Hospital Discharge and Transfer Guidance. Choice, Responsiveness, Integration & Shared Care

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1 Hospital Discharge and Transfer Guidance Choice, Responsiveness, Integration & Shared Care

2 Worcestershire Mental Health Partnership NHS Trust Information Reader Box Document Type: Document Purpose: Unique identifier: Title: Target Audience: Clinical Guidance Ensure staff understand their responsibilities in relation to discharge and transfer CP0027 Hospital Discharge and Transfer Guidance All clinical staff involved with hospital discharge and transfer Description: Superseded Documents: Ratified by: Hospital Discharge Policy and Transfer Policy Quality Committee Ratification date: December 2010 Implementation date: January 2011 Review period: 3 years Version update date: Review date: January 2014 Owner: Responsible group: Chief Operating Officer, Acute, Older Adult and Community Business Unit Leads Acute Care Forum Contact Details: Business Unit Leads The electronic copy of this document is the only version that is maintained. Printed copies may not be relied upon to contain the latest updates and amendments.

3 CONTENTS 1. Hospital Discharge and Transfer Guidance 2. HOSPITAL DISCHARGE PROCESS PATHWAY SIMPLE DISCHARGES 3. Introduction and Background 4. KEY PRINCIPLES HOSPITAL DISCHARGE PROCESS 5. Referral 6. On Admission 7. Assessment 8. Review 9. Pre-Discharge Meeting 10. Discharge care plan 11. Forty eight to twenty four hours prior discharge 12. Day of discharge 13. Infection Control Considerations 14. Carer Needs 15. INTER HOSPITAL TRANSFER PROCESS ROLES AND RESPONSIBILITIES 16. Consultant Psychiatrist 17. Named Nurse 18. Care Coordinator 19. Community Mental Health Team 20. Occupational Therapy Services 21. Physiotherapy. 22. Psychology Services 23. Approved Mental Health Professional 24. Older Adult Discharge Coordinator 25. Pharmacy Team EARLY DISCHARGE 26. Crisis Resolution and Home Treatment 27. Legal Requirements 28. Delayed Discharge 29. Interim placements prior to moving into a care home 30. Discharge Against Medical Advice Appendix 1

4 1. Hospital Discharge and Transfer Guidance a. This Hospital Discharge and Transfer Policy and Guidance are integral components of the Care Programme Approach and Mental Health Assessment and Care Planning Processes. b. The Transfer of Information Checklist [Appendix 1] includes everything the Trust will need to provide to the receiving service regarding the patient being transferred. This is to ensure their needs are met safely, even when the transfer of information is required urgently. 2. HOSPITAL DISCHARGE PROCESS PATHWAY SIMPLE DISCHARGES a. The referral to the ward, through Crisis Resolution and Home Treatment Service must include an assessment of diverse needs, consideration of issues relating to language, communication, access, privacy and dignity. b. Admission to inpatient facility; allocation of Named Nurse; contact with or allocation of a Care Coordinator; undertake initial 72-hour assessment; give service user and/or carers service information c. Commencement or continuation of Care Programme Approach process (Named Nurse or Care Coordinator), Carer Assessment and set review dates Review d. Pre-discharge planning meeting with service user and/or carer and/or advocate, Named Nurse, Care Coordinator; members of Care Team and Crisis Resolution and Home Treatment in attendance as required; e. Discharge plan agreed and responsibilities allocated. f. 24 hour prior discharge the Named Nurse or Care Coordinator check all arrangements in place. g. On the day of discharge do final checks, discharge and Care Programme Approach information forwarded and day follow-up form faxed Discharge h. Community follow up as per the Care Programme Approach care plan and 7 day follow-up arrangements. 3. Introduction and Background a. Hospital transfer or discharge involves a series of care events not a single one. Each inpatient will be assessed as no longer needing a hospital bed or requiring services not available in their current location. This should take place within a purposeful admission and intervention process that requires collective contributions from various agencies, disciplines and carers alike. It will be coordinated within a systematic process that is communicated to the service user, their relatives or carers and all parties concerned in the care management of the person. b. Whilst research literature on hospital discharge and transfer goes back at least thirty years there is remarkable consistency in the findings, which continue to report on the breakdowns in routine and the impact this has on: i. Increased dependency and potential for institutionalisation ii. Loss of service user confidence in their ability to cope iii. Depression iv. Loss of choice and control 1 P age

5 v. Increased chance of contracting a hospital acquired infection vi. Other service users to wait longer for care c. The problems that arise in discharge and transfer planning are of different types, these may include discharge or transfer that occur too soon, are delayed, are poorly managed or are going in to unsafe environments. It is important to ensure that when assessing the appropriateness for discharge or transfer, issues adversely affecting people on the grounds of race, disability, gender, sexual orientation, age, religion and belief are fully considered. d. The causes of these difficulties are diverse and include the following: 4. KEY PRINCIPLES i. Internal hospital factors (e.g. the timing of ward rounds, referrals for assessment, organisation and management of medication) ii. Coordination issues (e.g. communication and organisation differences across health, social care and other community based services) iii. Capacity and resource issues (e.g. the limited availability of transitional and rehabilitation places, placement difficulties associated with care homes and availability of a home care provider) iv. Service user and carer involvement and choice (e.g. the lack of engagement with service users and carers in decisions about their care and the limited choice of care options and the lack of involvement by the independent sector providers in operational and strategic planning issues) Department of Health (DOH 2003) a. The key principles for effective discharge and transfers of care are that: i. The engagement and active participation of service users and their carers as equal partners is central to the delivery of care and in the planning of a successful discharge. This collaborative approach will provide a seamless process for the transfer of patients from hospital to the most appropriate environment ii. Privacy and dignity considerations are essential to the admission and discharge process. iii. Unnecessary admissions are avoided and discharge planning begins before the point of admission for planned admissions and at the point of admission for emergency admissions iv. The policy should be applied with constant regard to the Trust Care Programme Approach and Clinical Risk Assessment and Management Guidelines v. Discharge should be facilitated by a whole systems approach to the assessment processes vi. The process should be co-ordinated by an agreed named person who has the responsibility for co-ordinating all stages of the service user journey. The principles of the Care Programme Approach Policy and the management of risk apply and there should be robust and regular communication between the inpatient area and community teams. Any referrals to Multidisciplinary Team will be actioned as soon as possible after the initial period of assessment. vii. Communication may be verbal or written but should always be recorded on the relevant documentation. Documentation will provide evidence of 2 P age

6 assessment and planning pertaining to the discharge process and meet the requirements of professional standards viii. Staff should work within a framework of integrated multi-disciplinary and multi-agency team working to manage all aspects of the process. ix. Effective use is made of transitional care and Crisis Resolution and Home Treatment services so that existing hospital capacity is used appropriately and individuals achieve their optimal outcome. x. Assessment for continuing health and social care is organised so that service users understand the continuum of health and social care services, their rights, and receive advice and information to enable them to make informed decisions about their future care. xi. If service users are assessed against any of the Continuing Health Care eligibility criteria they/or their carers will be kept informed and given written evidence of the outcome. xii. Service users have a right to expect confidentiality of personal and clinical information and staff will follow guidance outlined in the Care Programme Approach to maintain this. xiii. Service users, family and carers must not be adversely affected due to their race, disability, gender, sexual orientation, age, religion and belief are fully considered. b. The benefits of good discharge and transfer planning for the service user are: i. They will feel their needs are considered and met wherever possible ii. They are able to maximise independence iii. They will be an active part of the care process iv. They will experience care as a coherent pathway v. They will believe they have been supported and have made the right decisions about their future care c. The benefits of good discharge and transfer planning for the carers are: i. They will feel valued as partners in the process ii. They will consider their knowledge is used appropriately iii. They are aware of their rights and have their needs met iv. They feel confident about future care arrangements v. They are given choice about undertaking a caring role vi. They understand who to contact and when d. The benefits of good discharge and transfer planning for staff are: i. They feel their expertise is recognised and used appropriately ii. They receive key information in a timely manner iii. They understand their role iv. They develop new skills and knowledge v. They work within a system that enables them to do so effectively e. The benefits of good discharge and transfer planning for the Trust are: 3 P age

7 f. Resources are appropriately used g. Services are valued by the local community h. Staff feel valued and able to work safely i. Fewer complaints j. Targets are met k. Positive relationships are established and maintained with other agencies l. An avoidance of blame over responsibility for delays or incidents m. Standards for audit purposes n. Ensuring compliance with equality and diversity policy and legislation DH(2003) HOSPITAL DISCHARGE PROCESS 5. Referral a. Prior to admission every effort must be made to consider alternative approaches to assessment and treatment such as Crisis Resolution and Home Treatment. Referrals for inpatient assessment will be made through the community mental health teams or on call psychiatrist for service users with dementia (or suspected dementia) and through Crisis Resolution and Home Treatment for service users with functional disorders. It is important to ensure that when assessing the appropriateness for any service provision issues adversely affecting people on the grounds of race, disability, gender, sexual orientation, age, religion and belief are fully considered and documented. 6. On Admission b. In accordance with the Care Programme Approach as much of the following documentation as possible is available at admission: i. Appendix 1 plus: ii. Care Programme Approach documentation to accompany the patient upon admission. iii. Care Coordinator identified and written history and current presentation to be discussed. iv. Mental Health Act Assessments v. Risk Assessment vi. Safeguarding information vii. GP information viii. Other referrals or information e.g. CPN, social worker, Occupational Therapy ix. Accommodation (care home, hostel etc) information x. Carer information xi. Medication management xii. Any other supporting written information a. At the point of admission, assessment and care planning documentation should be readily available along with service user and carer information. The name of the Care Coordinator should be recorded; where admission is the first point of contact 4 P age

8 7. Assessment 8. Review the local community mental health team should be alerted in order to allocate a Care Coordinator. A Named Nurse should be identified. It is important to ensure that when assessing the appropriateness for admission, issues adversely affecting people on the grounds of race, disability, gender, sexual orientation, age, religion and belief are fully considered. b. Once admitted the discharge planning process begins. Service users and carers should be informed that once needs are assessed, interventions take place and a discharge plan identified, the service user will be informed of a discharge date and arrangements. Summaries of these discussions and confirmation that this information is given should be noted in the service user s records. c. In the first 72 hours an initial assessment, which includes a risk assessment, should be undertaken to inform an immediate care plan. Along with this the current home situation including any Adult or Children s safeguarding issues or whether subject to MAPPA level 2 or 3 and existing community services should be identified. Information regarding the service users normal place of residence should be checked through Adult and Community Services and referrals forwarded to other multi-disciplinary teams as necessary. For Older Adults If discharge is considered to be potentially problematic the discharge coordinator should be alerted. a. Where the service user is not known to the services the Named Nurse must commence the Care Programme Approach process. Local standards determine the length of time and components of the assessment process but the service user should have an initial care plan developed based upon admission information and risk assessments. b. The Named Nurse should ensure that referrals have been made and received. c. The carer should be offered a Carer Assessment in accordance with the Care Programme Approach. Any other issues related to necessary support should be identified e.g. psycho-educational or Behavioural Family Therapy programmes. d. Staff should be alert to any issues related to Adult or Children s safeguarding on admission or emerging through the assessment process. Disclosures can often be made at this time and consideration has to be given to the impact on both service user and carer on the impact of admission to hospital. a. Review dates will be set in accordance with the Care Programme Approach and based upon the needs of the service user primarily and carers. The discharge plan should be initiated at the first multidisciplinary meeting and raised at every review. b. Reviews should involve the service user and carer where appropriate, hospital and community representatives. Where the Care Coordinator cannot attend review meetings, they should contact the ward for an update every week. 9. Pre-Discharge Meeting a. Every service user will have a pre-discharge meeting, arranged as early as possible prior to discharge. A carer and/or an advocate may accompany them. The Named Nurse and Care Coordinator should attend or be appropriately represented. Where appropriate this should follow a Crisis Resolution and Home Treatment early discharge assessment. b. It should be acknowledged that the physical, psychological and social impact of hospital admission, discharge and transfer is significant and identified needs should be considered throughout the process. 5 P age

9 c. Any issues related to Adult or Children s safeguarding must be raised and Protection Plans developed and referred to in line with Safeguarding Adult processes. Any issues related to MAPPA where a person is subject to level 2 or 3 must be raised and noted. d. Assessments and intervention details should be confirmed verbally, in writing and minutes of the meeting or discharge care plans offered to the service user and carer. e. The discharge plan should be activated and referrals forwarded to relevant agencies. The Named Nurse must ensure that Continuing Health Care Assessments are undertaken promptly. Where necessary the possibility of having to move into a temporary or intermediate care placement should be repeated here with reference to information given at admission and details regarding this recorded. f. Discharge plans should make reference to community support that encourages good physical health and ensure that primary care is prompted to facilitate access to services where indicated. g. Where any home leave is arranged the Named Nurse must ensure that the Care Coordinator is involved and that all relevant agencies are informed, particularly where they are involved in support and preparation for discharge or transfer. h. Where an individual may require long-term care the service user, carer and team should explore alternatives and the family advised to consider second options for placement. i. When purchasing services through the contracting processes evidence must be obtained that the provider is able to meet the standard of care required to meet the needs of people from diverse backgrounds. j. Where a service user may be discharged to a care home the Named Nurse must develop an up to date risk assessment and comprehensive care management plan to support care delivery post discharge, particularly where care staff may find behaviours difficult to manage. k. Where a service user requires care home placement and the home has been identified, arrangements should be made for the care home staff to undertake their own assessment of the service user. l. Roles and responsibilities will be identified and recorded. The Care Coordinator, supported by the Named Nurse will take a lead role in contacting and establishing or re-establishing services. m. Suitable days and dates for discharge and transfer should be raised and confirmed, identifying any relevant issues related to weekday, weekend, and bank holiday discharges. n. The service user may have cash or valuables held by the Trust and nursing staff should give notice to access this. 10. Discharge care plan a. The care plan should identify the assessed needs and interventions necessary for a safe discharge including the need for Crisis Resolution and Home Treatment early discharge support. The service user must be supported to understand and sign the care plan before discharge and be given a copy to refer to. This process may require access to skilled interpretation services. Where appropriate the carer should also have access to and a copy of this information b. Where necessary, home visits and home leave should be timetabled and dealt with in accordance with the Mental Health Act and Care Programme Approach. 6 Page

10 c. Where a service user is being discharged to a care home the Named Nurse must communicate the details of assessment and care planning with a relevant senior member of staff at the home to ensure continuity of care. d. Where there are issues related to Adult or Children s safeguarding information and management should be detailed in the care and protection plans. e. Where there are issues related to MAPPA level 2 or 3 multi-agency management should be detailed in the plans of care plans, involvement commence with the relevant agencies and regular reviews undertaken. f. Agencies should be alerted to any confirmed discharge arrangements and dates which will include arrangements for 7 day follow-up. 11. Forty eight to twenty four hours prior discharge a. This is a minimum checklist and many stages will have already been achieved: b. The Named Nurse and/or Care Coordinator, or their nominated representatives, will: c. Liaise to manage the discharge arrangements, identifying who will do what and when d. Inform and support the service user and carer of all elements of the discharge care plan. Ensure they understand what is going to happen, when and who they can contact after leaving the ward. e. Confirm accommodation arrangements including hostels and care homes etc. f. Ensure that prescription items to take out (TTO s) are prescribed, ordered and will be available for collection. The Named Nurse, or their nominated representative, should ensure that any particular identified instructions on opening containers are communicated so the service user, or carer, is able to open and administer the medication. g. Ensure that all necessary aids, equipment etc. are available h. Confirm the discharge destination is aware of time and date of the service users arrival. i. Ensure community services e.g. 7 day follow-up, Crisis Resolution and Home Treatment and care packages are in place j. Confirm out patients appointments and Care Coordinator visits etc. k. Support the service user or carer in making transport arrangements l. Identify an escort, if appropriate m. Ensure the service user has access to the place they are moving to. n. Ensure arrangements for benefits and sick notes are in place o. Complete as far as possible the Discharge Checklist, Patient Discharge and TTO Forms. 12. Day of discharge a. The Named Nurse and/or Care Coordinator, or their nominated representatives, will: b. Liaise to manage the discharge arrangements, identifying who will do what and when. c. Where discharge has been arranged at short notice the multidisciplinary team must identify the most important elements of the care plan, ensuring that the service user will receive aftercare that manages risks identified 7 P age

11 d. Ensure discharge Care Plans are complete and signed off appropriately. e. Confirm again with the service user and their carers their understanding of discharge and aftercare arrangements, including immediate follow up, verbally and in writing. f. Confirm the name of the Care Coordinator, contact number and number of out of hour s services. g. Two nurses should check the prescription items to take out (TTOs) upon receipt and again check that the service user or carer can open containers and take medication safely. h. Ensure all property is handed over and relevant documentation completed. i. Check transport arrangements are in place. j. Complete all relevant documentation and forward onto the relevant agencies. Care Programme Approach including such things as risk assessment and management plans, MAPPA action plan, TTO form, contract for long term care placement or intermediate care arrangements etc. k. The Care Programme Approach form should be mailed electronically or faxed to the Care Coordinator l. Fax notification of discharge and 7 day follow-up form to Care Coordinator, Designated Community Mental Health Team Manager and Duty Worker. m. Wards will complete the agreed and established discharge documentation promptly and accurately. Immediate reference will take place to the documentation and record keeping requirements of the Trust Care Programme Approach Policy. n. Accurate and comprehensive records must be made of all information given to the service user and carer which includes the Information on Admission and Notice of Discharge date. o. The Responsible Clinician must record in the service user s records that the service user is fit for discharge. This information must be relayed to the service user and carer immediately wherever possible. p. If there is a gap between the scheduled and the actual date of discharge it should be reported through the Inpatient Lead and reviewed at the Delayed Discharge Meetings and recorded on the discharge care plan. It is important to note the reason for delay and/or any secondary problems that develop e.g. service user develops a chest infection that complicates discharge but does not warrant transfer to an acute general hospital. q. The multidisciplinary team, particularly the Care Coordinator and Consultant Psychiatrist, are responsible for ensuring effective communication back to General Practitioner. 13. Infection Control Considerations a. Prior to transferring, discharging or accepting service users into inpatient/residential areas, the Named Nurse, or their nominated deputy, must refer to the Infection Control Policies and Procedures for guidance on the care and management of the infection and the precautions needed to put in place. b. It is essential that information is considered both when transferring a service user with a known infection to another health care settings, a nursing or residential homes or service users own home that they receive either district nursing input or non nursing support services. 8 P age

12 14. Carer Needs a. Engagement with carers is an important part of the whole discharge process and it is essential to identify their needs. The Named Nurse and/or Care Coordinator should be nominated to offer or signpost the following information: i. Establish the service user s permission to share information ii. Give information on the Carers Development Officer for Black and Ethnic Minority Communities where appropriate iii. Go through the discharge plan verbally and give a copy iv. Give information on the service user s needs and how to help them v. Offer carers assessment vi. Explain what may be involved in being a carer vii. Information on benefits and the financial implications of caring viii. Charging for services ix. Access Centre x. Access to signers or interpreters xi. Challenging decisions and making complaints xii. Organising transport xiii. Information regarding return to work and/or education 15. INTER HOSPITAL TRANSFER PROCESS a. There must be full involvement of the Multidisciplinary Team in undertaking an effective handover of care and agreement, which is documented in case notes before any transfer takes place. b. Where a transfer is necessary the Named Nurse, or their nominated deputy, should discuss with the service user the reasons for the transfer in a format that the service user understands and details about possible transfer back. c. Where a transfer is necessary to another ward a comprehensive verbal and written handover is necessary. d. Where a transfer is necessary to a ward or unit outside the Trust i.e. acute trust, community hospital, a comprehensive handover must take place verbally and in writing along with a transfer letter. e. Carers should be notified immediately of the transfer and the reasons for it. f. The receiving ward or unit is responsible for checking, amending and updating any existing documentation as appropriate and ensuring information is communicated with reference to the Care Coordinator in accordance with Care Programme Approach. g. Where transfer is to another hospital, a screen may be necessary for hospital acquired infection. ROLES AND RESPONSIBILITIES 16. Consultant Psychiatrist a. The responsibility of the medical discharge lies with the Consultant Psychiatrist or whoever is deputising in their absence, in conjunction with the team. 9 P age

13 17. Named Nurse b. The Consultant Psychiatrist and team will, as part of the admission process discuss with the service user and carer, the reasons for admission, likely length of stay and outcome of admission. They will communicate the temporary nature of the hospital admission. All communication must be appropriate to the needs of the individual and all discussions should be comprehensively documented. c. The Consultant Psychiatrist will ensure the service user and carer, the Care Coordinator and relevant members of the multi disciplinary team discuss what care and support arrangements will be possible. d. The Consultant Psychiatrist will ensure that a member of the team has informed service users and carers of their right to Continuing Health Care Assessment and Reviews, including eligibility for health funding. e. The Consultant Psychiatrist will, along with other professionals, consider the changing needs of the service user following discharge. These may include housing, benefit and independent living skills etc. f. In relation to care home approval, the Consultant Psychiatrist along with other professionals, will take part in the assessment process. g. The Consultant Psychiatrist will ensure that discharge does not take place until there is an agreed package of care and any arrangements related to Adult Protection are in order and confirmed. h. The Consultant Psychiatrist will ensure that the discharge summary is faxed to the GP within 24 hours of discharge. i. Discharge summaries should contain a section on physical health and arrangements for future plans for physical health care. j. The Consultant Psychiatrist will ensure that TTO medication is prescribed k. The Consultant Psychiatrist will ensure the Care Coordinator or their nominated representative has arranged initial follow up within agreed timescales. l. The Consultant Psychiatrist is responsible for coding the service user s diagnosis and ensuring this is inputted appropriately a. A Named Nurse will be identified on admission in accordance with the Named Nurse Pathway and take on the responsibilities of assessment, care and discharge planning. b. The Named Nurse will be supported by the Care Coordinator in all aspects of assessment, care and discharge planning. c. Where the admitting nurse is not the Named Nurse they must communicate all relevant information as soon as possible to the Named Nurse. d. The Named Nurse will identify themselves as such to the service user and carer on admission or as soon as possible thereafter. e. The Named Nurse will ensure that assessment, care planning and review processes take place in accordance with Care Programme Approach and local standards, including Continuing Health Care Assessments. They will, along with the team, identify needs and the services necessary for a safe and early discharge and make reference to any issues related to Adult Protection. They will reinforce the function of the ward as one engaged in active assessment and treatment. f. The Named Nurse and Care Coordinator will be the primary communicators with the service user, their family and carers. 10 P age

14 g. In collaboration with other professionals the Named Nurse will ensure the Care Programme Approach Care Plan is developed along with any extra provision of support. h. The Named Nurse will ensure all necessary arrangements will be communicated including time and date of discharge, transport, and access to accommodation, valuables. i. The Named Nurse will ensure discharge medication is ordered at least 24 hours in advance of discharge. j. The Named Nurse or nominated deputy will support the service user on the day of discharge, ensure property and TTO s are collected and complete discharge information. k. The Named Nurse will ensure that the Ward Manager or their nominated deputy has information to complete the Delayed Discharge Form and fax to the discharge coordinator by midday each Friday. 18. Care Coordinator a. In line with Care Programme Approach, the Care Coordinator retains responsibility for monitoring the delivery of care, convening care programme approach reviews, maintaining contact with the service user and carer, maintaining communication with others involved in the care, treatment and support of the service user including non statutory organisations, and reassessing the service user s needs and current risk situation. b. Where known the Care Coordinator must alert the ward about any issues related to Adult Protection or MAPPA level 1 or 2, particularly those that may have an impact on safe discharge planning. c. The Care Coordinator must maintain contact with the service user throughout their hospital stay, whether in local resources or inpatient areas outside of the county. They must begin the process of planning for discharge at the point they are aware of the service user s admission. The minimum standard for such contact is weekly. d. The Care Coordinator should introduce them self to ward staff when visiting the ward in person. e. The Care Coordinator should detail their contact with the inpatient case notes as well as community based notes. f. The Care Coordinator must ensure that any identified carers are well informed with regards to issues related to discharge, charging policies and care options including interim or intermediate placements. g. The Care Coordinator must ensure that all other services or people involved in the discharge of the service user are aware of the care plan and discharge arrangements. 19. Community Mental Health Team a. Members of the team may be the Care Coordinator but may also have core responsibilities in the following areas: b. Receiving referrals and undertaking pre-discharge assessments c. Maintaining communication with the whole multidisciplinary team (including community and inpatient service). d. Identifying necessary aids to living, educational, vocational or community resources that will be needed to support safe and timely discharge. 11 P age

15 e. Identify from their professional perspective when the service user has reached the appropriate level of ability to support safe discharge. 20. Occupational Therapy Services a. The occupational therapy team may assess a service user s functional ability with activities essential to their daily living. They will, along with the care team identify the service user s needs and initiate or instruct on appropriate therapeutic activities. In consultation with the community occupational therapy service they will check necessary equipment and those adaptations are in place prior to home leave and discharge. 21. Physiotherapy b. Where possible any assessments will take place within the service user s own home, given that a full risk assessment has taken place and there is the potential for the service user to return there. c. The occupational therapist will liaise closely with the Care Coordinator and Named Nurse and communicate verbally and in writing. a. The physiotherapist may assess service users for their functional ability and mobility and identify with the service user and Named Nurse their needs and goals. b. The physiotherapist will undertake any necessary pre-discharge arrangements and will provide or arrange equipment or other relevant services where necessary. c. The physiotherapist will liaise closely with the Care Coordinator and Named Nurse and communicate verbally and in writing. 22. Psychology Services a. Upon receipt of a referral the psychologist will assess the service user s cognitive, functional and psychological status. b. The psychologist may use specialist assessments e.g. risk dependent upon identified need. c. The psychologist will contribute to the care plan through individual sessional input or in an advisory capacity in terms of management. d. The psychologist will liaise closely with the Care Coordinator and Named Nurse verbally and record all activity within the Care Programme Approach Care Plan. 23. Approved Mental Health Professional a. An Approved Mental Health Professional may be involved where the service user is admitted under the Mental Health Act Older Adult Discharge Coordinator 25. Pharmacy Team a. The Discharge Coordinator will assist and advise the wards regarding screening, assessments and funding panels. b. The discharge coordinator will gather, verify and circulate delayed discharge information and monitor and report problematic discharges to the Older Adult Business Unit Lead. c. The Discharge Coordinator will convert the delayed discharge information into SITREPS. 12 P age

16 EARLY DISCHARGE a. As part of the healthcare team the pharmacist is a key player in medication management both as a source of medicines information and practical guidance for service users and carers preparing for discharge. b. The pharmacist will identify any compliance aids that may be necessary to assist the service user to take their medication. c. The community pharmacist will advise on ongoing medication issues and ensure the service user does not suffer from excessive, inadequate or inappropriate consumption of medicines. 26. Crisis Resolution and Home Treatment a. Early discharge is a discharge facilitated through the intensive involvement of the Crisis Resolution and Home Treatment service that would not have occurred in the absence of intensive support offer by them. b. Early discharge should only occur following assessment by the Crisis Resolution and Home Treatment service. This assessment should consider the needs and opinion of the service user and their carer, the service user s Care Coordinator and the inpatient team. c. The discharge planning process should include a pre-discharge meeting as detailed above. Early discharge can also be provided to facilitate a period of home leave. When on facilitated home leave the Inpatient Consultant will retain Responsible Clinician responsibility. d. Members of the inpatient team, Care Coordinator, service user and carers can refer for early discharge assessment. 27. Legal Requirements a. All discharges will be undertaken in accordance with legal requirements of the Mental Health Act 1983 (as amended), Mental Capacity Act 2005 and the NHS and Community Care Act 1990and any other applicable legislation. 28. Delayed Discharge a. As standard practice dictates the following will be given careful consideration when planning a service user s discharge: i. Service user s diagnosis ii. Mental Health Act status iii. Mental Capacity Act status iv. Care Programme Approach status v. Discharge status i.e. fit or otherwise vi. Whether carers are objecting or delaying vii. Service user and carer concerns viii. Recorded discussions with service users and carers particularly with the RMO or their nominated deputy ix. Discharge destination x. Impact of delayed discharge on physical and mental health 13 P age

17 b. There is a clear duty of care upon all statutory services to act in the best interests of vulnerable adults and specifically where the adult lacks capacity to make informed decisions c. Service user choice is considered extremely important, but once assessed, treated and deemed fit for discharge and not eligible for NHS continuing inpatient care, service users do not have the right to occupy indefinitely an NHS bed. d. A small number of service users may be eligible for a continuing care inpatient bed under the Mental Health Act. e. Whilst service users have the right to refuse to be discharged from NHS care, if they refuse to enter a care home, he or she cannot insist in staying in the acute bed. The multidisciplinary team must consider the following: f. Where can the service user be safely moved to? g. What care should they receive? h. Once these considerations are confirmed the hospital and community staff should work with the service user to find suitable alternative accommodation. i. The team may have to refer to the Safeguarding Adult processes if a carer refuses to accept or allow the service user back into their home. j. Differences apply to certain detained service users (see. S.117 MHA 83 Policy). 29. Interim placements prior to moving into a care home a. Effective discharge processes are aimed at ensuring that a service user does not stay in hospital longer than necessary and that a timely and comprehensive package of care is negotiated and offered to maximise a service user s independence. b. An interim placement, that meets the service user s needs, should be considered when a first choice of home is unavailable. c. If waiting for a desired care home to become available causes an unacceptable delay in the transfer from hospital, the following processes should be put in place: d. If a service user has capacity, then they should be informed about the possibility of an interim placement. The Consultant Psychiatrist supported by the Named Nurse and ward team should explain to the service user that it is clinically inappropriate for them to remain on the ward whilst they are waiting for a care home placement. e. Where the service user does not have capacity the above discussions should be undertaken in line with the Mental Capacity Act f. The interim placement must be able to meet the assessed care needs of the service user and they must receive active support to move on to the home of their choice when available. g. There must be support available (e.g. independent advisory/advocacy) to the service user and carer, including to self funding service users, in making important decisions. h. If the status quo remains after these discussions and the service user and/or carer are deemed competent (or, where the service user is not deemed competent) they should be put on notice that the transfer to a safe home will take place on a set date. i. The service user and/or carer should be: 14 P age

18 j. Be informed that if they have any concerns about the quality of the home proposed they have the right to register a complaint. However they should also be informed that the ultimate decision lies with the NHS Trust and the Local Authority, where applicable. k. Be urged to confirm whether they have a particular home in mind to which the service user can be discharged. l. Reminded of the information given at admission regarding discharges and the possibility of temporary placements and all discussions and interventions must be clearly documented in the records. m. The Trust has a statutory duty to be proactive in taking all reasonable steps to facilitate discharge for service users, funded or otherwise and takes these responsibilities seriously. However there may be occasions where service users and/or carers feel that the Trust is acting either improperly or negligently. Where there is any indication of this clinical staff must report to their line manager who can ensure that the situation is managed effectively. 30. Discharge Against Medical Advice a. There may be occasions when inpatients wish to discharge themselves against medical advice. This could be a formal or informal inpatient. b. Where service users are formal or informal the nurse in charge must always try to elicit the reason for wishing to leave the hospital or in the carer s case wishing to remove the service user from the hospital. Information and/or reassurance may be all that the service user and/or carer needs to feel more comfortable about staying in hospital for treatment. c. Where an informal service user and/or carer still want discharge without due regard to the discharge planning processes outlined in this document, the nurse in charge should determine through an immediate review of risk, and discuss with the Responsible Clinician and Named Nurse if possible, whether the service user is safe to discharge themselves. If not then they should invoke Section 5(4) of the MHA 83 and contact the clinical coordinator and psychiatrist immediately. d. Where a service user admitted as informal patient their intention to discharge against medical advice the Consultant Psychiatrist or their designated deputy should be immediately contacted. They should be a thorough discussion of the services user s current mental health and risk status and a judgement made, led by the Consultant Psychiatrist or their nominated deputy regarding the application of restriction under Section 5(2) of the MHA 1983which will trigger a full Mental Health Act assessment. e. The doctor or nominated deputy must reinforce the importance of not leaving against medical advice but if failing to change the service user or carer s mind should record clearly and comprehensively the discussion and the service user s decision. f. The nurse should maintain comprehensive service user records detailing the discussions that take place. g. Where the service user has an identified Care Coordinator they should be contacted as soon as possible, if not the community mental health team leader should be contacted and given relevant information. It may also be appropriate to contact Crisis Resolution and Home Treatment to assess for early discharge support. h. The nurse in charge should notify the service user s GP and any other professionals or carers involved as soon as possible when the service user has left the ward. 15 P age

19 Appendix 1 Transfer Information Checklist CQC Outcome 6: The information includes everything the other service, individual, team or agency will need to ensure the needs of the person who uses services are met safely, even when the transfer of information is required urgently. As a minimum this includes: Information Required Information made available their name gender date of birth address unique identification number where one exists emergency contact details any person(s) acting on behalf the person who uses services, with contact details if available records of care, treatment and support provided up to the point of transfer assessed needs known preferences and any relevant diverse needs previous medical history that is relevant to the person s current needs, including general practitioner s contact details any infection that needs to be managed any medicine they need to take any allergies they have key contact in the service the person is leaving reason for transferring to the new service any advance decision any assessed risk of suicide and homicide and harm to self and others. Was the information is transferred in time to make sure that there is no delay to the assessment of needs by the other service, team, individual or agency. 16 P age

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