient cannot be persuaded to remain on the ward and insists on taking their discharge the following procedure should be followed. The patient should be asked to sign the form 'Self Discharge from Hospital' available from the Stock Printed Forms Catalogue. Inform next of kin where appropriate Inform community services where appropriate If the patient refuses to sign the form this MUST be documented in the patients notes An incident form may be completed at the discretion of the nurse in charge of the ward. It is the responsibility of the medical Staff to document 'own discharge' in the medical record and to inform the patients G.P Paediatric discharges Please refer to the Paediatric discharge policy Obstetric Discharges Please refer to Women s Services Discharge guidelines. 6.9 Transfer out of hospital Out of Hours It should not be routine practice to transfer inpatients out of hospital after 20.00hours without agreement from the patient/carers and any service providers involved. Special considerations will apply to the transfer of patients out of hospital at weekends and Bank Holidays including availability of community-based services and transport requirements. Those responsible for the decisions to transfer out of hospital out of hours, will need to take into account service availability and carers needs. Particular care should be taken to ensure adequate support is in place for patients who are transferred out of hospital at weekends. 7 Training Training requirements associated with the policy will include the use of the Frail Older Persons Tool for medical staff and the completion of the Complex Discharge Care plan for nursing staff. Page 19 of 33

20 All nursing staff discharging patients identified as frail older person will require training on the completion of the Complex Discharge Care Plan. New clinical staff to the trust will receive training in discharge planning. 8 Equality and diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This document has been appropriately assessed. 9 Monitoring Compliance Standard / process / issue Discharge of frail older persons process Documentation completion in line with policy Completion of discharge Audit Discharge nurse care plans specialist Completion of handover Audit Discharge Nurse to community services Specialist Review of discharge datix Audit Discharge Nurse issues Specialist Review of discharge Audit Discharge nurse complaints specialist Delayed discharges Audit Emergency care facilitator 10 Consultation and review Monitoring and audit Method By Committee Frequency Audit CGARD Discharge Annual Review Group Audit CAT Discharge Annual review group Discharge review group Discharge review group Discharge review group Discharge review group Discharge review group Annual Annual Annual Annual Weekly/ reported monthly When reviewing this Policy all appropriate guidance has been taken into account. In addition to relevant subject specific guidance, the legal requirements have also been taken into account. The involvement of the Discharge Review Group and all relevant stakeholders responsible for ensuring the safe and effective implementation of the Policy have been asked to contribute, comment and agree the content of a document before it is passed to the Clinical Policy Group for approval. 11 Implementation (including raising awareness) This will be raised with the Senior Nursing Team, Older People s Medicine Senior Clinicians, Matrons and Clinical Ward Leaders meetings. 12 References Community Care (Delayed Discharges etc.) Act 2003 Page 20 of 33