Accountable Director Executive Director of Nursing and Secure Services Head of Nursing

Transcription

1 Policy Number SD40 Policy Title DISCHARGE/ TRANSFER POLICY Accountable Director Executive Director of Nursing and Secure Services Author Head of Nursing Safeguarding is Everybody s Business. This policy should be read in conjunction with the following statement: All Mersey Care NHS Trust employees have a statutory duty to safeguard and promote the welfare of children and vulnerable adults. This includes: Being alert to the possibility of child/vulnerable adult abuse and neglect through their observation of abuse, or by professional judgement made as a result of information gathered about the child/vulnerable adult. Knowing how to deal with a disclosure or allegation of child/adult abuse. Undertaking training as appropriate for their role and keep themselves updated. Being aware of and following the local policies and procedures they need to follow if they have a child/vulnerable adult concern. Ensuring appropriate advice and support is accessed either from managers, safeguarding ambassadors or the Trust Safeguarding team Participating in multi-agency working to safeguard the child or vulnerable adult (if appropriate to role). Ensure contemporaneous records are kept at all times and record keeping is in strict adherence to Mersey Care Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation Ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session The date for review detailed on the front of all Mersey Care NHS Trust Policies does not mean that the document becomes invalid from this date. The review date is advisory and the organisation reserves the right to review a policy at any time due to organisation/ legal changes. Staff are advised to always check that they are using the correct version of any policies rather than referring to locally held copies. The most up to date version of all Trust policies can be found at the following web address: es_and_procedures.aspx

2 DISCHARGE / TRANSFER POLICY POLICY NO SD40 RATIFYING COMMITTEE Corporate Procedural Document Review Group DATE RATIFIED Jan 2014 Interim Review Dec 2015 Interim Review Feb 2016 NEXT REVIEW DATE April 2016 POLICY STATEMENT: This policy applies to all persons who are discharged from Mersey Care NHS Trust in-patient care and should be read in conjunction with the Care Programme Approach document / Care Management guidelines & Mental Health Act, 1983 Code of Practice. ACCOUNTABLE DIRECTOR: Executive Director of Nursing & Secure Services POLICY AUTHORS: Head of Nursing KEY POLICY ISSUES Effective planning for discharge Communication of discharge plan Delayed discharge Discharge/Transfer Policy SD40 January 2014 Page 1

3 Version Control Version Author Date Meeting / comments from Version 1 Mina Valentine Dec.2010 Service colleagues Corporate Procedural Document Review Group Version 1.2 Mina Valentine Jan 2011 Head of Risk & Resilience Deputy Director of Nursing & Care Mental Health Act Practitioner Compliance Analyst Version 1.3 Maria Tyson Dec 2012 Minor updates 2

4 DISCHARGE POLICY CONTENTS 1. INTRODUCTION 1.1 Rationale 1.2 Scope 1.3 The policy - objective 1.4 Policy Statements 1.5 Principles of Good Practice 2. The requirements and arrangements for the discharge and transfer of service users within the care planning process. 2.1 The Purpose of Admission to Hospital 2.2 National Standards That Apply To The Management Of Inpatient Care 2.3 A Positive Outlook / Discharge Planning 2.4 Mental Capacity Act Service Users Detained under the Mental Health Act 2.6 Section 117 Mental Health 2.7 Leave of Absence Day In-patient Review 2.9 Community Treatment Orders 2.10 Discharge Against Medical Advice 2.11 Deprivation of Liberty Safeguards (DoLS) 2.12 Delayed Discharge Arrangements 2.13 Transfer within Services (Community) 2.14 Service User Discharge Information 2.15 Involvement of Service Users, Relatives / Carers, IMCA s 2.16 Medication Management 2.17 Equipment 2.18 Service User Choice 2.19 Care Programme Approach (CPA) Documentation 3. ROLES AND RESPONSIBILITES (DISCHARGE) 3.1 Role of Responsible Clinician and Medical Team 3.2 Role of Clinical Team / Ward Manager 3.3 Role of Nursing in Charge 3.4 Role of Named Nurse / Professional 3.5 Role of Occupational Therapy 3.6 Role of Care Co-coordinators/Nominated Representative 3.7 Role of Allied Health Professionals 3.8 Role of Social Services 3

5 3.9 Role of Community Mental Health Team 3.10 Role of Capacity and Flow Coordinators 3.11 Role of Ambulance Service 4. BENEFITS OF EFFECTIVE DISCHARGE 5. CONCLUSION 6. AUDIT AND MONITORING 7. TRAINING 8. DISTRIBUTION 9. REVIEW 10. REFERENCES 11. APPENDICES This policy should be read in conjunction with the Care Programme Approach document / Care Management guidelines and the Mental Health Act, 1983 Code of Practice. 4

6 INTRODUCTION 1.1 Rationale This policy has been compiled so as to ensure that discharge from, or transfer within Mersey Care NHS Trust is effective and efficient. It should be consistent across the Trust, with the exclusion of the Secure Division and encompasses a whole systems approach to care. The policy has been constructed to comply with the NHS Litigation Authority Risk Management Standards. This policy is based on the premise that admission to, transfer between, and discharge from services, should be seen as one integrated and seamless process. To view the policy otherwise, can lead to an inconsistent, delayed and unsatisfactory result for all involved. A whole system approach is one that recognises the contribution that all partners make to the delivery of person centred care. The whole system is not simply a collection of organisations that need to work together, but rather a variety of people, professionals, services and facilities that all have individual service users as their unifying concern. Working in partnership is essential in ensuring the effective discharge of service users and all agencies must accept their inter-dependency responsibilities and the fact that the action of any one of them may have an impact on the whole system. The different agencies must jointly agree as to the vision of the priorities of the service(s), the roles and responsibilities, the resources, the risks, the review mechanisms associated with effective discharge. From 1 April 1993, it has been the responsibility of the Local Authority to meet the Social Care and housing needs of service users, while the National Health Service has been responsible for the Continuing Healthcare of service users. It is the duty of the relevant Primary Care Trust and Local Authority to provide, in cooperation with relevant voluntary agencies, aftercare services for any person to whom section 117 of the Mental Health Act applies, until such time as the Primary Care Trust and the Local Authority are satisfied that the person concerned is no longer in need of such services. Mersey Care NHS Trust seeks to offer support and care to all individuals in an environment which is least restrictive, can meet individual needs & is as close to the persons home as is possible. Before admission into hospital, all other appropriate alternatives to meet individual needs will be considered i.e. intensive intervention at home with Crisis Resolution Home Treatment (CRHT), or admission into a short term facility as an alternative to an acute hospital inpatient bed. However, there are times when an individual who is experiencing mental health distress, a safe, secure and therapeutic inpatient environment is the favoured option. A Multi-Disciplinary Team approach is central to providing comprehensive care based on effective communication. This should be provided within the context of the Care Programme Approach (CPA). There are four main areas where an integrated whole system approach to working, underpins the discharge care pathway: 5

7 1 Capacity Planning 2 Reviewing Performance 3 Hospital discharge and inter-agency agreements 4 Development of integrated care pathways 1.2 Scope This policy covers the Local Divisions of Mersey Care NHS Trust. Within each area teams will have their own Operational Policy Documents, which themselves will include guidance on discharge and transfer. Within the above named Divisions there are the following Transitional Protocols; which will support the transfer of Service Users from one area to another: Adult / Older Adult services Forensic / Adult CAMHS / Adult Learning Disabilities / Adults / Older Adult Adult / Older Adult / Inpatient / Crisis Resolution and Home Treatment In addition, within each Care Area, there will be different scenarios requiring a range of procedures (see embedded documents) Discharge of Service Users from Mersey Care NHS Trust to another Trust, which may be either, another Mental Health Trust, an Acute Trust, or a Primary Care trust Discharge of Service Users to a Psychiatric Intensive Care Unit outside of Mersey Care NHS Trust Discharge of Service Users to Residential / Nursing Home environment, which will continue to require reviewing in line with the Local Authority Commissioning process. Transfer between Mersey Care NHS Trust and neighbouring NHS Trusts. This Policy should be read in conjunction with the Transfer of Care (Handover Policy) SD Objective The policy is essential in order that there is a strategic and operational approach to discharge planning so that there is a clear understanding of roles and responsibilities between Health and Social Care, Voluntary and Independent Sectors. It should be noted that all processes referred to are done so in the context of the Trusts Care Programme Approach Policy, compliance with the electronic recording system of epex and all Professional Codes of Conduct, the trusts Information Sharing and Information Governance Policies. The terms Discharge and Transfer are used interchangeably, although in essence, if a service user moves from one area of the Trust to another, this should be viewed as transfer. The term Discharge is often used to denote the 6

8 move. It is only when a Service Users care leaves Mersey Care NHS Trust, should this be considered a discharge. In any event, due process remains fundamentally the same, which ever scenario applies. There is no singular definition of discharge ; however Mersey Care NHS Trust considers discharge to mean the point at which the relevant Multi Disciplinary team decides that a services user is well enough to leave hospital or to be discharged from Community Services. The Responsible Clinician is pivotal to this process. However, discharge must not be seen as an isolated event. Discharge should be viewed as a process, which is planned as soon as a Service User is either admitted to hospital, or is being cared for by Community Services. Care is provided in line with the Recovery Model and wherever and whenever possible Service Users should be supported to return to move into alternative or / independent living environments. A discharge process can be considered to be either Simple or Complex. Approximately 80% of all discharges are deemed to be Simple. A Simple discharge is defined as when a Service User is discharged with no requirement for Health or Social Services input or follow up, other than from their own General Practitioner. A Complex discharge is defined as any other kind of discharge i.e. where a Service User needs to return for further appointments, requires transfer to an alternative environment such as a Care Home or alternative hospital, or who requires planned services within the community. All of the following issues need to be considered in planning and facilitating a Service User being able to leave hospital, be transferred within, or discharged from Trust service: 1. Discharge Planning 2. Roles and Responsibilities 3. Service User / Carer Information 4. Discharge of Service Users with Additional needs 5. Discharge from hospital Against Medical Advice 6. Service users refusing to be discharged 7. Medication upon discharge 8. Resolution of disputes 9. Information sharing requirements 1.4 POLICY STATEMENTS The Consultant, in conjunction with a Multi-Disciplinary Team, must be satisfied that every reasonable and practicable effort has been made to provide each Service User with the care he/she requires for his/her return to the community. Continuing care for those who require this should also be provided. The ultimate responsibility for discharge lies with the Responsible Clinician. 7

9 Professionals making decisions about discharge from hospital have a fundamental duty to consider both the safety of the Service User and the protection of other people. A Service User should not be discharged unless and until those making the decision are satisfied that he/she can live safely in the community, and that effective treatment, supervision, support and care are both accessible and available 24 hours a day / 7 days a week. Service Users who are subject to sections 3, 37, 45a, 47 or 48 of the Mental Health Act 1883 (unless subject to restriction) are considered for Supervised Discharge as part of normal discharge Section 117 planning. Any application for Supervised Discharge must be made whilst the Service User is detained under the Act. The Responsible Clinician overseeing a Service User s care may, once considered a requirement, discharge a Service User from hospital under a supervised Community Treatment Order (CTO). The order should specify variable conditions that the Service User must abide by, including the need to comply with treatment. This should be discussed with the Service User / Carer, planned in advance and formulated prior to discharge, so as not to delay the discharge process. All admissions into Mental Health in-patient services are considered for Care Programme Approach, therefore on discharge; all service users who exhibit a primary diagnosis of mental illness and were it is identified will be subject to CPA. These service users must have a Care Plan and Risk Assessment, which meets Care Programme Approach standards. Where required a Care Coordinator should also be allocated soon after admission, review date agreed and any other follow up appointments including seven day follow up and out-patient appointments. Whilst in hospital each Service User will have a Named Nurse/Professional who is responsible for his/her inpatient nursing care and for coordinating the individual Service Users discharge arrangements. This should be done in consultation with the Clinical / Multi-Disciplinary Team. In their absence the Ward Manager / nominated Deputy is responsible for co-ordinating discharge arrangements. 1.5 Principles of Good Practice To provide Service Users, Carers and Trust Staff with a framework for enabling timely, safe and appropriate admission to, discharge from and transfer within Trust services. To establish standards of practice in admission, care planning, discharge and transfer from one clinical are to another. To ensure that discharge is planned at the earliest opportunity across primary, community, intermediate, secondary and social services. To provide continuity of care through effective communication across all professionals and teams. 8

10 To clarify individual roles and responsibilities and timescales for each action. To minimise variation in Service User experience. To ensure consistency of experience for all service users, including equality of availability of least restrictive alternatives to in-patient admission. To support each individual and support equality of opportunity. To ensure each Service User and their Carers are physically and psychologically prepared for transfer or discharge to an agreed environment. To provide each Service User and their Carers with written and verbal information in meeting their needs on transfer or upon discharge. To facilitate a smooth transfer / discharge by ensuring that all identified health and social care need are addressed, and that all relevant documentation and information is relayed to those assuming responsibility of care. To ensure that Information governance principles, particularly in relation to confidentiality, data protection and information sharing are adhered to at all times during the transfer / discharge process. To minimise the occurrence of Delayed Discharges. To ensure that an up to date Risk Assessment contributes to the process To promote the highest possible level of independence for every service user / carer. To understand the range of services provided within Health and Social Care in order to facilitate the effective and timely discharge of Service Users from Mersey Care NHS Trust. Any Safeguarding Children / Adults / Vulnerable Adult issues are addressed in the assessment process, reviewed throughout the admission and again at discharge. Staff must refer to Mersey Care NHS Trust Safeguarding Policies and Procedures. The Health Visitor (for children) aged under 5, Social Worker for those aged 5-16 and the Care Coordinator of a Vulnerable Adult must be kept informed of the discharge / transfer arrangements. To ensure that for Service Users who are detained under the Mental Health Act (1983), that all statutory requirements are fully met. 9

11 The Service Users Capacity to Consent to any aspect of the process is established and recorded (NB Best Interest Checklist) The Service User / carer, and / or Independent Mental Capacity Advocate (as appropriate) is fully involved in this process as equal partners. To fully understand the role of the Service User, Family, Carer and those persons appointed under the terms of the Mental Capacity Act play, in the planning and the implementation of safe discharge. This is to ensure that the arrangements for discharge are least restrictive on the Service Users rights and freedom. It is essential that any discharge needs which are identified at an early stage are communicated to the appropriate professional so that the discharge plan can be developed i.e. the need to involve an IMCA at an early stage where the Service User is known to lack capacity and has no one to represent them. To ensure that all staff receives the required training with discharge planning arrangements unified assessment and Care Management. To ensure that every Service Users discharge is person centred, planned and seamless across Primary, Secondary and Community Care. To understand the links between other policies and how they impact upon the Transfer / Discharge process. The decision to discharge a Service User from Mersey Care NHS Trust services must be clearly recorded taking into account relevant risk factors. The discharge plan should clarify the role of other agencies who may be involved and the action/s they are expected to take. Particular care should be paid to discharge arrangements where the service user is being discharged out of the Trusts catchment area, to ensure adequate involvement, communications and formal agreement of the care plan with the new care team. Issues regarding Equality and Diversity needs are assessed and communicated between services, including: Cultural or religious needs Communication needs Gender Disability Age Sexual Orientation Carer s needs Advocacy needs NB Whilst there may be procedural differences between the Clinical Services, these underpinning principles apply throughout the Trust. 10

12 2 THE REQUIREMENTS AND ARRANGEMENTS FOR THE DISCHARGE AND TRANSFER OF SERVICE USERS WITHIN THE CARE PLANNING PROCESS. 2.1 The Purpose of Admission to Hospital The Mental Health Policy Implementation Guide Adult Acute In-patient Care Provision (DoH, 2002) and the National Service Framework for Older People Modern Standards and Service Models (DOH 2001), states that: The purpose of an adult acute psychiatric inpatient service is to provide a high standard of humane treatment and care in a safe and therapeutic setting for service users in the most acute and vulnerable stage of their illness. It should be for the benefit of those service users whose circumstances or acute care needs are such that they cannot at that time be treated and supported appropriately at home or in an alternative, less restrictive residential setting. In-patient admission may be indicated for severe mental illness, especially if there is a risk to the safety of the patient or others, or where particular problems require more intensive assessment and treatment. A full range of psychological and physical treatments should be available. When acute inpatient admission is indicated, the following questions need to be asked: Have all alternative methods of Care and Management in the Community been tried, without success? Why were they unsuccessful? Can the most probable reason(s) be identified? Categories of factors: Illness related Treatment related Psychosocial related Why is management in the community no longer possible or effective? Unacceptable level of risk to self / others Nature and degree of Mental Disorder (level of insight; compliance etc) Psychosocial factors (substance misuse, homelessness, public concern i.e. family, neighbours, law enforcement agencies etc.) Within the meaning of the MHA 1983 as amended by the MHA 2007: Discharge from hospital can be a major life event for both the Service User and Carer(s). It also has substantial implications for the use of Health and Social Care resources. Good quality discharge should not be a matter of chance (DoH 1994). This places a responsibility on all Health and Social Care professionals 11

13 involved in working together, in order to asses, plan and meet the needs of people leaving hospital (Henwood and Wistlow 1994). Strategic Health Authorities (SHAs) have to ensure that Health Care is provided in their local areas, whereas Primary Care Trusts (PCTs) are responsible for coordinating services and ensuring they are run efficiently (Shamash 2002). One of the key elements of the Clinical Governance Agenda is improved quality and effectiveness (DoH 1988). Hospital discharge arrangements are based upon legislation and guidance, and government initiatives have attempted to focus attention and resources away from acute hospital services to primary and preventative care (DoH, 1989, 1988) Avoidance of delays in discharge must be a priority for all staff. As soon as the acute phase of inpatient care is completed, those who are medically fit for transfer / discharge, should be discharged from acute hospital beds in a timely and safe manner to an alternative or their final destination. What happens during the discharge process direct form an Acute Ward is a key part of a Service Users experience of hospital care. Regardless of where the Service User is admitted from, they want to know how long they are likely to stay in hospital, information as to their treatment plan and when they can be expected to be discharged. This helps Service Users to feel involved in their decisions and motivates in achieving goals towards recovery. It also allows them to make plans for their own discharge. The key is to ensure that the inpatient beds that are needed are available before the demand for them builds up to an unmanageable level. Ensuring that discharge numbers match admission numbers is also pivotal, if large shifts in demand for beds is to be avoided. The aim of improving use of beds is to move from a system which reactively responds to undue bed pressures, to one where the timing of admissions and discharges is planned and delays at all stages of the Service User journey is minimised. As a result Service Users know how long they should expect to be in hospital and should also know in advance, the time of day they should expect to be discharged, so as to plan accordingly Service Users requiring admission can have confidence that their admission will not be cancelled, or delayed and that they will not have a long wait in accessing an acute inpatient bed The time professionals have to spend managing the results of mismatches between demand and capacity will reduce to allow time for Service User care. 2.2 National Standards That Apply To The Management Of Inpatient Care All service users should have a copy of their Care Plan which will include: Agreed services which will meet the needs of the service user. Identifies the roles of those who will provide these services. 12

14 The action to be taken in a crisis by the service user, their carer, and their Care Co-ordinator. Advises the GP how they should respond if the service user requires additional help Is regularly reviewed by their Care Co-ordinator [National Service Framework Standard 4]. All Care Plans should be made available across all the Trust sites 24 hours a day, 7 days a week [Healthcare Commission Performance Indicators for Mental Health Trusts]. 2.3 A Positive Outlook / Discharge Planning A Positive Outlook, a general practice toolkit to improve discharge from Inpatient Mental Health Care (Care service improvement partnerships 2007), contains clear messages about the needs and benefits of focusing on reducing present levels of occupancy and provides clear evidence, from the range of positive practices that makes a reduction achievable. Critical to good care planning must be a multi-professional comprehensive Risk Assessment informing the decision to admit and identifying when discharge readiness may be achieved. As such, an Estimated Date of Discharge (EDD) must be identified and discussed with the Service User / Carer within 7 days of admission. The EDD must be clearly documented and highlighted within the clinical notes. Central to the operation of this policy is the need for a Multi-Disciplinary approach based on effective communication that develops Care Plans to meet individual patient needs. Discharge planning should start at the point of admission. Planning for discharge and support after inpatient care should commence in the initial in-patient assessment stage and formulated as part of the inpatient care plan. This should were required, involve CRHT, in order to facilitate an early discharge. [Mental Health Policy Implementation Guide, Adult Acute Inpatient Care Provision 2002]. The Care Plan should be discussed and agreed with the Service User and where appropriate their Carers, throughout their stay and should be signed by Service User / Carers with a copy given to them. This also applies to the final discharge care plan which should be completed, mutually signed and provided at least 3 days prior to discharge but ideally on the latest day of discharge prior to leaving. Community based staff should be involved in hospital discharge planning from an early stage. The CPA provides a framework for care, wherever the service user is, including Residential, as well as Community settings. [Effective Care Co-ordination in Mental Health Services - DOH 1999] Clear communication & the sharing of information between all those involved in a persons care is central to prompt and effective discharge planning. This should include the highlighting of any issues which may require prompt intervention so that the length of stay and delay in discharge do not become protracted. 13

15 Multi Disciplinary Assessment should also focus on maintaining the Service User s accommodation in the community. Therefore it is important that Community services and resources are engaged and their involvement initiated at the earliest stage. 2.4 Mental Capacity Act 2005 For Service Users who lack capacity, the Mental Capacity Act 2005 must be applied with reference to the best Interests Checklist found under section 4 of the Mental Capacity Act Family / Carer s must be involved in decisions being made for the Service User and consideration given to instructing an Independent Mental Capacity Advocate (IMCA) if required, due to the nature of thee move, or in relation to treatment, or in other circumstances as appropriate. Person Centred Approach: The underlying philosophy of the Mental Capacity Act 2005 (MCA) is to ensure that individuals who lack capacity are the focus of any decisions made or actions taken, on their behalf. This requires an individual approach that prioritises the interests of the person who lacks capacity, not the views or convenience of those caring and supporting that individual. Staff should make every effort to ensure that vulnerable people are helped to make as many decisions as possible fro themselves. What is Capacity? Mental capacity in the context of the MCA means the ability to make a decision. A person s capacity to make a decision can be effected by a range of factors such as a stroke, dementia, a learning disability or a mental illness. People with a mental illness do not necessarily lack capacity. However, people with a severe and enduring mental illness may experience a temporary loss of capacity to make decisions about their care and treatment. A person s capacity may vary over time or according to the type of decision to be made. Physical conditions, such as an unfamiliar or intimidating environment, can also affect capacity, as can trauma, loss and health problems. A temporary lack of capacity will also include those who are unconscious or barely conscious whether due to an accident, being under anesthetic or as a result of other conditions or circumstances such as being under the influence of drugs or alcohol. Five core principles of the Mental Health Capacity Act (Mental Capacity Act, section 1: Code of Practice, Chapter 2): The following core principles must be followed in any assessment of or decision about a person s capacity. Staff who provide Health or Social Care will need to keep a record of all assessments and decisions they have made. This should be included in the person s records. The five core principles: 14

16 1. A person must be assumed to have capacity unless it is established that they lack capacity 2. A person should not be treated as unable to make a decision unless all practicable (doable) steps to help them to do so have been taken without success 3. A person is not to be treated as unable to make a decision merely because they made as unwise decision 4. An Act done or decision made, under this Act for / or on behalf of a person who lacks capacity must be done, or made, in their best interests. 5. Before the Act is done, or the decision is made, regard must be had as to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person s rights and freedom of action. Using the Mental Capacity Act in planning discharge from hospital: Regardless of whether or not a person is detained under the Mental Health Act, the individual s capacity to make decisions needs to be considered in planning for discharge from hospital. 2.5 Service Users Detained Under the Mental Health Act Service Users being moved from one Mersey Care NHS Trust site to another Mersey Care NHS Trust site for the purposes of acute mental health can be transferred under section 19(3) without the need to complete a form under section 19, as the hospital managers are the same. This then means a new Responsible Clinician can be allocated to the Service User at the new unit. This will be the most likely scenario for those moving for bed purposes for example. All areas should identify who will be responsible for coordinating the transfer arrangements. Only if Section 17 leave is used, perhaps to go for Electroconvulsive Therapy at another site, will the Responsible Clinician remain at the original hospital. If the Service User is going to remain at the other site for a period of time and it is within Mersey Care NHS Trust, the responsible Clinician can revoke the Section 17 leave and a section 19(3) transfer can be made, with a new Responsible Clinician allocated to the Service User at the new site. Those detained under Section 5(2) or section 5(4) cannot be moved under section 19(3) as other detained Service Users can. For restricted Service Users, the Secretary of State needs to give consent to any transfer. If a Service User is under Section 17 leave, the Responsible Clinician at the originating hospital technically retains responsibility for the Service User until the leave is revoked. Section 19 does not apply to those Service Users detained under Sections 5(2) and 5(4) these sections will be of no effect in another hospital; or 35, 36, 38 there is no mechanism in the Act to physically transfer authority to detain; the 15

17 authority for the Service User to be detained in another hospital can only be found with a fresh remand order from the Court. Service Users detained under Sections 135 or 136 can be moved from one place of safety to another (effective from 30 th April 2008). Service Users subject to Mental Health Act Restriction Orders or Directions (37/41, 44, 45A, 47/49 and 48/49 can only be transferred with the consent of the Secretary of State, obtained via a warrant from the Ministry of Justice (MoJ). However, Form 24 must still be completed to authorize the transfer of authority to detain. Detained Service Users who are moving from one hospital to another both managed by the same authority, can be moved without formality under Section 19(3) Mersey Care NHS Trust has an internal transfer form, which is completed by Mental Health Act Administration. Discharge Planning Meetings are to include multi-agency professionals where a definitive discharge plan is agreed with the Service User, Family / Carer. The agreement should be clearly documented in the Service Users records. All service users with a history of serious self-harm, previous serious suicide attempts and a diagnosis of depressive disorder should be seen within 48 hours post discharge (Preventing suicide A Toolkit for Mental Health Services ). All Service Users excluding the above, who are subject to CPA must be contacted and seen within 7 days post-discharge from hospital. [Healthcare Commission Performance Indicator Admission and Discharge Standards]. Original Trust documentation should not be taken outside of the Trust. The transferring team must therefore ensure that sufficient clinical information is copied and handed over to the receiving trust to ensure safe and seamless transfer of care and treatment. This documentation must include: Basic Service User information Needs Assessment Risk Assessment Most recent and up to date CPA Care Plan Nursing Care Plan / Notes Most recent MDT review Discharge summary / Responsible Clinician report (once available) Prescription Chart Minimum last 72 hours progress notes Staff must ensure that third party information is not copied and shared without the prior consent of the person who initially wrote / provided the information. Staff must also ensure that the information securely and safely and that Mersey Care NHS Trust Information Governance Policy is adhered to. 16

18 2.6 Section 117 of the Mental Health Act Patients detained under Sections 3, 37, 37/41, 45A, 47, 47/49, 48 or 48/49 of the Mental Health Act have a statutory entitlement to a needs assessed package of mental health aftercare. Section 117 aftercare must be offered for as long as it is deemed that they need it. Need is determined as providing a service that reduces the likelihood of serious relapse of an individual s mental health likely to require readmission to hospital. The provision of s.117 aftercare is the joint responsibility of the local health authority and the local social services authority. 2.7 Leave of Absence Leave of absence from the ward or unit is often used as an adjunct to the discharge process. Where required, service users may be granted short (overnight or weekend) periods away from the ward usually in the service users own home, but occasionally with formal or informal carers in alternative locations. Given that the service user is not yet ready for discharge it must be assumed that there are still needs, which cannot be fully met in the community. It follows then, that all leave periods involving overnight stays, must be planned carefully using the Care Programme Approach as outlined within this policy. As not all aspects of CPA will be applicable, certain key matters must be addressed before the service user proceeds on even the shortest period of overnight leave. These are: For both voluntary and detained service users, all leave periods must be authorised by the Responsible Clinician or alternative appointed doctor. The leave period must form part of a programme of care and as such an associated written plan of care must be discussed and agreed with the Service User / Carers, formulated and clearly documented. Immediately before leaving the ward / unit and proceeding on leave the service user is seen by a suitably experienced, qualified nurse who will make a final assessment of the service user, so as to determine that there is no evidence of gross deterioration. The nurse will record his / her findings in the clinical notes, which will reflect a comprehensive assessment. (NB entries such as the service user has proceeded on leave must be avoided). Clear instructions as to when the service user will be expected to return to the ward / unit should be provided. This will include the action the service user / carer must take if this is not possible. Additionally, instructions should be clear to fellow nursing staff, service user / carers as to the action that will be taken, should the service user fail to return to the ward / unit as agreed. Where the service user has been subject to general anaesthesia on the day of leave (e.g. due to undergoing Electro-convulsive therapy) a responsible adult is available to stay with the service user for the following 24 hours from the time of the administration of anaesthesia. Unless essential, leave periods should commence at the earliest possible time of day, when services are more readily available to support the transition from hospital to community. Those returning from weekend leave should, where possible do so on the morning of review when support services are generally more available to facilitate their safe return. Due to optimised out of hours bed 17

19 usage, returning from weekend leave on a Sunday evening (or Bank Holiday) should be avoided. Any medication required by the service user during the period of leave must be ordered and obtained in advance and before leave commences. This should where practicable, be issued as early as possible on the morning of leave and as the service user is leaving the ward / unit. Details of the service users leave arrangements must be communicated to other professionals concerned with their care, in particular the CPA Care Coordinator. Extended leave is a period of leave which exceeds 5 days and must only be granted in exceptional circumstances. As an alternative early discharge under the care of CRHT team should be considered. The CPA documentation must contain a clear crisis plan which addresses the actions to be taken in the event of the leave process breaking down. The service user / carers must be provided with all relevant contact numbers, which will be explicit within the information Day In-patient Review Any Service User who has been in a Ward / Unit for more than 30 days should have a 30 day Inpatient Review. It is the responsibility of the Ward Managers or nominated deputy to arrange this structured meeting. The purpose of the review is to ensure that Care, Treatment & Management Plan is re-evaluated. The meeting should review the Discharge Plan & document the rationale for extended length of stay in the Care Record. With the exception of Forensic and Addictions, each area should involve the Capacity & Flow coordinator within the meeting, whose role is to provide guidance to the team and/or discuss appropriate solutions, including short term alternatives, acting as the conduit between inpatient & community services. 2.9 Community Treatment Orders Aftercare under Supervision (sections 25A-25J) was repealed by the MHA 2007, effective from 3/11/2008. The same Act introduced Community Treatment Orders (sections 17A-17G) which effectively replaces Aftercare Under Supervision. Like its predecessor, Community Treatment Orders (CTOs) apply to patients detained under section 3, 37, 47, 49 or 45A (where the Limitation Order has been lifted). It enables the Responsible Clinician to discharge those patients from hospital without full discharge of their detention which is suspended for the duration of the CTO. Discharge is dependent upon specific conditions which if breached authorises the Trust to recall that patient to hospital. On recall the patient must be assessed by the Responsible Clinician who will decide whether or not to revoke the CTO which would have the effect of reactivating the suspended detention order Discharge Against Medical Advice Should a Service User decide he / she wishes to leave hospital and take his / her own discharge the Nurse in Charge must discuss with the Service User the 18

20 reasons for wanting to leave and all attempts made to dissuade the Service User from doing so. Service Users requesting to Discharge Against Medical Advice must be asked to complete the Discharge Against Medical Advice form (See Appendix 2). An urgent review by Medical / Nursing staff should be completed to ensure the service user is Fit for Discharge. Should the Service User refuse to complete the necessary form, their Responsible Clinician / Medical Staff must clearly document this information within the Service Users records along with any appropriate aftercare arrangements Deprivation of Liberty Safeguards (DoLS) As part of the discharge planning process for an individual who is leaving hospital to go into 24 hour residential care, the need for a standard authorisation under the Deprivation of Liberty safeguards should be considered. If it is felt by the team that this is required, the authorisation should be applied for and in place before the individual leaves hospital. Individuals who have been in hospital should not, as a matter of good practice, be transferred on an urgent authorisation. If an individual is in hospital under a current standard authorisation this is not transferable to an alternative address, a new assessment will be required Delayed Discharge Arrangements Following admission and where a delay in discharge is anticipated due to complexities within the case, a Responsible Clinician / Multi-Disciplinary Team meeting should be held in order to address this. Where appropriate Service Users / Carers and significant others must also be involved. With the exception of Addictions and Forensic Service, the Trust Capacity and Flow Coordinator Services should also be invited to attend, whose role is to assist clinical teams in suggesting suitable alternatives to hospital settings, in order to support with discharge planning. An agreed discharge date should also be set, which should be recorded and managed within the process described (See appendix 3). Service Users who no longer require inpatient care to manage their acute care needs should be referred to the CRHT service without delay for assessment in order to facilitate early discharge into the community. Once discharge is agreed upon, Mersey Care NHS Trust will ensure: That a discharge checklist is completed, and where necessary arrange the transfer arrangements to any other facility. That the letter of discharge has been completed and is forwarded to the relevant person e.g. GP, Care Coordinator at another hospital, and any other relevant professionals involved in any safeguarding children and adult issues etc. All Service Users have been given the opportunity to receive copies of their correspondence. If required, suitable transport is arranged. This should be discussed in advance with the Service User and his / her Family / Carer. Service Users should be encouraged to make their own transport arrangements if being discharged home / alternative community setting. If this is not 19

21 possible, other alternatives should be considered dependent upon the presentation and Risk Assessment of the Service User / circumstance. e.g. ambulance, police. That discharge takes place at the earliest possible time of day 7 days a week, provided services are available for a safe and effective discharge. That the Service User is provided with discharge information with relevant contact numbers in addition to information about Local and Trust services. Date of 48 hour / 7 day follow up arrangements (in accordance with Mersey Care NHS Trust procedures). That relevant medication is provided upon discharge and instructions as to its use are provided. Service Users property is returned to them and signed for That discussions relating to discharge are accurately recorded in the Service Users notes. Consideration is given to interim / intermediate care where appropriate if a placement is delaying discharge from a hospital bed. The assessment for and the delivery of Continuing Health and Social care, is organised so that individuals understand the continuum of Health and Social Care Services, their rights and choices and they receive advice and information to enable them to make informed decision about their future care. In those situations where a Service User does not have capacity to make such decisions, it will be necessary to ascertain if there are decision making mechanisms in place as provided by the mental Capacity Act. Where there are no such decisions their best interests must be acted upon, taking into account any previously known wishes, including the views of their family and Carers. This will be done in conjunction with the Responsible Clinician overseeing the clinical care of the Service User, in conjunction with the Multi Disciplinary Team, Family / Parent / Carer(s). Service Users, who are detained under the relevant sections of the Mental Health Act 1983 and its amendments, can only be discharged in accordance with statutory requirements. The epex Record system is completed accordingly Transfer Within Services (Community) Where transfer form one community team to another is indicated e.g. when a Service User has registered with a new GP Practice, there must be a properly planned process so as to ensure a seamless handover of care. Transfer will not usually occur during a clinical episode i.e. during admission or a period of Home Treatment. Transfer should take place following agreement between relevant teams. Prior to transfer of CPA meeting should take place attended by all relevant parties and resultant CPA documentation disseminated. Please see Mersey Care NHS Trust CPA policy for comprehensive guidelines. 20

22 The importance of timely and comprehensive handover of information, both verbal and written, when transferring a service user from one care team to another cannot be overstated and underpins all the guidance above Service User Discharge Information Service Users who are being discharged from hospital have the right to: Full information regarding their diagnosis and assessment of their health and social needs in preparation for discharge. Be fully involved in planning their own discharge, together with a Relative, Carer or Friend as appropriate. Have the discharge plan start on or before admission where possible. Full information on the services available in the community relevant to their care, including local substance misuse services where relevant. Full information on short or long-term Nursing or Residential Care, including financial implications. Be provided with telephone contact numbers for help or advice postdischarge. Be provided with a clear, legible discharge letter detailing the support services provided for them (where appropriate). Full information on eligibility criteria for NHS continuing healthcare (where appropriate). Consider whether a review of a personal budget (Direct Payments), needs to be agreed. Information on PALS and Advocacy support. Access to Mersey Care NHS Trust Complaints Procedure and any complaint regarding their discharge arrangements investigated and a full explanation provided, as with any other complaint made to the Trust. If still not satisfied, then the Service User / Parent / IMCA and Carer(s) will be given access to the Health Service Ombudsman. NB: If the service user is eligible under Section 117 of the Mental Health Act, correct procedure should be followed Involving Service users / Parents / IMCA s and Carers: The engagement and active participation of individuals and their carer(s) or IMCA s as equal partners is central to the delivery of care and in the planning of a successful discharge. A person-centred approach must also recognise the important contribution made by parents, IMCA s and carers. It is important to remember that young people also may be carers and that they should be offered a carer(s) assessment if they are under 16 years of age, when the adult receives a community care assessment. 21

23 Person-centred care must be much more than just keeping the service user informed and up-to-date with decisions about their care as passive players in the process. Professionals bring the professional and technical expertise, service users/parents and carer(s) bring their individual experience, expertise and aspirations. The provision of information examined at a pace that is suitable for the individual, will allow any questions and concerns to be raised. Care must be taken to ensure that a service user who has communication difficulties, e.g. after a stroke, is involved as fully as possible in planning his or her care. Pre-admission assessment also helps the Service User and Carer plan for admission into hospital and to understand what to expect and prepare for on return home. The admission process is the critical time to explain to Service Users and their Carer(s) what to expect and how they are to be involved in key decisions, remembering that they are the experts in how they feel and what it is like to live with, or care for, someone with a particular condition or disability. Any form of communication must take account of the individual s ability to understand and absorb information. The same information will need to be available in plain language and in a variety of appropriate forms. This should include, for example, appropriate ethnic and minority languages and presentations in large print, Braille and British Sign Language. Other formats might also be appropriate including audiotapes and visual formats such as interactive CD-ROM, in accordance with Mersey Care NHS Trust procedures. For some Service Users it will be necessary to involve an IMCA or interpreter to provide further assistance. Every effort must be made to ensure consistency and continuity of information from different personnel. Full information on the services available in the community relevant to their care must be provided to service users and their carer(s). Full information on short-or long-term Nursing or Residential Care, including financial implications must be provided and discussed. The Service User/ Parent / IMCA or Carer(s) must be provided with an appropriate contact number where they can get help or advice on discharge. The Service User / Parent or Carer(s) must be given a clear, legible discharge letter detailing the support services provided for them (where appropriate). The Service User / Parent / IMCA or Carer(s) must be given full information on eligibility criteria for Continuing Care. An identified point of contact will be available to offer support and 22

24 advice to service users, parents, carer(s), statutory and voluntary agencies, where appropriate. The Service User / Parent / IMCA or Carer(s) will be provided with information on advocacy support Medication Management Medication Management plays an important role in preparing Service Users / Parents and their Carer(s) for transfer / discharge, either from hospital or Community Team which has an impact on the recovery and / or maintenance of their conditions following discharge. Any medication or dressings required by the Service User on discharge from hospital should be requested from Pharmacy at least 24 hours in advance. The Nurse in Charge / Care Coordinator has the responsibility of ensuring the Service User / Parent and / or Carer understands the importance of the medication being taken to ensure compliance. An assessment of their ability to self medicate must also be made and if the Service User requires assistance on discharge this must be communicated to the appropriate Health and Social Care professionals. This will include any Domiciliary Care Agencies Equipment Any equipment requirements should be assessed in advance of admission, transfer or discharge and arrangements put in place to secure delivery in alignment with an identified and agreed date. Service Users / Parents and Carer(s) should be trained in the use of any equipment. Follow-up arrangements should be made as necessary to check equipment provided is adequate and being used correctly. Information provided to the Service User will cover the procedure for return. Service Users / Parents may require equipment or adaptations to help them manage at home, or for their carer(s) to be able to care for them safely. Traditionally, responsibility for providing equipment has been split between the NHS and Local Authority Social Services Departments. It is important that all Health and Social Care professionals understand the processes to following those situation Service User Choice Service Users and their carers should be consulted on and help determine the most appropriate placement and care package available to them in achieving discharge from ward or community services. Where a Service User and / or Carers do not agree on the arrangements the guidance produced at Appendix 4 of this policy should be followed (See Appendix 4) Care Programme Approach (CPA) Documentation 23

25 The Mersey Care NHS Trust standard Care Programme Approach (CPA) documentation which relate and apply to the arrangements referred to within this Discharge/Transfer Policy should be utilised in respect of recording appropriately agreed discharge planning arrangements and these documents can be located on the Trust s web site Policy No: SD Out of Hours Discharge Process It will not be routine to discharge patients out of hours as it is a planned process, however, in the event that an unplanned or out of hours discharge occurs the process outlined within this policy document will be followed and recorded in the health records. 3 ROLES AND RESPONSIBILITIES (DISCHARGE) 3.1. Executive Director of Nursing & Secure Services The Executive Director of Nursing and Care is the Trust Board member with the overarching responsibility for ensuring that a policy for the effective discharge and transfer of service users exists, that the policy is implemented effectively, that all staff are aware of and operate within the requirements of the policy and that systems are in place for the effective monitoring of the standards contained within the policy Role of Responsible Clinician and Medical Team As Responsible Clinician (RC), the Consultant Psychiatrist is responsible for discharging duties under the Mental Health Act or delegating these when appropriate in liaison with the multi-disciplinary team. 1) Prior to, or as soon as possible following admission, a Consultant / Medical Staff will explain to the Service User and/or Carer, the Service User's treatment plan and provide information including length of stay, an estimated discharge date (EDD) and support likely to be needed on discharge. This information should be recorded in the service user s clinical notes. 2) If discharge medication is required, a member of the medical staff must complete the appropriate discharge medication forms. 3) Ensure all Service Users who have been identified as requiring CPA have a Care Coordinator appointed and an associated aftercare plan. 4) Discuss concerns raised by Service Users, relatives and other professionals with regard to discharge arrangements. 5) Clearly document on discharge what medical interventions will be required e.g. Out-patients appointment. 6) Provide the Service User with certificates needed to enable him / her to claim entitled benefits. 24

26 7) Check discharge summary on day of discharge, prepared by Named Nurse, particularly the diagnosis and medication and authorise with a signature. A copy must be offered to the Service User. 8) Ensure that, in the event of a Service User discharging him/herself against medical advice, the General Practitioner and Care Coordinator / team offering follow up are notified within 24 hours (by telephone) and that where required a review meeting is organised. 9) Dispatch formal discharge letter to General practitioner within two weeks (ten working days) of Service Users discharge Role of Clinical Team / Ward Manager 1) It is the responsibility of the Manager to ensure, adherence to this policy and procedure that Service Users have a Named Nurse / Professional and that at the point of discharge a checklist of procedures specific to that area of the service are carried out. 2) Upon discharge it is the responsibility of the Ward Manager / Deputy to ensure the Service User's GP/ CMHT is notified, by completing & faxing the discharge form (See Appendix 5). A more comprehensive discharge letter will be sent to the GP within ten working days of discharge by the RC or member of the medical team. 3) The Service User's Next of Kin / Carer / significant other & Community Team (Care Co-ordinator) should be informed of discharge, unless the Service User specifically states they do not wish to consent to this. Such statements must be recorded and witnessed in the Service User's notes. 3.4 Role of Nurse in Charge In addition to those duties identified under Discharge against Medical Advice, the nurse in charge of the relevant ward / unit is usually the last professional to have contact with the Service User prior to discharge and as such has specific responsibilities. 1) Ensure that the Service User has necessary medication (enough to last until with either the GP or Consultant as appropriate) and understands the verbal and written instructions given to him / her. 2) Where the Service Users on-going medication is to be provided by the GP, the Nurse in Charge should advise the Service User to make an appointment, giving necessary assistance and advice as required. 3) Ensure that any property, including valuables, are returned to the Service User and a receipt obtained Role of Named Nurse/Professional The Named Nurse is responsible for coordinating service users discharge arrangements as well as their in-patient care and as such must ensure that the 25

27 Care Co-ordinator or alternative nominated person is aware of transfer / discharge, if they were not directly involved in the process. 1) Discharge notification should be completed within 24 hours of discharge. It should be identified who is best placed to complete this task on discharge. 2) When preparing for discharge, the Named Nurse is to ensure that everyone involved with the Service Users care planning is invited to the CPA Discharge Planning meeting, including CMHT staff / Care Coordinator, Carers, Inpatient Multi Disciplinary Team and those with any other relevant responsibilities. As much notice as possible should be given. 3) If a Service User is discharged at short notice or takes their own discharge, the Named Nurse / ward staff need to communicate this to all staff involved in care package to ensure that follow up can be arranged by the next working day. 4) For all planned discharges, ensure that the date and time of discharge is discussed with the Service User, Carer and where applicable, Care coordinator, and that arrangements for escort from the ward are available. 5) Ensure that an Out patients / alternative follow up appointment (where applicable) is arranged and the Service User notified of the date / time, prior to leaving the ward. 6) Ensure the Service User has a copy of his / her CPA Care Plan and understands its contents, including how to contact the Care coordinator and who to contact in an emergency (including out of hours). 7) Complete the discharge checklist and enter in to Service Users records. 8) Arrange for a Practitioner to make direct contact with the Service User within maximum of seven days of discharge from hospital. 3.6 Role of Occupational Therapist The aim of the Occupational Therapy service is to provide functional assessment and treatment for all service users admitted into Inpatient services. The Occupational Therapy team is a critical part of the multi-disciplinary team and aim to work collaboratively with service users to promote recovery and appropriate discharge. Occupational Therapy is founded upon the belief that individuals have the potential to influence their own health through the use of meaningful activities or occupations. The therapeutic potential of purposeful and meaningful activity is seen as central to promoting recovery and wellbeing. By grading and adapting activity which is meaningful to the individual service users they can be empowered to develop life skills and coping mechanisms which enhance their function and life roles. 26

28 1) All service users admitted to Inpatient services will be seen by an Occupational Therapist within three days of admission to perform a baseline functional and risk assessment. 2) Referral to Occupational Therapy for specific assessment and intervention can be made by the multi-disciplinary team at any point during the admission. No formal referral form is required due to the nature of internal referral process. 3) Detailed occupational performance assessments will be made during a Service Users inpatient admission at the most appropriate time of their recovery and in preparation for discharge planning. 4) Prior to their discharge, the Occupational Therapy service, where appropriate, should provide Occupational Therapy assessments in the same environment to assist with discharge planning. 3.7 Role of Care Co-coordinators/Nominated Representative Care Co-ordinators will be identified as part of CPA and may come from any discipline. Many Service Users have Care Coordinators involved prior to their admission. He / she will maintain his/her involvement during an individuals inpatient care and will be actively involved in the Service Users discharge. 1) The Care Co-ordinator must maintain sufficient contact with the service user whilst in hospital and advice colleagues of changes in circumstances. 2) The Care Co-ordinator must meet a service user prior to discharge from hospital and attend all relevant MDT meetings. 3) The Care Co-ordinator will be responsible for monitoring the delivery of care in the community. 4) The Care Co-ordinator will be responsible for arranging review meetings. 5) The Care Co-ordinator will be responsible for arranging alternative points of contact when the Care Co-ordinator is not available. 6) Care Co-ordinator will maintain CPA document following discharge. 7) Inform relevant parties of the termination of CPA/Section ) The Care Co-ordinator should maintain links with the service user, family/carers and other community support 9) The Care Co-ordinator will maintain links with other providers of care e.g. residential/nursing home/supported accommodation. 10) The Care Co-coordinator should assist in identifying and meeting accommodation requirements, working with other agencies to accommodate the service user s needs. 27

29 11) It is the responsibility of the Care Co-ordinator to ensure Discharge Care Plan is completed. 12) The Care Co-ordinator should meet the service user at least once prior to discharge, to help prepare the Discharge Plan and CPA documentation. 13) If the Care Co-ordinator cannot attend, a nominated Deputy should be identified. Any clinical team meetings arranged to consider discharge must also be attended by either the Care Co-ordinator or nominated deputy. 14) At the Discharge CPA Meeting, the arrangements for the seven-day follow up contact should be agreed with the service user and recorded in the relevant part of the CPA Care Plan. Once contact has been made, this should be recorded on EPEX. 15) Follow-up appointments, with the Care Co-ordinator need to be made within five working days, if applicable, to be agreed at Discharge CPA. Both service user and Carer should be aware of arrangements and contact names and telephone numbers should be given in writing to the user and Carer. A copy of the completed CPA form should be provided for both service user and Carer. 16) Identify if the Service User is entitled to aftercare under Sec.117 Mental Health Act [i.e. in this admission or previous admissions they were detained under any of the following sections on the Mental Health Act 1983]: - Sec. 3, Sec.37, Sec. 45A, Sec.47, Sec r if they are granted leave under Sec Role of Allied Health Professionals All appropriate Clinical Services should have been involved in the discharge care plan via the Care Programme Approach. 1) All discharge arrangements will be discussed and agreed with the Service User and other relevant agencies before the end of that episode of care and in conjunction with the Responsible Clinician and Multi Disciplinary Team. 2) All Service Users using the Allied Health Professional Services while an in-patient will be given a review appointment including a contact name and telephone number where appropriate. 3) Where relevant, all Service Users will be discharged from Allied Health professionals care with the prescribed aids and individualized home programme / intervention. 4) Allied health Professionals Services should liaise with the Local Authority Services for provision of disability equipment and adaptations if appropriate. 28

30 3.9 Role of Social Services Depending on the requirements of the Service User, Social Workers work as part of the Community Mental health Teams, as part of Hospital Social Work Teams, or as part of generic Community Social Work teams. The role and function of the Social Worker in connection with the discharge of Service Users from hospital includes preparing Service Users and Relative/s in readiness for discharge and assessing the appropriateness of social support services being provided, including housing. The range of services from which the Social Services Department is responsible includes Domiciliary Help and Support and Care, Residential Care services including Nursing Home provision and the provision of Disability equipment and home adaptations Role of Capacity and Flow Coordinator Mersey Care NHS Trust has appointed Capacity and Flow Coordinators within in each Service (with the exception of Forensic and Addictions Services). The role of the Capacity and Flow Coordinator is to provide leadership and support in ensuring efficient use of capacity, taking a whole systems approach to capacity flow and discharge planning process, liaising with stakeholders, local authorities and commissioners to ensure services have access to accommodation that best meets the needs of Service Users, fostering effective communication to manage the interface with all agencies with the exception of Forensic and Addiction Services (See Appendix 7) Role of Ambulance Service The ordering of the ambulance transport should be made to Mersey Regional Ambulance Services with as much notice as practically possible so that the correct arrangements can be made. The onus in deciding the type of transport required and categorization of the Service User is with the person booking the ambulance. The ambulance service should be informed at the time of booking of any special arrangements for equipment to accompany the Service User and any arrangements that have been made for a relative or friend to receive the Service User at the identified destination. Where a request is made for journeys outside of Mersey Care NHS Trust, it is the responsibility of the ambulance service to inform the Ward Manager of any costs to be charged. It is the responsibility of the ambulance crew to inform staff on the discharge ward if there is no-one at home to receive the Service User whom they have been told should not be left in the house alone. If they have any concerns about the welfare of the Service User the crew should be requested to notify Ambulance Control. 4. BENEFITS OF EFFECTIVE DISCHARGE Service user or Family Needs are met Able to maximize independence Feel part of the care process, an active partner and not disempowered 29

31 Do not experience unnecessary gaps or duplication of effort Understand and agree to the care plan Motivated in achieving goals towards re-enablement Experience care as a coherent pathway, not a series of unrelated activities Believe they have been supported and have made the right decisions about their future care Carer/family/IMCA Feel valued as partners in the discharge process Consider their knowledge has been used appropriately Are aware of their right to have their needs identified and met Feel confident of continued support in their caring role and get support before becomes a problem Have the right information and advice to help them in their caring role Are given a choice about undertaking a caring role Understand what has happened and who to contact Health and Social Care Professionals Feel their expertise is recognised and used appropriately Receive key information in a timely manner Understand their part in the system Can develop new skills and roles Have opportunities to work in different settings and in different ways. Work within a system which enables them to do so effectively Organisations Resources are used to best effect Service is valued by the local community Staff feel valued which, in turn, leads to improved recruitment and retention 30

32 Meet targets and can therefore concentrate on service delivery Fewer complaints Positive relationships with other local providers of health and social care and housing services Avoidance of blame and disputes over responsibility for delays Information Governance principles are adhered to in respect of privacy/confidentiality and information sharing CONCLUSION Good communication is a pre-requisite for a well co-coordinated service user journey from preadmission through to discharge. Staffs involved in discharge planning are frequently working to conflicting pressures and priorities between organisations, professions and service users, IMCA s, carer(s) and relatives. It is essential that there is communication at all levels within a system if there is to be effective partnership working between organisations and between staff and the service users, carer(s) they are working with. This also needs to extend to communication with the wider public about service plans, priorities, pressures, access routes and the roles and responsibilities of different organisations. Effective information sharing must be handled safely and securely in line with the Trust s Information Governance and Information Sharing policies in order to protect both the service users and the organisation(s) (and staff) involved. Effective discharge can in most cases begin before admission and where this happens it is essential that appropriate assessments of needs are carried out by competent individuals and that information is communicated to professionals and carers. Each service user discharged from hospital will have a discharge plan which will reflect where appropriate Unified Assessment and Care Management. In the case of children this will reflect the standards outlined in the National Service Framework and Continuing Care Management for Children. Staff must consider, as part of any plans to discharge or transfer a service user if the service user is likely to have, or resume contact with their own child, or any other children in their network of family and friends (even when the children are not living with the service user) (NPSA 2009). Delayed discharge can lead to stress, boredom, increase in self harm behaviour, violence and dependency and decrease staff morale and should be avoided. Medicine management forms a crucial part of the discharge process. Refer to Trust Policy on Medicine Management. Medication should be ordered in advance of the discharge date to ensure supply is available on the day of discharge. Service users should have an understanding or their medication prior 31

33 to discharge, where and how to get further supply and how to take their medication. Identify formal obligations in accordance with health and social care policy and legislation, including section 117 Aftercare refer to Trust Procedures relating to the Mental Health Act. Ensure discharges are spread over the days of the week and do not peak on certain days Identify any carers, and ensure that carer s needs, specifically relating to discharge and transfer are addressed. Ensure that assessments and care plans, including discharge plans identify actions that relate specifically to the home situation, such as, payment of bills, looking after pets, taking care of relatives, keeping in touch with work etc. Ensure that consent is sought for the sharing of clinical documentation with any new healthcare provider or that risks are mitigated for sharing information without consent. Discharge from services is a planned process, following a multi-disciplinary discussion and actively incorporates the views of the service user and carers. All relevant information in relation to risk assessments is passed on to those responsible for care. Exceptions to this may occur when discharge is at short notice or is against medical advice. In either event the statutory obligations of the Mental Health Act 1983 (as amended by the 2007 Act) and Mental Capacity Act (2005) should be considered where appropriate i.e., if the service user has been detained then reference needs to be made to the Mental Health Act 1983 (as amended by the 2007 Act) Policy. 32

34 6. AUDIT AND MONITORING Process for Monitoring e.g. audit Responsible Individual Group or Committee Frequency of Monitoring Responsible individual group or Committee for Review of Results & Action Planning Care Records Audit Team or Ward Manager Quarterly Service Director and Governance Forums Delayed Discharges Monitored by Mersey Care NHS Trust Performance Unit Weekly Service Director and Governance Forums AIM (Accreditation for Inpatient Mental Health Services) by Royal College of Psychiatrists Centre for Quality Improvement. Ward Manager RCP Annually Service Director and Governance Forums 72 hour and 7 day follow up / Readmissions / Length of Stay and HONOS Monitored by Mersey Care NHS Trust Performance Unit Weekly Service Director and Governance Forums 7.0. Training The Executive Director of Nursing and Care will ensure the Learning and Development Team make available appropriate training to staff who require it which bests support the transfer and discharge arrangements described within this policy based on the Trust s Training Needs Analysis DISTRIBUTION This policy and its related procedures will be available from the policy unit and onto the Trust Intranet REVIEW This policy will be reviewed every 3 years. 10. REFERENCES Mental Health Act 1983 (as amended by the Mental Health Act 33

35 2007) Mental Capacity Act 2005 CSIP (2007) A Positive Outlook A good practice toolkit to improve discharge from inpatient mental health care Department of Health (1998) The New NHS modern & dependable. London: HMSO Department of Health (1999) - Effective Care co-ordination in Mental Health Services. Modernising the Care Programme Approach - London: DoH Department of Health (1999) National Service Framework for Mental Health - London: DoH Department of Health (2001) Mental Health Policy Implementation Guide Department of Health (2002) Mental Health Policy Implementation Guide: Adult acute inpatient care provision Department of Health (2003) Discharge from Hospital: Pathway, Process and Practice. London: DoH Department of Health (2006) from values to action: the Chief Nursing Officer s review of mental health nursing Department of Health (2007). The National Framework for NHS Continuing Healthcare & NHS Funded Nursing Care NHSE (National Health Service Executive) (1999) Effective Care Coordination in Mental Health Services. London: DoH NHSE (1994) Hospital Discharge Workbook, A Manual of Hospital Discharge Practices. London: DoH Health and Social Care Joint Unit and Change Agent Team (2003) Discharge from hospital pathways, process and practice, Department of Health: London. Health and Social Care Joint Unit and Change Agent Team (2003) Discharge from hospital: pathways, process and practice, Department of Health: London. National Audit Office (2003) Ensuring the effective discharge of older service users from NHS Acute Hospitals, National Audit Office: London. 34

36 Appendix 1 MERSEY CARE NHS TRUST ADULT MENTAL HEALTH 30 DAY IN-PATIENT REVIEW GUIDELINES The number of service users who require to be admitted in to our in-patients with complex needs and who require an extended period of care in our patients units has increased. Adult Mental Health has had a standard for the 60 Day In- Patient Review in place for some time. This review is to ensure that patients have their in-patient admission re-evaluated and to develop a plan which discusses the reason for extended length of stay, to discuss care pathways and a proposed discharge plan. The meeting should include senior staff from the unit, who are not part of the Multi Disciplinary Team to give, where appropriate, some guidance to the team and / or discuss appropriate solutions to any problems encountered. The targets to reduce the length of stay for our service users is currently 30 days, this is set by the Commissioners Teams, which now means that we need to reduce our reviews to a 30 Day In-Patient Review. This review will call for Ward Managers, Named Nurses and Care Co-ordinators to work together to alert each Multi Disciplinary / Acute Team that a 30 Day In-Patient Review is required. It is the responsibility of the Ward Manager or nominated Deputy to arrange the structured meeting. It is important when organising the meeting that a Ward Manager or nominated Deputy and a Senior Manager from the local Management Team, along with other appropriate clinicians, are invited to the meeting, this will hopefully assist the teams to review if 35

37 necessary and develop an action plan for discharge. This review needs to have a organised approach and be incorporated into clinical notes. There is a proforma attached as a guide to the structure to the meetings. Clinical placement will highlight when a review is required and bring it to the attention of the Bed Management Group. These guidelines need to be used in conjunction with the In- Patient Operational Policy, Appendix 8, Nursing Preparation for Ward MDT Meeting, and Appendix 10, Multi Disciplinary Team Meetings, prompts for record keeping. MATTY BYRNE - Professional Project Manager Dec

38 MERSEY CARE NHS TRUST ADULT MENTAL HEALTH 30 DAY REVIEW PROFORMA Name: Date of Birth: Epex No.: Address: Community Team: Care Co-ordinator: Present: Consultant: Clinical Summary: Delay in Discharge: Actions From Meeting: Responsibility: Time: Date of Next Meeting: 37

39 Appendix 2 Discharge Against Medical Advice From Hospital Patients Name: Name of Ward: To the Medical Staff and Committee of Management: I Of (address)..... Hereby declare that I am leaving/removing myself from the hospital entirely of my own accord. Possible consequences have been explained to me and I accept full responsibility. Signed... Witness (1) Witness (2) Print. Print. Print. Date Time 38

40 Appendix 3 Delayed Discharge Reporting Bed Management Coordinator to be notified of all admissions SIMPLE DISCHARGE; No further involvement needed by C + F unless requested by MDT COMPLEX DISCHARGE; C + F to request MDT/Review meeting during which; Potential blockages to discharge will be identified Action Plan including timescales to be agreed and documented To be reviewed as and when required Service user discharged, delay avoided DELAYED DISCHARGE; Ward Manager to discuss delay with C + F once identified If confirmed as a Delay Ward Manager to complete weekly Delayed Discharge Form Reasons for Delay to be identified DD Form to be sent to Performance on a weekly basis C + F to attend weekly DD Meeting and report on individual SU s progress and actions required to reduce the delay 39