DISCHARGE AND TRANSFER POLICY FOR MENTAL HEALTH AND LEARNING DISABILITIES

Transcription

1 DISCHARGE AND TRANSFER POLICY FOR MENTAL HEALTH AND LEARNING DISABILITIES Policy Details NHFT document reference CLP056 Version Version Date Ratified Ratified by Trust Policy Board Implementation Date Responsible Director Chief Operating Officer Review Date Related Policies & other documents CLP010 - CPA Policy, CLPr023 - Delayed Discharge and Transfers of Care Procedure, CLP020 - The Mental Health Act 1983 (As amended by the 2007 Act), CLP028 - AWOL Policy, CLP031 - Policy for Identifying an Inpatient Bed, CLP056b - Discharge and Transfer Policy for Community Healthcare and Community Hospitals, CLP063 - Policy for the Preparation and Production of Patient and Carer Information, CRM001 - Risk Management Policy CRM002 - Incident Policy, IGP107 - Health Records Management Policy, IGP108 - Policy for Producing Patient Information, IGP021 - Recording and Administration Procedure for Inpatient Discharge, MMP001 Control of Medicines Policy, OP-CRHTT - Crisis Resolution Home Treatment, OP-SPOA - Single Point of Access Freedom of Information category Policy 1 of 39 Implementation Date:

2 TABLE OF CONTENTS 1. DOCUMENT CONTROL SUMMARY INTRODUCTION PURPOSE DEFINITIONS DUTIES OF SPECIALIST SERVICES Chief Operating Officer Inpatient members of Staff (including Responsible Clinician and Multi-disciplinary Team) CPA Coordinator, Key Worker, Named Nurse, Allocated Staff Nurse (Ward Staff), Responsible Clinician, Multi-Disciplinary Team and CRHT Team/IST case holder/ctpld nurse Lead Clinicians, Service Managers/Senior Matrons/Ward Matrons Mental Health Act Team POLICY PROCESS Transfer Procedure Handover Requirements Out of Hours Handover Inpatient Discharge Procedure for all Patients Section Ensuring Post Hospital Discharge (Seven Days) Follow up Arrangements in the Community Procedure for Following up Service Users After Discharge Day of Discharge Within 24 hours of Discharge Two Days Post Discharge Four Days Post Discharge Recording Contacts in epex Discharges from Community Based Mental Health Services Out of Hours Assessments requiring no further action from Community Based Mental Health Services Upon completion of an emergency assessment the referrer will be notified and informed of the outcome of the assessment and any actions agreed by the CRHTT. This will be done on the same or next working day, by telephone Arrangements for Medication Post Discharge Management of medicines on handover between care settings Patient Information Practical Tasks on the Day of Discharge Practical Tasks Post Discharge Mandatory Training Specific Training not covered by Mandatory Training MONITORING COMPLIANCE WITH THIS DOCUMENT of 39 Implementation Date:

3 8. REFERENCES AND BIBLIOGRAPHY RELATED TRUST POLICY APPENDIX 1 - PATIENT TRANSFER CHECKLIST APPENDIX 2 - INPATIENT DISCHARGE PROCESS APPENDIX 3 - DISCHARGE CHECKLIST APPENDIX 4 - CPA CARE PLAN APPENDIX 5 - DISCHARGE AT PATIENT S OWN REQUEST FORM APPENDIX 6 - DISCHARGE SUMMARY APPENDIX 7 - DISCHARGE QUESTIONNAIRE I WANT GREAT CARE.. 35 APPENDIX 8 NHFT EQUALITY ANALYSIS TOOL of 39 Implementation Date:

4 1. DOCUMENT CONTROL SUMMARY Document Title Document Purpose (executive brief) Status: - New / Update/ Review Areas affected by the policy Policy originators/authors Consultation and Communication with Stakeholders including public and patient group involvement The purpose of the Policy is to provide Patients, Carers and Staff with a framework for enabling timely, safe and appropriate discharge and transfer from in-patient services to an appropriate destination according to the patient s needs including handover requirements Review The policy applies to all mental health and learning disabilities services except where approved variations are described within this policy Will Strangward - Discharge Co-ordinator, Andres Patino, Head of Hospitals (South) Sue McLeod, Jackie Collins, Stephanie Durnin, Christian Winter, Marie Grkinic, Jayne Evans, Deborah McAuley, Modern Matrons, Chief Pharmacist Archiving Arrangements and register of documents Equality Analysis (including Mental Capacity Act 2007) Training Needs Analysis See Section 6 The Risk Management Team is responsible for the archiving of this policy and will hold archived copies on a central register See Appendix 8 Monitoring Compliance and See Section 7 Effectiveness Meets national criteria with regard to NHSLA 4.9 and 4.10 NICE N/A NSF N/A Mental Health Act Section 117 CQC N/A Other N/A Further comments to be considered at the time of ratification for this policy (i.e. national policy, commissioning requirements, legislation) For Community Healthcare and Community Hospitals please refer to CLP056a - Discharge and Transfer Policy for Community Healthcare and Community If this policy requires Trust Board ratification please provide specific details of requirements Hospitals TPB 4 of 39 Implementation Date:

5 2. INTRODUCTION This policy is to provide all mental health and learning disability practitioners working within the Northamptonshire Health Care NHS Foundation Trust with the standards and responsibilities governing the transfer or discharge of patients from inpatient facilities. This policy is supported by the Care Programme Approach Policy. Transfer of care between wards and discharge form wards should be a seamless process which does not interrupt the patients care pathway. Discharge planning is not an isolated event but a process which may involve a range of inpatient user and community professionals and service depending on the needs of the patients. This document sets out the standards that the trust adheres to deliver safe transfer of care. 3. PURPOSE The purpose of the Policy is to provide Patients, families Carers and Staff with a framework for enabling timely, safe and appropriate discharge and transfer from in-patients/residential services to an appropriate destination according to the patient s needs. Patients admitted to the Mental Health inpatient wards are admitted from the community via the crisis resolution home treatment team. Patients admitted to Learning Disability ATU are via consultant psychiatrists or the duty doctor s treatment team alongside the ISS Duty Clinician and In-patient staff team. Admission to hospital is not discharge from the community. The process of discharge and transfer must be part of a comprehensive Risk Assessment and Risk Management Plan to enable Patients to be supported in gaining independence on the recovery or Challenging Behaviour Care Pathway. The purpose of the handover is to ensure the transfer of high quality clinical information, the effective transfer of information ensures the protection of patients and minimises clinical risk. Continuity of information underpins all aspects of a seamless service providing continuity of patient care and patient safety. 4. DEFINITIONS 7day Follow up form is a single page document forwarded before the date of discharge, by the Ward Manger to the service or individual who has been identified to achieve that task. CMHT Community Mental Health Team CRHT Crisis Resolution Home Treatment Discharge from an inpatient ward includes discharges to Crisis Resolution and Home Treatment Services, Specialist Services or Community Mental Health Teams or to Primary Care, 5 of 39 Implementation Date:

6 IST/CTPLD(Community Team for People with Learning Disabilities)//private/voluntary provider and other secondary services. Discharge letter is a comprehensive typed letter of full discharge arrangements, including medication, risks and future appointments posted to the GP by a Psychiatrist within 7 days of discharge. Discharge Summary is a short hand written summary of the discharge arrangements faxed to the GP by the discharging nurse within 24hours of discharge. Handover of information - refers to the information which is given between shifts on inpatient wards within a 24hour period. However information given may be from any time span if it felt appropriate. IST Intensive Support Team Transfer refers to patients who are transferred between wards within NHFT. NHFT Northamptonshire Healthcare NHS Foundation Trust 5. DUTIES OF SPECIALIST SERVICES 5.1. Chief Operating Officer The Chief Operating Officer is responsible for ensuring the implementation of this policy across the clinical areas Inpatient members of Staff (including Responsible Clinician and Multi-disciplinary Team) All inpatient members of staff have a responsibility for ensuring that they comply with the Inpatient Discharge Policy CPA Coordinator, Key Worker, Named Nurse, Allocated Staff Nurse (Ward Staff), Responsible Clinician, Multi-Disciplinary Team and CRHT Team/IST case holder/ctpld nurse CPA Coordinator/CMHT retains their role whilst the patient is an inpatient. Discharge planning should be coordinated by the CPA Coordinator/CMHT, Key Worker, Named Nurse, Allocated Staff Nurse (Ward Staff), Responsible Clinician, Multi-Disciplinary Team, and Crisis Resolution Home Treatment Team where appropriate. IST/CTPLD 5.4. Lead Clinicians, Service Managers/Senior Matrons/Ward Matrons They have the responsibility for dissemination of this policy to local areas under their responsibility, to ensure that staff are aware of and comply with this policy 5.5. Mental Health Act Team The Mental Health Act Manager will provide reminders to clinical staff and be a source of advice when needed in the discharge planning arrangements for patients subject to detention under the Mental Health Act. This includes patients being discharged under Community 6 of 39 Implementation Date:

7 Treatment Orders. The Mental Health Act Manager will be notified of transfers of patients detained under the Mental Health Act. 6. POLICY PROCESS 6.1. Transfer Procedure Transfers will only take place within Northamptonshire Healthcare Foundation Trust (NHFT) when a patient needs to be moved for clinical and / or personal reasons. A transfer is a move from one NHFT service to another NHFT service. If a transfer is needed the nurse in charge of the ward will discuss with the consultant/ctl on call out of hours, patients suitable for transfer, need to consider policy on meeting the MH needs of people with a LD. If a service user is transferred to any psychiatric provider they will not require follow and should be recorded as transfer to Other Provider Psychiatry. The ward staff will update the Working with Risk 1 (See CLP021- Working with Risk policy for copy.) Nursing staff must complete the patient transfer form Also an up to date HCAI(Infection Control Assessment) should be attached. Staff must provide a comprehensive face to face referral which should be nurse to nurse. When a patient is transferred to a ward on another site, the Responsible Clinician (RC) completes a handover report. (At the earliest available opportunity) This includes a summary of a patient s:- -Significant Known History -Current presentation -Mental Health Needs -Current Management/Discharge plans Refer to CLP031 - Policy for Identifying an Inpatient Bed The transfer will be recorded on Epex Handover Requirements Any handover, whether given or received must be recorded on epex The information given by NHFT on any handover of care should be in line with the Transfer process covered in section 6.1 including the completion and update of a Working with Risk 1. The information to be received on any handover of care in relation to admission will be in line with the requirements of epex, OP- CRHTT - Crisis Resolution Home Treatment and OP-SPOA - Single Point of Access Staff should communicate an accurate concise account of information on matters which have arisen from the previous 24 hours regarding the care and treatment of the patient group. 7 of 39 Implementation Date:

8 In order to facilitate effective handover, differing approaches may be required, at different establishments. It may be necessary and productive to have the team together, or if the unit is particularly busy, or dependent upon the category of unit, a one to one basis may be more appropriate. The person in charge of the shift may need to receive handover or ensure remaining staff receive handover at the earliest opportunity. Location of handover needs to ensure confidentiality; therefore this may need to be in the office or away from patients / visitors. Patient s are not to be left unattended during handover. A visual check of a patient must be undertaken at handover. A verbal report will be given and this must reflect and reinforce appropriate information recorded in Epex. If handover occurs between NHFT services it is the responsibility of the staff member in charge to ensure handover is completed, and all staff receive a full and comprehensive report accompanied by an up to date Working with Risk 1; These will include:- Patient Presentation Feedback from group 1:1 sessions Leaves and visits Feedback from other professionals Physical observations and investigations/nutrition and hydration charts MDT Feedback Care and Treatment Plans Receiving opinion: Any missed medication Identification of work required Changes /updates to care plans Diary messages Staffing issues General management issues Infection control /environmental checks completed Any environmental risks 6.3. Out of Hours Handover There will be cases when a patient will be admitted out of hours and on these occasions patients will be provided with a nurse escort in line with the identified needs to ensure that any handover occurs in a seamless way. Where an out of hours handover is required, the transfer process in section 6.1 and the handover requirements in 6.2 must be followed Inpatient Discharge Procedure for all Patients The procedure for a patient to be discharged to supported accommodation or home should always be followed as set out in Appendix 2 and will be recorded on Epex. The ward must ensure the Discharge Checklist at Appendix 3 is followed. 8 of 39 Implementation Date:

9 The information to be given to the patient on discharge to a supported accommodation or home is: A copy of the CPA care plan, if appropriate A copy of the discharge summary The name and contact details of CPA care co-coordinator, if subject to CPA Details of follow up arrangements and contingency plan- this is on CPA paperwork CATSS Telephone Number IST/ISS duty: For patients discharged to another provider (and not supported accommodation or home) the Transfer information sited in 6.2 is in written format along with up to date Risk and Infection Control Assessments are given to the receiving provider. This discharge will also be recorded in Epex. Where appropriate, every patient will have an up to date CPA Care Plan (Appendix 4) prior to their discharge. Where the CPA framework is appropriate, refer to CPA Policy. MDT should complete the Discharge Summary (Appendix 6). A copy should be sent to the G.P./CMHT and offer to the service user. On discharge all patients will be given an I want great Care discharge questionnaire (Appendix 7) and asked to provide service feedback. It is essential that the Patient, family and carers/advocates, where appropriate, are always involved in the discharge planning process with the multidisciplinary team. The patient s Responsible Clinician (RC) is ultimately responsible for the discharge decision. This can fall to on-call Clinicians out of hours. It is the joint responsibility of the ward team, the CPA Care Coordinator and Responsible Clinician to agree when the patient is fit for discharge. If the discharge cannot proceed, the patient would be classified as a delayed discharge, refer to the CLPr023 - Delayed Discharge and Transfers of Care Procedure In the absence of the key worker, the associate key worker or another identified nurse is responsible for making discharge plans. Where patients are detained under a section of the Mental Health Act (1983) the Responsible Clinician must authorise the removal of the section, sign the appropriate Mental Health Act (1983) discharge form, and complete Section 117 (Mental Health Act 1983) aftercare requirements (not required for S2 etc). Discharge from Mental Health Services: The relevant CMHT must be informed if the service user is known prior to admission or CMHT is deemed appropriate on discharge. Discharge from Learning Disabilities Services: The relevant CTPLD/care manager/ist case holder must be involved at the earliest opportunity to prevent delayed discharge due to interim placement being inappropriate in majority of cases 9 of 39 Implementation Date:

10 If the preferred choice of accommodation/residential/nursing home is not available, discharge must still take place to alternative accommodation that meets the patient s needs, (not always appropriate in LD services.) The patient can negotiate a preferred choice once in the alternative setting. In exceptional circumstances, when there is a delay between the patient being ready for discharge and appropriate accommodation being available, funding of alternative accommodation may be considered for a period no longer than 1week. Any decision to do this should prompt completion of a risk assessment for example Working with Risk 3 - please refer to CLP021 - Working with Risk Policy. This is an issue in LD as may not be appropriate for an individual to move to an interim placement In the case of patients requiring acute medical intervention at a General Hospital they will be discharged from mental health/learning disability in-patient services if deemed appropriate and where physical needs out-weigh their mental health needs. There will be cases when a patient will be discharged out of hours to other services or into the Community and on these occasions patients will be provided with a nurse escort in line with the identified needs to ensure that they discharge occurs in the seamless way. If this is the case follow the discharge process. Mental Health Services: Where the CPA framework is in place prior to admission this continues to apply to patients admitted to General Hospitals for inpatient care. Where the CPA framework hasn t been in place prior to admission the patient will be admitted for a period of 72 hours prior to CPA becoming appropriate. In the majority of cases hospital discharge is not the point of discharge from care, but a transfer in location of the delivery of care. Learning Disabilities Services: Where CPA is applicable, CPA continues to apply to patients admitted to a general hospital for inpatient care and therefore hospital discharge is a transfer in location of the delivery of care. For both Mental Health Services and Learning Disability Services: Prior to discharge from inpatient services a CPA review, in accordance with CLP010 - CPA Policy, will be held to ensure: A discussion takes place to agree whether CPA or No CPA is appropriate on discharge. If CPA remains applicable on discharge the review will ensure: The CPA care plan has been agreed with more intensive input for the first three months following discharge from inpatient services based on clinical need. A 7 day follow up is in place (48 hours for those who have been at high risk during admission) Agreement has been reached and documented where problems with engagement are anticipated as to what actions are going to be taken Copies of the CPA care plan have been circulated to all involved, including all the patients 10 of 39 Implementation Date:

11 A CMHT input has been agreed prior to discharge. The hospital discharge summary has been completed and a copy faxed / ed to the GP and community team and a copy given to the patient. Patient medication is arranged, see section 6.9. If no CPA is appropriate, a CPA or pre-discharge planning meeting will ensure: A lead professional is identified. This should fall to the Primary Care Liaison Service where possible. The G.P. would then be the lead professional. A support plan is agreed with the patient, recorded on the discharge summary. 7 day follow up is in place if applicable. In the absence of any acute illness the patient can be advised to arrange their own follow up with the G.P. and will be contact by CATTs. Staff should ensure records on epex show No CPA at the point of discharge. The hospital discharge summary has been completed and a copy faxed / ed to the GP and community team (if appropriate) and a copy given to the patient Where a patient makes a request to take their own discharge against medical advice, the nurse in charge of the ward/unit will assess whether the patient is liable to be detained under the Mental Health Act (1983).If already detained refer CLP020 - The Mental Health Act 1983 (As amended by the 2007 Act) In the event that the patient is not detainable, the nurse in charge of the ward/unit will discuss the reasons why discharge has been requested and notify the Duty Medical Officer to attend the ward/unit to review the patient at the earliest opportunity. In this event, the nurse in charge of the ward/unit will encourage the patient to remain on the ward/unit until such time as they have been reviewed by the Duty Medical Officer. Should the patient insist upon leaving the ward/unit before review by the Duty Medical Officer can take place, the nurse in charge of the ward/unit will request that the patient signs the Trust s discharge against medical advice disclaimer forms. (Appendix 5) Where a patient leaves hospital before a review can be arranged (i.e. discharge against medical advice) the person/nurse in charge will be responsible for informing the relevant service that will be providing follow up care (if patient requires follow up) and passing on the CPA care plan or support plan (Mental Health Services) CPA care plan / or personal care plans (Learning Disabilities Services) that has been agreed so far. This should be done as soon as possible after discharge as 7 day (48 hour) follow up still applies and will have to be arranged by the team providing follow up. Learning Disabilities Services only: For patients not under CPA similar standards apply. Including care plans, risk assessments and management plans and fully documented transition plans. See 11 of 39 Implementation Date:

12 above (section 4) however, once discharged may no longer be under CPA Where a patient has been discharged against medical advice before a CPA care co-coordinator/cmht involvement is allocated and there is an acknowledged need for after-care, the team manager (of the team providing after-care) in liaison with in patient service will take the lead in deciding what action to take and record this on the CPA care plan. If it is not possible to identify a CPA care co-coordinator/some form of involvement within the team, the team manager will be the CPA care co-coordinator on a temporary basis until one can be agreed. All patients discharged from hospital will have their epex number forwarded to the Crisis and Telephone Support Service (CATSS) as part of the discharge procedure. CATSS will attempt to ensure that all patients discharged from hospital receive a follow up telephone call within 24 hours of discharge Section 117 Health and local authorities have a statutory duty under section 117 to provide after-care services for patients who have been detained in hospital under sections 3, 37 (whether or not with restriction under section 41), 47 or 48 of the Mental Health Act 1983, until they are jointly satisfied that this is no longer necessary. The CPA Policy & Practice Guidance clearly outlines Section 117 requirements Ensuring Post Hospital Discharge (Seven Days) Follow up Arrangements in the Community Both local and national targets state that all service users discharged from inpatient care (including those who discharge against medical advice) will wherever possible have face-to-face contact with a mental health worker (of any discipline) either within forty-eight hours or seven days. If face-to-face contact is not possible then telephone contact will take place. Service users who do not require 7-day or 48 hour follow-up are identified within the following categories: - Service users transferred to other mental health inpatient facilities Service users who have been admitted for planned respite care Service users who have been admitted for a short period and for whom it is deemed mental health services are inappropriate Service users who die within 7 days of discharge Where legal precedence has forced the removal of a service user from the country Procedure for Following up Service Users After Discharge 12 of 39 Implementation Date:

13 Discharge is a process and not an isolated event. It has to be planned for at the earliest opportunity to ensure clear understanding and contribution to care planning decision as appropriate. Prior to discharge a discussion takes place to agree whether CPA or no CPA is appropriate on discharge. This decision should be recorded on the needs assessment screen in epex. If CPA remains applicable on discharge the review will ensure: The CPA care plan has been agreed with more intensive input for the first three months following discharge from inpatient services based on clinical need. 7 day follow up is in place (48 hours for those who have been at high risk during admission) Agreement has been reached and documented where problems with engagement are anticipated as to what actions are going to be taken Copies of the CPA care plan have been circulated to all involved, including the service user A CPA care co-coordinator has been agreed. The hospital discharge summary has been completed and a copy faxed / ed to the GP and community team and a copy given to the service user. Service user medication is arranged If no CPA is appropriate on discharge the review will ensure: A lead professional is identified A support plan is agreed with the service user, recorded on the discharge summary 7 day follow up is in place The hospital discharge summary has been completed and a copy faxed / ed to the GP and community team and a copy given to the service user Day of Discharge On the day of discharge: The service user will be given a copy of their hospital discharge summary (where CPA or no CPA is appropriate) (see Appendix 1) and care plan (only where CPA is appropriate) (see Appendix 2) which details who will be providing the follow up and when by the ward nurse responsible for completing the discharge. The service user will be informed by the ward nurse that the Crisis and Telephone Support Service (CATSS) will follow up with a telephone call within 24 hours of their discharge; this will be to ascertain how they are coping in the community and confirm their scheduled follow up appointment. 13 of 39 Implementation Date:

14 The ward nurse will inform the CATSS that the service user has been discharged. The ward nurse will fax a copy of the hospital discharge summary to the GP, relevant CMHT/service providing follow up. The type of follow up, either 7 day or 48 hour, will be recorded on the patient ward stay page of epex by the person discharging the service user. See Appendix 3 for details. On discharge all service users will be asked to provide service feedback on a CRT viewpoint (electronic data collection device) Within 24 hours of Discharge The CATSS will telephone the service user to ascertain their well-being and confirm the follow up appointment. The CATSS member of staff will record this contact on the patient contact screen in epex. N.B The remainder of the policy does not apply to service users who have been admitted to the ward for detox or they do not require follow up from mental health services Two Days Post Discharge The appointment with the CPA care co-ordinator or other nominated professional should have taken place. If the service user does not attend the appointment the CPA care coordinator or nominated professional will telephone the service user. If telephone contact cannot be made a home visit should take place to ascertain the welfare of the service user, unless a risk assessment indicates that a visit to the service user s home should not take place. All actions and contacts made by the CPA care co-ordinator or nominated professional must be recorded in the contact screen in epex Four Days Post Discharge If a face to face or telephone contact has not been made by either the CPA care co-ordinator, nominated professional or CATSS then a police welfare check will be requested by the CPA care co-ordinator or lead professional. 14 of 39 Implementation Date:

15 Once contact has been established an appointment should be made for the service user to see the CPA care co-ordinator or nominated professional within the 7 days from discharge. If a face to face contact is not possible then a telephone call to the service user should be made by the CPA care co-ordinator or nominated professional. All actions and contacts made by the CPA care co-ordinator, lead professional or nominated professional must be recorded in the contact screen in epex Recording Contacts in epex A record of the visit / telephone call will be recorded on the patient contacts page of epex by the person undertaking the contact. This record will include use of either the 7-day or 48 hours follow up code in the second activity box. See Appendix 3 for example. If the person designated to carry out the face-to-face contact is unable to, (e.g. they are off sick) contingency arrangements will need to be put in place by the manager of the service to ensure the follow up is provided and recorded in epex Discharges from Community Based Mental Health Services Patients being discharged from community based mental health services will be fully involved in decisions about their discharge and follow up care provision by other professionals where indicated. The care coordinator will hold a pre discharge meeting with all healthcare providers involved in the future care of the patient and this may involve GP, social care providers, primary healthcare staff; housing providers, probation services; carers or other providers of support. All patients being discharged from community based mental health services will receive the following interventions: Up to date risk assessment and management plan. Discharge plan clearly detailing the interventions to be received and by which agency/provider, for example receiving medication from GP. Medication prescribed on discharge together with an assessment of medication concordance and interventions. Early warning signs of relapse and relapse prevention plan. Clear plan of how to refer back to services or receive additional support if required. Assessment of risks of non engagement of services and management plans to address these. Contact details of professionals and providers involved in their on going care plan. 15 of 39 Implementation Date:

16 6.8. Out of Hours Assessments requiring no further action from Community Based Mental Health Services Upon completion of an emergency assessment the referrer will be notified and informed of the outcome of the assessment and any actions agreed by the CRHTT. This will be done on the same or next working day, by telephone Arrangements for Medication Post Discharge All patients who require treatment with medication to continue post discharge should be given a supply before they leave hospital. This supply may take the form of discharge medication supplied by the Trust against a TTO prescription or the return of supplies of patient s own medicines brought into hospital on admission or a combination of the two in accordance with MMP001 Control of Medicines Policy. Patients who discharge themselves against medical advice but who require medicines post discharge should be provided with a supply of discharge medication obtained in the usual manner through pharmacy against a TTO prescription. If the patient is wishing to leave the ward immediately it will not be possible to provide the supply prior to their departure and arrangements must be made with the patient or their carers to collect the medication from the ward at an agreed time following delivery from pharmacy. If discharge occurs out of hours (i.e. when pharmacy is closed) arrangements should be made to provide a supply at the earliest opportunity. The ward team should follow the local practice relevant to their supplying pharmacy (KGH/NGH). TTOs may not be available until the next working day. The emergency duty pharmacist may be contacted for advice and to discuss when a TTO supply will be available. Once this information is known arrangements should be made for the patient or carer to return to collect the medication at an agreed time. When a patient is discharged information about their discharge medication must be forwarded to the GP as part of the discharge summary Management of medicines on handover between care settings. When patients are transferred between the care of NHFT and another hospital setting e.g. one of the acute hospitals, details of their current medication must be transferred with them. This may be in the form of a copy of their current prescription chart or detailed within any letters of referral to the receiving organisation. A record of what information has been transferred with the patient should be made within the patient s notes. Medication issued to an individual patient should not routinely be transferred with the patient unless it is labelled with instructions for use i.e. dispensed as discharge medication. 16 of 39 Implementation Date:

17 A record of any verbal communication about the patient s medication at the point of handover of care to another organisation must also be documented in the patients record. It is expected that when patients are admitted into the care of NHFT from another organisation that details of their current medication will be provided Patient Information Patients and their carers should at all times be involved, as far as is practicable, with the planning arrangements for their discharge. Information should be shared in a format, written and/or verbal so that they are aware of the arrangements and what to do in relation to their condition following discharge. Please refer to CLP063 - Policy for the Preparation and Production of Patient and Carer Information Practical Tasks on the Day of Discharge Follow hospital discharge checklist (Appendix 5) Complete CPA care plan if not already completed (Appendix 4) Refer to Discharge Process Flow Chart (Appendix 2) to ensure the planning steps have been completed Practical Tasks Post Discharge The medical discharge summary will be completed and sent to the Patient s GP and all discharge paperwork should be available on Epex at the earliest available opportunity Mandatory Training Training required to fulfil this policy will be provided in accordance with the Trust s Training Needs Analysis. Management of training will be in accordance with the Trust s Statutory and Mandatory Training Policy Specific Training not covered by Mandatory Training Not applicable to this document. 7. MONITORING COMPLIANCE WITH THIS DOCUMENT The table below outlines the Trusts monitoring arrangements for this document. The Trust reserves the right to commission additional work or change the monitoring arrangements to meet organisational needs. Aspect of compliance or effectiveness being monitored Method of monitoring Individual responsible for the monitoring Monitoring frequency Group or committee who receive the findings or report Group or committee or individual responsible for completing any actions 17 of 39 Implementation Date:

18 Duties The transfer and discharge of patients to include the definition of all patient groups transfer and discharge requirements of all patients transfer and discharge requirements which are specific to each patient group information given to the receiving healthcare professional information given to the patient how a patients medicines are managed and discharge the recording of information given to receiving healthcare professional and to the patient process for transfer or discharge out of hours The effectiveness of the Discharge Transfer policy definition of all patients group discharge requirements which are specific to each patient group. documentation to accompany the patient upon discharge. information to be given to the patient process for discharge out of hour Compliance with the requirements of discharge The effectiveness of the Handover to include compliance To be addressed by the monitoring activities below. Audit of a Senior Annually. sample, of 10 Matron records of inter-ward transfers from each clinical network Patient questionnaire Readmission within 28 days of discharge. 48 hour and 7 day follow up Patient Questionnaire Aims for older Adults 1 day of each month per ward Senior Matron Ward Matrons Annually Head of Service and senior management team Head of Service and senior management team 6 monthly Head of service/senior Chief Operating officer Chief Operating officer Chief Operating Officer clinical team 18 of 39 Implementation Date:

19 with : Handover requirements between all care settings How handover is recorded Out of hours handover Staff have completed training associated with this policy in line with the TNA Epex Training will be monitored in line with the Statutory and Mandatory Training Policy. Where a lack of compliance is found, the identified group, committee or individual will identify required actions, allocate responsible leads, target completion dates and ensure an assurance report is represented showing how any gaps have been addressed. 8. REFERENCES AND BIBLIOGRAPHY There are no references or bibliography associated with this document 9. RELATED TRUST POLICY CLP010 - CPA Policy CLP016 - Policy for Delayed Discharges CLP020 - The Mental Health Act 1983 (As amended by the 2007 Act) CLP028 - AWOL Policy CLP031 - Policy for Identifying an Inpatient Bed CLP052 - Policy 7 Day/48 hour Follow-up CLP056b - Discharge and Transfer Policy for Community Healthcare and Community Hospitals CLP063 - Policy for the Preparation and Production of Patient and Carer Information CRM001 - Risk Management Policy CRM002 - Incident Policy IGP107 - Health Records Management Policy IGP108 - Policy for Producing Patient Information IGP021 - Recording and Administration Procedure for Inpatient Discharge MMP001 Control of Medicines Policy OP-CRHTT - Crisis Resolution Home Treatment OP-SPOA - Single Point of Access 19 of 39 Implementation Date:

20 APPENDIX 1 - PATIENT TRANSFER CHECKLIST Patients name Epex number. Transfer From..Transfer to.. Ensure the patient has:- Date/time completed BY whom The patient has been informed of and reasons for the transfer. The patient has collected all belongings and bed area has been checked. The Case notes are collected (copied for external transfer) no longer using SCR Section papers (if applicable) are collected and MHA Administrator informed. Form H4 part1 completed (for external transfer) The patients own Medication and Medicine chart have been collected. The patient s property and Property/cash sheet are collected. The Patient s next of kin or significant other have been informed of the transfer. Inform the patients care coordinator or lead professional of the transfer. Alter the office board, computerised bed state, index card and any other local documentation as necessary. Inform the receiving ward that the patient is on their way. Clearly communicate all safeguarding issues. 20 of 39 Implementation Date:

21 Part two: (When the patient arrives) PLEASE ENSURE PATIENT IS: DATE COMPLETED BY WHOM: Introduced to staff & patients Orientated to environment & ward policies/practices Issued a Welcome Pack Issued room keys Offered to store valuables in safe/room box Part three: (Paperwork) PLEASE ENSURE: DATE COMPLETED BY WHOM: Levels of Observations assessed & recorded (as per policy) Care plan devised Relative/carer informed (with consent) & phone numbers/visiting times given Patient included on fire/bed board Keyworker/associate nurse allocated CPA care co-ordinator informed (if not possible, write a note in the diary) Record on Ward report Up-date transfer details in Up-date EPEX) WARD REFERRAL Date Received: Transferring Ward: Patient Details: Name: Date of Birth: Sector: Care Co-ordinator: 21 of 39 Implementation Date:

22 Psychiatric History: Current Episode: Legal Status: Nursing Observations: Current Medication: (Non-stock medication to be transferred with patient) Attitude to Medication: Current Plan: Does the patient have a drug or alcohol related problem? (If yes, please specify): Does the patient have a forensic history? (If yes, please specify): Does the patient have any physical / mobility problems? The following assessment tools have been copied and sent with patient Manual handling Yes No N/A Waterlow Yes No N/A Falls risk assessment Yes No N/A MUST nutritional tool Yes No N/A Continence assessment Yes No N/A 22 of 39 Implementation Date:

23 Infection control risk assessment Yes No N/A HCA1 Do not resuscitate current status Yes No N/A Advance decisions Yes No If yes please detail below Any ongoing care requirements? e.g. depot injections, lithium monitoring, B12, blood glucose monitoring, wound care etc. Yes No If yes please detail below Outstanding appointments? Yes No If yes where, when, time, transport arranged? (If yes, please specify): Need to consider communication tools and aids for LD RISK ASSESSMENT: Is the risk assessment up-to-date? YES / NO (If not, ask for it to be updated before transfer). PRESENTING RISKS: (Explore factors, including history). Suicidal Intent: YES / NO (Preferred method) Deliberate Self Harm: YES / NO (Describe methods) Accidental Fire Risk: YES / NO Self Neglect: YES / NO Hygiene / Dietary Intake 23 of 39 Implementation Date:

24 Vulnerability / Exploitation / Sexual Dis-inhibition: Violence & Aggression: YES / NO (Give examples) If female, do they need female corridor: YES / NO Absconding Risk: YES / NO Please discuss this referral with other staff, before patient arrives. 24 of 39 Implementation Date:

25 Healthcare Associated Infections Risk Assessment Checklist Tool Admission Transfer Discharge If a transfer or discharge where to? Date: Patient/Patient details Consultant: Name: GP: DOB: Address: MRSA Yes No NK Is the patient known to be infected or colonised with MRSA? *Is the patient from a nursing or residential home or another Trust? *Has the patient any wounds/skin lesions/pressure sores? *Has the patient a history of frequent acute hospital admissions? Has the patient had an MRSA screen undertaken? If yes: Where When Result (N/K = Not known) Has a specimen been sent? Has an organism been identified? If yes: Where When Result Has patient had treatment? If yes: What and when completed NB: Patients with diarrhoea caused by Clostridium Difficile toxins or enteric pathogens such as E.coli or salmonella should be isolated in single room until 48 hours symptom free. There is also an integrated C.diff pathway in ICP004 for confirmed cases. Others communicable disorders Does the patient have or is suspected of having any of the following communicable disorders: Smear positive TB Chicken pox or shingles Influenza Impetigo Scabies Other please specify If yes to any of these isolate patient and inform Infection Control Nurse. Other factors which predisposes to HCAI Yes No Does the patient have a urinary catheter or other indwelling device in situ? Is the patient receiving enteral feeding? Is the patient currently receiving antibiotics? If yes to any of these ensure care plan includes specific care of patient with i.e. urinary catheter and observe for any signs of infection. Assessment undertaken by (write/type Name) 25 of 39 Implementation Date:

26 NB: If yes to all questions * consider high risk and undertake MRSA screening as per policy ICP002. NB: If MRSA positive on admission or positive on screening please use integrated pathway in ICP002 Diarrhoea Yes No N/K Does the patient have diarrhoea? Is the diarrhoea thought to be of an infectious nature? Referral received by: Print name: 26 of 39 Implementation Date:

27 APPENDIX 2 - INPATIENT DISCHARGE PROCESS PLANNED DISCHARGE FROM INPATIENT WARD/UNIT UNPLANNED DISCHARGE FROM INPATIENT WARD/UNIT Actions completed prior to discharge CPA review meeting to be arranged by named inpatient nurse: to invite CPA care cocoordinator to ward review. Decision made whether to continue CPA post discharge. Identify any other support services required i.e. CRHTT to support for early discharge. Patient is discharged without notice or takes his/her own discharge. Inpatient ward/unit staff to review HONOS and risk assessment, and notify CATSSIST/ISS duty clinician Patient has CPA care coordinator allocated. No CPA care co-ordinator allocated CPA review agree: CPA care plan 48 hour/7 day follow up Date of next review HONOS outcome score reviewed Risk Assessment reviewed and updated. Patient discharged from ward with: Follow up Copy of CPA care plan if appropriate required Copy of discharge summary Name and contact details of CPA care cocoordinator if subject to CPA agree what follow up care is MULTI DISCIPLINARY TEAM to Details of follow up arrangements and needed and who will provide contingency plan- this is on CPA paperwork Contact CATSS Telephone The Number current IST/ISS version of duty any clinician community policy, procedure, protocol or guideline is the version held on the NHFT CPA care co-coordinator to 27 of 39 Implementation Date: GP / CPA Co-ordinator Health informed and Learning and faxed Disabilities arrange review to establish CPA care plan. copy of CPA care plan and CPA hospital discharge form on day of discharge CATSS Notified IST/ISS duty clinician Ward staff to inform CPA care coordinator, GP, RC (CTL on-call Out-Of-Hours) and anyone else involved as soon as is practical after discharge. MULTI DISCIPLINARY TEAM to decide whether follow up care is required team for follow up and CPA care coordinator No follow up required Discharge to care of GP

28 APPENDIX 3 - DISCHARGE CHECKLIST Discharge date: Part one: (Day of discharge) AFFIX ADRESSOGRAPH PLEASE INFORM: PHARMACY (order TTOs & Sign/date when giving to patient) Inform GP (if not possible, write a note in the diary) Notify CATSS not LD CMHT / COMMUNITY TEAM (if not possible, write a note in the diary) Admission Ward (bed availability) 7 Day or 48hour follow up required (please state) PLEASE: COMPLETED BY: COMPLETED BY: Return belongings from safe/room box Collect room key Give patient means to provide feedback. Record on Ward report Amend fire/bed board Arrange follow-up appointment: Update EPEX with correct follow up flag Part two: PLEASE ENSURE: DATE: COMPLETED BY: Discharge summary is FULLY completed: DOCTORS (preferably team doctor) MUST record ALL Medication on discharge SPECIAL INSTRUCTIONS ICD-10 DIAGNOSIS NURSES MUST record SUMMARY of admission AFTERCARE arrangements (Including follow-up & outpatient appointments). Risk assessment is updated THEN: Photocopy completed discharge summary & up-todate risk assessment TWICE: one copy for the discharge folder one sent to the CPA care manager, (Campbell House, Campbell Square, Northampton) FAX completed discharge summary & up-to-date risk assessment: GP Care co-ordinator File Originals in the scanned Photocopy of completed discharge summary (ONLY) sent to patient Record completion on discharge sheet Update Contact notes GIVE TO WARD CLERK, TO ORGANISE DISCHARGE LETTER WITH MEDICS/admin team 28 of 39 Implementation Date:

29 APPENDIX 4 - CPA CARE PLAN epex Number NHS Number.. Addressograph Name: Address: Name of CPA Care Co-ordinator: Address: Postcode: Tel No: NHS No: DOB: CPA Care Co-ordinator Tel No: Name and Contact Details of Carer Development and Support Worker: (Where applicable) People involved with patient Name/Relationship/Contact Number Type of Review Attended Circulated Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N (REVIEW CODES: 1 = TELEPHONE 2 = 1 & 1 MEETING 3 = MDT MEETING 4 = WRITTEN REPORT) Date of plan or review: LEGAL STATUS Legal Status: SUMMARY OF NEED Date of next review: ACTION (Include days, frequencies, time) BY WHOM Mental Health Needs 29 of 39 Implementation Date:

30 Including medication and side effects SUMMARY OF NEED Relationships/Responsibilities including details of child care responsibilities, personal and social relationships ACTION (include days, frequencies, time) BY WHOM Accommodation Needs Current & Future Care of Self and Home Meaningful Occupation Including employment & educational opportunities Physical Health Needs Management of Income Psychological Therapy 30 of 39 Implementation Date: