Older Adults Division: Admission & discharge protocol

Transcription

1 Linclnshire Partnership NHS Fundatin Trust (LPFT) Older Adults Divisin: Admissin & discharge prtcl DOCUMENT VERSION CONTROL Dcument Type and Title: Older Adults Divisin Service Prtcl: Admissin & Discharge prcedure. Authrised Dcument Flder: Service Operatinal Prtcls New r Replacing: New Dcument Reference: Versin N: V1 Date Plicy First Written: Nvember 2014 Date Plicy First Implemented: Nvember 2014 Date Plicy Last Reviewed and Updated: Nvember 2016 Implementatin Date: Nvember 2016 Authr: Apprving Bdy: Steven Rberts Divisin Manager Older Adults Service steering grup Apprval Date: Nvember 2016 Cmmittee, Grup r Individual Mnitring the Older Adults Divisinal Management Team Dcument (DMT) Review Date: Nvember 2017

2 Linclnshire Partnership NHS Fundatin Trust Older Adults Divisin: Practice Standards Prtcl Inpatient Services: Admissin & Discharge Prtcl Nvember 2016 O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 2

3 Linclnshire Partnership NHS Fundatin Trust Cntents: Intrductin 4 1: Aims f the Prtcl 4 2: Prtcl Principles 5 3: Definitin f Terms 5-6 4: Admissin Criteria : Bed Lcatin & Suitability Prcess and Respnsibility Pathway 1: OAD Bed gatekeeping and access pathway 6: Admissin Prcedure Standards Pathway 2: Admissin and Discharge Standards : Carer invlvement/engagement : Patient pre-leave and discharge standards Appendix 1: Mental Health Clusters Appendix 2: Assessment & Care Planning Flw Chart Appendix 3: Admissin Infrmatin/Standards Frm Appendix 4: Pathway checklist fr OA admissin/discharge. Appendix 5: MDT Meeting Recrd Frm Appendix 6: Multidisciplinary Ward Rund Standards Appendix 7: Out f Area Treatment Referral frm O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 3

4 Linclnshire Partnership NHS Fundatin Trust Intrductin: Linclnshire Partnership NHS Fundatin Trust (LPFT) Older Adults Divisin s (OAD) aim is t prvide a service that respects the privacy, dignity, chices and cnfidentiality f each individual service user, acknwledging their culture, physical ability, gender, sexual rientatin, and religius beliefs. We aim t prvide a persn centred service the Specialist Inpatient Area s (SIA s) f Langwrth and Brant Wards (Lincln), The Rchfrd Unit (Bstn) and The Manthrpe Centre (Grantham) fr individual s experiencing dementia and r mental health prblems that present with cmplex needs. The inpatient areas are intended fr shrt, fcussed perids f assessment and / r assciated treatment f individuals with cmplex needs that cannt be prvided in a less restrictive envirnment. All SIA s within LPFT supprt the fllwing missin statement: The team value everyne as individuals. We strive t enable by wrking t identify, engage and enhance individuals psychlgical, spiritual, scial and physical needs, strengths and ptential. The safety, dignity and respect f thse we care fr are upmst. The team actively supprt cllabrative engagement f bth patients and carers in the design, planning and delivery f care, prmting an pen and hnest apprach wherein the supprt f carers is essential and feedback n service quality is valued. 1: Aims f the Prtcl: The verall aim f the prtcl is t prvide a quality framewrk with clear guidelines n the admissin and discharge prcedures fr peple experiencing cmplex mental health (MH) r dementia related needs. T ensure that nly patients with cmplex needs that require specialist assessment and/r treatment are admitted and that such care represents the least restrictive ptin. T ensure high quality care is prvided fr patients wh require inpatient admissin T set ut and clarify the care pathway standards and prcesses fr everyne invlved, inclusive f patients and carers. Each ward shuld have an infrmatin pack fr patients n admissin/transfer which clarifies further the way the ward perates and what is expected during an in-patient stay O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 4

5 Linclnshire Partnership NHS Fundatin Trust 2: Prtcl Principles: T ensure that the service is always able t respnd apprpriately t the needs f patients wh are judged t need admissin t an in-patient setting fr assessment r treatment. T ensure that patients are admitted t an apprpriate clinical setting suitable fr their needs and which des nt expse them t avidable risks, e.g. cntrlled access/egress, falls, ligature. T ensure the psitive and effective management f risk. T ensure the prvisin f high quality care within clear peratinal framewrk and pathways f care. 3: Definitin f Terms: Dementia Care Inpatient Areas (DC-IA s): are designed t assess and treat peple with dementia (regardless f age) that present with severe and cmplex behaviural and psychlgical prblems. Older Adult Mental Health Inpatient Areas (OA-MHIA s): are designed t assess and treat peple with severe and cmplex MH prblems and significant physical illness r frailty which cntributes t, r cmplicates the management f their mental health status. Usually these needs require specialist skills frm a MDT that are trained in care f Older Adults. Admissin: The prcess that is required fr a patient t be admitted int in-patient services and thus regarded as an in-patient. Frmal/infrmal patients: A frmal patient is ne detained under the Mental Health Act (1983) see LPFT Mental Health Act Plicy. An infrmal patient is a patient wh is nt detained under the mental health act. Hwever nce the prcess f assessment fr admissin is cmmenced r the prcess f admissin is cmpleted, the patient may be liable t detentin under the Mental Health Act and/r assessments under the Mental Capacity Act (MCA, 2005) see LPFT Mental Capacity Act (Including Deprivatin f Liberty Safeguards) Plicy. Observatin level: the decisin as t which level f bservatin a patient will require n admissin and thrughut the in-patient stay. This shuld be a cntinuus and central aspect f the assessment prcess. This will be reviewed during the admissin within the multi-disciplinary team reviews and whenever pssible patient and relatives are cllabratively engaged in this prcess. The levels and standards f patient bservatin are set ut within LPFT Clinical Care Plicy (See sectin 14: Observatin and engagement, (Page 182)). O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 5

6 Linclnshire Partnership NHS Fundatin Trust Cmmunity Teams: There are a number f cmmunity teams that perate within the peratinal Divisins that may facilitate admissin: these include adult Cmmunity Mental Health Teams (CMHT s), the Crisis, Recvery and Hme Treatment (CRHT) teams and Older Adults Cmmunity Mental Health Teams (OA-CMHT s). These are designated t specific catchment/sectr areas. The Care Prgramme Apprach (CPA): The term Care Prgramme Apprach has been used since Octber 2008 t describe the apprach used in secndary mental health care t assess, plan, review and crdinate the range f treatment and supprt needs fr peple in cntact with secndary mental health services wh have cmplex characteristics as defined belw. Care Crdinatr: The term fr the persn wh crdinates the care and treatment fr a service user identified as being supprted by the Care Prgramme Apprach (CPA) prcess. Estimated Date f Discharge (EDD): The date that discharge is expected t ccur based n cnsideratin f clinical need and agreed target utcme measures. Smth hspital peratins flw frm EDD. Capacity management, bed management and patient thrughput are all dependent n EDD Delayed Transfer f Care (DTC): Delayed Transfer f Care ccurs when a service user is ready t be discharged frm care and is prevented frm ding s because f ther reasns (such as suitable accmmdatin nt being available). As a secndary mental health Trust, all individuals admitted t the Trust s inpatient beds will receive care and treatment thrugh the CPA prcess. This includes anyne detained under the Mental Health Act. O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 6

7 Linclnshire Partnership NHS Fundatin Trust 4: Admissin Criteria: A cre principle f the OAD care pathway is fr the prmtin and applicatin f the least restrictive care principle. Herein, admissin t an OA in-patient service shuld nly be fr thse individuals meeting the service admissin criteria (sectin 4.2) with a level f cmplexity that cannt be assessed, treated r managed in any ther less restrictive setting. See/as set ut in LPFT Clinical Care Plicy > sectin 7.1: Admissin t Hspital/Keeping an individual in Hspital, (Page 12). All admissins shuld be an apprpriate respnse t an apprpriate need and prvide an age and needs apprpriate therapeutic envirnment f care. 4.1: Cnsent t Admissin: The capacity and cnsent status f any individual being cnsidered fr care within an OA in-patient setting must be clearly determined as part f the admissin prcess. See/as set ut in LPFT Clinical Care Plicy > sectin 7.2: Cnsent t Admissin t Hspital/Keeping Smene in Hspital (Page 12). Clear and apprpriate infrmatin abut the in-patient service(s) (e.g. ward leaflet) must be prvided t the service user in rder t facilitate infrmed cnsent and supprt decisin making. If the individual has the capacity t decide whether t cme int hspital r remain in hspital then cnsent shuld be sught. If the individual des nt cnsent then cnsideratin shuld be given t assessment under the Mental Health Act > See LPFT Mental Health Act Plicy. If the individual des nt have capacity then cnsideratin shuld be given t a Best Interest Assessment under the Mental Capacity Act (see LPFT Mental Capacity Act (Including Deprivatin f Liberty Safeguards) Plicy.) r assessment under the Mental Health Act (MHA) In all circumstances the prcess and clinical ratinale/assessment f determinatin f capacity t supprt cnsent must be clearly recrded in the clinical ntes. 4.2: Essential Criteria 4.2.1: Dementia: Admissins fr assessment and treatment f severe behaviural and psychlgical difficulties (BPSD) in dementia. The BPSD shuld be f severe with care in the cmmunity nt being viable due t the cmplexity f presentatin and level f risk (high) the BPSD pse t physical r psychlgical well-being. It shuld als be prven that the patients needs cannt be safely assessed r treated in any ther care facility/less restrictive envirnment. O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 7

8 Linclnshire Partnership NHS Fundatin Trust Admissin will be cnsidered fr thse presenting with a diagnsis/r suspected diagnsis f dementia wh are n CPA t include thse wh are assessed t be in clusters: Organic: Clusters: 19, 20 & 21: see > Appendix 1: The fllwing criteria are essential in determining wh shuld be admitted t ensure apprpriate access fr an individual; On referral there needs t be evidence f an rganic cnditin affecting the brain causing cgnitive dysfunctin. Physical causes fr the change in behaviur r psychlgical well-being have been eliminated*. *In the cmmunity this wuld include getting the GP t rule ut delirium frm infectin, dehydratin, cnstipatin, cncurrent prescribed medicatin etc. r pain. Blds and urine Dipstix shuld have been carried ut if pssible. Admissin will have a clearly agreed therapeutic bjectives (see sectin 6.1: Clinical Standards) 4.2.2: Cmplex Mental Health: Admissin related t cmplex MH needs shuld be cnsidered when the individual is presenting a risk t themselves r thers. Admissin shuld nly be necessary t stabilise behaviur prblems that are unmanageable in any ther setting r t treat any severe psychiatric symptms Audit Cmmissin (2000). Admissin will be cnsidered fr thse presenting with mental health diagnsis wh are n CPA t include thse wh are assessed t be in clusters Nn-psychtic: Clusters 4, 5, 6, 7, 8: see > Appendix 1: Psychsis: Clusters 10, 12, 13 17: see > Appendix 1: Admissin will be fr assessment and treatment f mderate-severe t severe MH needs that cannt be facilitated in the cmmunity due t the cmplexity f presentatin and/r risk these needs pse t the individuals physical r psychlgical well-being. It shuld als be prven that the patients needs cannt be safely assessed r treated in any ther care facility/less restrictive envirnment. The fllwing criteria are essential in determining wh shuld be admitted t ensure apprpriate access fr an individual; On referral there needs t be evidence f cmplex need r risk (see LPFT Clinical Care Plicy: Sectin 10: Clinical Risk Assessment & Management (Page 72)) in accrdance with the identified MH clusters (Appendix 1) The individual wuld usually be smene with mental disrder and significant physical illness r frailty which cntribute(s) t, r cmplicates the management f O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 8

9 Linclnshire Partnership NHS Fundatin Trust their mental health status. This may include peple under 65 in exceptinal circumstances. Physical causes fr the change in mental health status, behaviur r psychlgical well-being have been eliminated*. *In the cmmunity this wuld include getting the GP t rule ut delirium frm infectin, dehydratin, cnstipatin, cncurrent prescribed medicatin etc. r pain. Blds and urine Dipstix shuld have been carried ut if pssible. Admissin will have a clearly agreed therapeutic bjectives (see sectin 6.1: Clinical Standards) 4.2.3: Physical Health (fr bth & 4.2.2): The individual shuld be deemed medically fit fr admissin: If the individual s primary needs are physical, then care shuld be prvided thrugh general care services. Their physical health cnditin will nt be t frail t allw their safe management in a mental health unit : Other requirements (fr bth & 4.2.2): The referrer will als need t demnstrate that: All admissins will present with cmplex needs and shuld be in receipt f Care Prgramme Apprach (CPA*) level (See LPFT Clinical Care Plicy: Sectin 9: Assessment & Care Planning (including CPA (Page 29)). That multidisciplinary team (MDT) management strategy have nt succeeded in cntaining the presenting prblems and there has been an increase in the level f risk. That all alternative care-prvisin ptins have been explred within the cntext f psitive risk-taking. That details f alternate avenues utilised, explred and/r discunted are clearly dcumented in the clinical ntes. The referrer has assessed the level f cmplexity and/r risk as high. This will reflect cmplex cncerns within the areas f Harm t self, Harm t thers, Neglect, Relapse and Hazards in the delivery f care. This will be reflected within the patient Risk Assessment/Clinical Risk Frmulatin, care recrd and electrnic ntes system. O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 9

10 Linclnshire Partnership NHS Fundatin Trust There will be a mutual agreement between the in-patient team and the referrer in the ratinale fr admissin. There will be clear gals fr discharge. The view and expectatins f the patient and/r carer frm an admissin must be cnsidered. Or: There is a need fr detentin under the Mental Health Act 1983*. * Any patient wh is t be detained under the Mental Health Act 1983 will be given pririty fr admissin. This hwever des nt negate the need fr clear clinical bjectives t be in place and als a cmmunicatin plan and a predicted discharge date. O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 10

11 Linclnshire Partnership NHS Fundatin Trust 5: Service Gatekeeping, Access & Lcatin: If the admissin criteria and standards (sectin 4) have been met then access t OAD in-patient bed prvisin can be prgressed via the fllwing rutes and respnsibilities. 5.1: Admissin during cre service hurs (Mn-Fri: ) (Pathway 1) 5.1.1: During cre service hurs all admissins t OA in-patient services shuld be: Discussed/reviewed with/by OA service Cnsultant. Supprted and facilitated thrugh the Admissin and Discharge Pathway Crdinatr (ADPC)*. Discussin and review with the ADPC at pint f admissin cnsideratin t ensure need meets; Service criteria (sectin 4) Clinical standards (sectin 6) Least restrictive ptin available *The ADPC will liaise with in-patient and cmmunity teams and the patients Respnsible Clinician as required t facilitate agreement as t patient suitability and identificatin f suitable in-patient facility (based n lcality and/r diagnsis, service capacity and acuity management). Admissin agreed/accepted by an OA services Cnsultant** 5.1:2: Fllwing agreement/acceptance fr admissin: If there is bed capacity/availability within LPFT OAD services > then the ADPC will supprt the CMHT t liaise and wrk with the in-patient wards t lcate a suitable bed and supprt the admitting team in the safe management f the admissin prcess (as per pathway 1). If there is n bed capacity/availability within LPFT OAD (r, if apprpriate LPFT adult) services > the admitting team/cmht retains respnsibility t identify and secure an ut f area bed in liaisn with the CCG Cmplex Care Team (CCT) supprted by the ADPC (as per pathway 1). CMHT cmplete Acute Out f Area (OOA) Treatment referral frm (Appendix 7) Fax/ as directed n frm. Als cpy f frm t OAD ADPC. CMHT and ADPC t liaise with CCG CCT t identify OOA bed and agree funding stream and authrisatin. CMHT/ADPC t cmmunicate with accepting OOA team t facilitate transfer f service user and required infrmatin : In the absence f the ADPC the prcess fr bed lcatin is: If there is bed capacity/availability within LPFT OAD services > then the ward which wuld be the usual nminated recipient (based n lcality and diagnsis) is respnsible fr the lcatin f a bed (even if n bed available n the nminated ward). The nminated ward will: Liaise with all OAD wards t identify a suitable bed O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 11

12 Linclnshire Partnership NHS Fundatin Trust Liaise with the referring team t facilitate the admissin prcess t the identified bed. If there is n bed capacity/availability within LPFT OAD (r, if apprpriate LPFT adult) services > Remains as per abve. Pathway 1: OAD Bed gatekeeping and access pathway during cre service hurs If nt n CPA then > cmmence CPA and apply principles and applicatin f CPA framewrk t supprt care (Appendix 2) Patient need/cmplexity escalating: admissin being cnsidered Discuss with Cnsultant/MDT review f patient needs against admissin criteria. Review with ADPC DOES NOT meet admissin criteria Review care package Review alternatives t admissin (Enhanced care package/chc/ Scial care) Clearly recrd ratinale fr nn-admissin and agreed care-plan MEETS admissin criteria: sectin 4 Cnsent t admissin clarified: sectin 4.1 Infrmal Outcme clearly MHA recrded in DLS ntes Prvide service user/carer with infrmatin abut the ward t supprt infrmed cnsent. Cntinue t Supprt in Cmmunity Bed capacity in OAD/LPFT: sectin 5.1.2: NO bed capacity in OAD/LPFT INFORM > Admissin & Discharge Pathway Crdinatr (ADPC): Cmplete: Acute Out f Area Treatments Referral frm (Appendix 7) > FAX/ t SWCCG Admitting CMHT t > Cmplete admissin sheet Ensure admissin criteria/clinical standards met (as per Sectin 6.1). PATHWAY 2: Admissin & Discharge standards ADPC t > Identify apprpriate bed Check admissin criteria/standards met (as per Sectin 6.1) Facilitate transfer/admissin INFORM > Admissin & Discharge Pathway Crdinatr (ADPC): Admitting CMHT/ADPC: T liaise with CCT t > Identify Out f Area bed Secure funding apprval Ensure admissin criteria/clinical standards met (as per Sectin 6.1). Liaise with identified OOA prcesses and pathways 5.2: Admissin utside cre service hurs (Mn-Fri: & Weekends): 5.2.1: Fr admissins accepted utside f OAD cre service hurs: If there is bed capacity/availability within LPFT OAD services > then the ward which wuld be the usual nminated recipient (based n lcality and diagnsis) is respnsible fr the lcatin f a bed (even if n bed available n the nminated ward). The nminated ward will: Liaise with all OAD wards t identify a suitable bed Liaise with the referring team t facilitate the admissin prcess t the identified bed. O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 12

13 Linclnshire Partnership NHS Fundatin Trust If there is n bed capacity/availability within LPFT OAD (r, if apprpriate LPFT adult) services > then an ut f area bed can be sught if all ther ptins have been exhausted. The ward which wuld be the usual nminated recipient (based n lcality and diagnsis) is respnsible fr the lcatin f a bed (even if n bed available n the nminated ward). The nminated ward will: Fllw agreed prcedures and cntacts t identify an ut f area bed. Cmplete Acute Out f Area Treatment referral frm (Appendix 7) Fax/ as directed n frm. Als cpy f frm t OAD In-patient and Cmmunity Service managers, ADPC and Business Manager. Liaise with the referring team t facilitate the admissin prcess t the identified bed. Cntact the n-call manager fr apprval f identified ut f area placement. O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 13

14 Linclnshire Partnership NHS Fundatin Trust 6: Admissin Prcedure Standards: 6.1: Clinical standards: 6.1:1: In accrdance with LPFT Clinical Care Plicy: Sectin 9: Assessment & Care Planning (including CPA) (Page 29); In respnse t nted clinical deteriratin and increasing need and cmplexity f a service user whilst within the cmmunity setting, the applicatin f the principles and practice f Care-Crdinatin/CPA shuld be pr-actively applied as the first respnse t supprting enhanced need (see Pathway 1). As a secndary mental health Trust, all individuals admitted t the Trust s inpatient beds will receive care and treatment thrugh the CPA prcess. This includes anyne detained under the Mental Health Act. A classificatin f CPA shuld be recrded in the electrnic health recrd at the pint f admissin. If a service user that is admitted t an inpatient area already has an identified CPA Care Crdinatr r lead prfessinal, they must remain in the active rle as CPA Care Crdinatr and remain in cntact with the service user and named nurse t ensure cntinuity f care particularly in relatin t discharge planning. If a service user wh is admitted t an inpatient bed has nt previusly been supprted by LPFT, the named nurse will act as the CPA Care Crdinatr (but will recrd themselves as the Named Nurse in the patient s health recrd) until a decisin is made whether r nt further care is required n discharge. At all pints f admissin/transfer, bth internal and external, the lead prfessinal/care crdinatr must prvide a detailed verbal handver. This must be supprted by a written dcuments/infrmatin as set ut in belw: 6.1:2: The care-crdinatr must prvide the fllwing frms and assessments t the admitting team; OAD admissin infrmatin sheet (See > Appendix 3) Clinical Risk Frmulatin* Capacity assessment (cmpleted r if nt required mentin in clinical ntes) Needs assessment (cmpleted in Risk Frmulatin histry sectin) Wellbeing plan * List f current medicatins These assessments must reflect the current clinical state immediately prir t and leading t admissin. If these are nt immediately available due t the type r time f admissin, then these assessments are t be prvided by the admitting team within ne full wrking day. *These can be either as a hard cpy r electrnically n the clinical systems. 6.1:3: The care-crdinatr will ensure that the Wellbeing Plan includes; O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 14

15 Linclnshire Partnership NHS Fundatin Trust Clearly defined clinical bjectives/target symptm; in relatin t the admissin with demnstrable health gains - these must be shared frm the utset with the persn with dementia, the carer and the MDT. Target symptms are be identified/rated via a cmpleted assessments as set ut in the OAD Clinical Pathways: Dementia Depressin & suicide risk Anxiety Psychsis Assciated utcme measures.(i.e. what will indicate readiness fr discharge) That the clinical bjectives define a perid f interventin lasting n lnger than 28 days. That the requirements in accrdance with the MCA (2005) fr infrmal admissin are satisfied. Unless admitted under the MHA (1983) a MCA (2005) must be cmpleted fr all admissins knwn t the service*. If there is a lack f capacity with regards the admissin then a Best Interests assessment must be cmpleted fr all admissins knwn t the service. *whilst within the act there is a presumptin f capacity, the elevatin f risk and clinical features indicative f/required fr admissin t secndary care in-patient services represent a clear indicatin f need t establish capacity in relatin t deprivatin f liberty i.e. behaviurs indicative f an impairment, r disturbance in the functining f, the mind r brain. 6.1:4: The Wellbeing Plan bjectives are t be i) discussed, ii) agreed and iii) dcumented in the reasn fr referral, bjectives fr admissin and predicted date f discharge sectins f the OA ICP Inpatient Admissin frm. Any disagreements arund the reasn and/r suitability f the admissin are als t be dcumented in the clinical recrd. 6.1:5: A clear cmmunicatin and engagement plan t supprt the clinical bjective is t be agreed n admissin between the admitting ward and cmmunity teams. This is t be clearly recrded in the clinical nting systems and shuld include; Expectatins arund MDT attendance > as set ut in Appendix 6 include: Care-crdinatr will attend* MDT t review gals and suitability fr/f admissin at initial MDT within 5 wrking days f admissin. Pre-discharge/CPA review; t supprt and agree discharge plan and develp pst-discharge care-plan. Clinical input and discharge planning respnsibilities f bth the ward team and care-crdinatr: See; Appendix 6: Multidisciplinary Team Ward Rund Standards. O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 15

16 Linclnshire Partnership NHS Fundatin Trust Sectin 8: Patient pre-leave and discharge standards. Pathway 2: Admissin and Discharge standards: Patient need/cmplexity escalating: admissin being cnsidered PATHWAY 1: As per > PATHWAY 1: Bed gatekeeping/ access pathway: Prir t admissin < Patient n CPA with: Well-being plan, Crisis & cntingency plan, Needs assessment. Risk frmulatin Cnsent t admit and assciated legal status agreed: Infrmal with capacity Capacity assessment cmpleted DLS t supprt as required. MHA Dcument in ntes. Detailed verbal handver f infrmatin supprted by required assessment/care plans in either hard r electrnic cpy Care-crdinatr allcated 2 wrking days < If existing cmmunity carecrdinatr then cntinues. If n care-crdinatr then: Initially named nurse CMHT care-crdinatr t be allcated within 2 wrking days. Cmplete CHC Checklist When clinical bjectives met and/r ptimal presentatin achieved/less restrictive ptins available > cmplete CHC checklist IF Psitive checklist Decisin Supprt Tl (DST) Cmplete within < 10 wrking days Undertake DST t supprt discharge: Engage SU & carer in full prcess Jintly agree DST recmmendatin Cmplete Admissin Infrmatin frm: (Appendix 3) Prir t admissin < Agree clinical bjectives fr admissin: day f admissin < Objectives fr admissin clearly agreed and recrded: Supprted by: Standardised assessment measures (as per clinical pathways) Agree utcmes required fr pint f discharge with EDD: With assciated predicted assessment utcme Within 72 hrs f admissin < Cmplete nursing/medical actins as per Pathway Checklist f OA admissin/discharge: sectins 1 5 (Appendix 4) Initial MDT review: within 5 wrking days < Review f admissin. Of: Clinical bjectives Apprpriateness/cntinued need. Agree treatment and management plan Cnfirm EDD and assciated utcme measures. MUST include*; Care-crdinatr Carer/NK (as agreed) Running MDT review: < weekly Cntinued review against agreed: Clinical bjectives Treatment and management plan EDD and assciated utcme measures. Deemed fit fr discharge: Medically fit agreed by MDT. Funding stream identified/agreed. Pre-discharge/CPA MDT review: Review f admissin. Of: Clinical bjectives met/ptimised. Agree discharge & crisis and cntingency plan Agree and bk 7-day fllw-up visit. MUST include*; Care-crdinatr Carer/NK (as agreed) Standardised assessments t supprt admissin as per OA clinical pathways: Dementia Depressin & suicidality Anxiety Psychsis MDT reprting/infrmatin requirements as per OA MDT meeting recrd frm (Appendix 5) *If unable t physically attend: either deputy, virtual attendance t be undertaken. Organisatin and quality standards fr MDT management and practice as per Multidisciplinary Ward Rund Standards (Appendix 6). YES DTC present NO If DTC identified: Recrd/reprt as DTC ADPC assist in active review & crss service liaisn/reslutin O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 16

17 Linclnshire Partnership NHS Fundatin Trust 6.1:6: All actins utlined within the Pathway Checklist fr OA Admissin/Discharge (Appendix 4) are t be cmpleted as per sectins: Admissin by medical team within 4 hurs Actins by nursing team as per: 4 hurs f admissin 12 hurs f admissin 24 hurs f admissin 72 hurs f admissin In additin the admitting dctr shuld cmmunicate with the nursing team any significant findings relating t the physical examinatin and shuld: Request a full bld screen n all patients. Agree an apprpriate level f bservatin and PRN medicatin (if required). If nt prvided request a GP medical summary t ensure treatment fr cmrbid physical ailments cntinue. All newly admitted and/r transferred patients shuld be reviewed by a member f the medical team as sn as pssible but n later than 72hrs after admissin (unless due t bank hlidays). As per the allcated care-crdinatr must remain in the active rle as CPA Care Crdinatr and remain in cntact with the service user and named nurse/ward thrughut the perid f in-patient care t ensure: Cntinuity f care particularly in relatin t discharge planning Review prgress against the clinical bjectives fr admissin Supprt and mnitr identified utcme measures in relatin t discharge transitin pint and readiness (see als sectin 8) 6.1:7: Capacity Assessment: Unless admitted under prvisin f the MHA (1983), r nt cmpleted prir t admissin due t surce f admissin a mental capacity assessment is t be undertaken within ne wrking days f admissin in rder t ascertain and infrm decisins relating t cnsent t care and treatment (see > LPFT Clinical Care Plicy: sectin 7.7: Cnsent t Care & Treatment (Page 14)), restraint, restrictin and/r deprivatin f liberty safeguards (DLS). The assessment utcmes relating t capacity, restrictin(s) and liberty are t be fully dcumented and care-planned within ne wrking day (but als represent an n-ging prcess) clearly utlining: Restrictins n liberty e.g. access t and frm ward, day t day restrictins. Hw liberty will be psitively prmted within these restrictins : Fllwing a capacity assessment, if an individual is fund t lack the capacity fr a cmplex decisin(s) then the best-interest prcess shuld be fllwed as per LPFT plicy and the utcmes fully dcumented and care-planned. Examples wuld include but nt be restricted t: O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 17

18 Linclnshire Partnership NHS Fundatin Trust Use f cvert medicatins The use f physical interventin t prevent specified actins The use f mechanical restraints (e.g. bed sides) 6.1.9: The senir health prfessinal respnsible fr the admissin shuld infrm the persn being admitted abut their legal status at the pint f admissin. They shuld; Use clear language Discuss rights and restrictins with the persn Prvide written and verbal infrmatin Make the discussin relevant t the ward the persn is being admitted t Explain whether r nt the individual are under bservatin and what this means. Check that the persn has understd the infrmatin : Observatins: If the persn is under bservatin then the admitting nurse r persn respnsible shuld tell the persn* what level f bservatin they are under and; Explain what being under bservatin means Explain clearly the reasns why the persn is under bservatin and when, r under what circumstances, this will be reviewed. Explain hw they will be bserved and hw ften Explain hw bservatin will supprt their recvery and treatment Discuss with the persn hw their preferences will be respected and hw their rights t privacy and dignity will be prtected. Offer the persn an pprtunity t ask questins. *where the persn lacks capacity then the designated carer/nk shuld be fully infrmed f the persn s treatment care and supprt (see belw) : The presence f Advance Decisins t Refuse Treatment and/r Advance Statements shuld be checked and taken int accunt (see LPFT Mental Capacity Act (Including Deprivatin f Liberty Safeguards) Plicy.) 6.1:12: In cases where a deprivatin f liberty safeguard (DLS) is assessed t be required in line with the guiding principles f the act, then the DL safeguards prcess is t be dcumented and implement within ne wrking day (see LPFT Mental Capacity Act (Including Deprivatin f Liberty Safeguards) Plicy.) 6.1:13: If adult abuse is suspected n admissin immediately refer t and fllw LPFT Safeguarding Plicy. 6.1:14: If a Care C-rdinatr is nt allcated r knwn at the time f admissin, it is the respnsibility f the Ward Team t cmmunicate with the apprpriate CMHT Team Crdinatr t have a Care C-rdinatr allcated within ne wrking day f admissin. In the absence f an existing care-crdinatr the respnsibility fr the cmpletin f baseline assessments lays with the ward team. O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 18

19 Linclnshire Partnership NHS Fundatin Trust 7. Carer invlvement/engagement: This sectin utlines the expected standards fr patient & carer infrmatin and engagement at and arund the pint f admissin and discharge. Whilst set ut separately frm clinical prcesses (sectin 6.1), in practice they represent a singular, cherent prcess with an emphasis n the management f perceptins f carers/first time visitrs t the ward, and the establishment f a partnership f care. The standards set ut in this sectin shuld represent a cnsistent systematic apprach n every admissin. 7.1: Cre principles and Infrmatin Sharing: The fundamental principle is that service user s carers shuld be fully invlved in the care planning and n-ging care delivery and review prcesses where apprpriate and pssible. If there are instances where this is nt pssible, staff shuld dcument this. There needs t be respect fr the rights and needs f the carers alngside the persn s right t cnfidentiality. In line with Trust plicy the wishes f the patient with regards t the sharing f their infrmatin and engagement and invlvement in their care and treatment pathway must be explicitly discussed and the utcme and wishes recrded. The capacity f the patient t cnsent t/make these decisins must be clearly determined in line with LPFT Mental Capacity Act (Including Deprivatin f Liberty Safeguards) Plicy. All standards set ut in the fllwing sectin that entail the infrmatin sharing and cnfidentiality agreements/wishes are dependent upn the abve agreements and capacity status f the service user. 7.2: On Admissin: On arrival the patient & carer(s) are t be greeted and taken t quiet/private rm/area away frm immediate ward envirnment and ffered/prvided with refreshments : As part f the admissin prcess the admitting nurse is t prvide infrmatin regarding the nature and purpse f ward prir t the patient and/r carer being intrduced t the main clinical envirnment. This is in rder t pr-actively prepare, infrm and manage perceptins. Specifically areas fr discussin include: Things they may see (e.g. cnfrntatin, de-escalatin, unusual behaviurs etc.) the causes and reasns fr these, and; Wh t apprach with any cncerns r anxieties : If admitted fr dementia-related need: Knwing Yu dcument: the central rle f bigraphical infrmatin and cntinued carer invlvement in persn-centred assessment and care is t be explained. The cmpletin f the OA Knwing Yu leaflet by the carer is t be requested within 5 wrking days. T supprt this prcess, an appintment t meet with the ward OT within 3 wrking days is t be arranged t explain the therapeutic tl-kit mdel f care and assist the carer t; Review and/r cmplete the Knwing Yu dcument. Discuss and cmmence a Memry-bx. O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 19

20 Linclnshire Partnership NHS Fundatin Trust Dependent n chice the OT appintment can ccur n the ward r at the patient/carers hme. If a hme visit is requested and this is ut f the lcal CCG catchment area the ward is t cntact the apprpriate lcality OT (either ward r cmmunity team based) within ne wrking day t arrange a visit within 3 wrking days : T supprt the verbal rientatin a cpy f the ward infrmatin pack is t be prvided: This shuld include: The ward infrmatin leaflet and welcme letter. Key staff and cntacts infrmatin sheet Chice agenda infrmatin sheet 7.2.4: A physical rientatin t the ward shuld be ffered after the actins set ut in sectin have been cmpleted : Review the service users cnsent t share infrmatin with family members, carers and ther services during the in-patient stay. Clearly recrd the utcmes in the clinical ntes : The clinical bjectives and purpse f the admissin perid are t be discussed and agreed and dcumented in the clinical recrd : As per MDT ward rund standards (Appendix 6): there shuld be cntinued practive engagement and invitatin t include key identified carers in all MDT ward rund discussins. If carers are unable t attend ward runds then it is the named nurse s respnsibility t ensure that pre-mdt cmmunicatin ccurs and that the views and infrmatin f and frm the service users carers are represented and recrded in the MDT meeting setting : Infrmatin is t be prvided t the carer with regards: The lcal and prcess fr cmmunicatin and infrmatin. The lcal and Trust prcess fr raising cncerns and/r cmplaints : A carer s needs assessment is an pprtunity fr a carer t express their feelings and needs with the aim f finding ut what impact the caring respnsibilities have n the carer s life. The carer must be infrmed f their right t have a Carer s Needs Assessment; sme carers may nt fully understand what the assessment entails and it is the respnsibility f thse wrking with carers t what it can mean fr the carer and t encurage them t take up an assessment. The chice f whether r nt t have ne rests with the carer. See > LPFT Clinical Care Plicy: Sectin13: Carers Assessment : Carers, where identified as prxy fr service user due t cnsent status, shuld be actively engaged with t prvide service satisfactin feed-back via agreed service and Trust measures (e.g. Friends & Family, DEMQOL etc.) 7.2.8: The infrmatin prvided t the patient and/r carer shuld be dcumented in the clinical ntes. Any issues r barriers t prviding the infrmatin shuld als be clearly dcumented in the clinical nting system. O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 20

21 Linclnshire Partnership NHS Fundatin Trust 8: Patient pre-leave and discharge standards: Patient leave r discharge brings specific risks and issues that require careful cnsideratin and planning in rder t minimise and manage risks effectively and ensure cntinuity f care. The purpse f this prtcl is t clarify the standards which clinical teams shuld wrk t, t ensure that perids f leave and/r patient discharge frm Inpatient care is: a. Safe and effective, b. Timely and neither premature r unduly delayed c. Prperly planned. As an ver-arching principle it is imprtant that patients are invlved in the planning and decisinmaking abut perids f leave r discharge and that the plan f care shuld take accunt f any preferences the service user may have. Cre standards fr Leave and Discharge: 8.1: Patients and NOK shuld be given adequate ntice, where pssible, abut prpsed leave and/r discharge discussins/arrangements and given clear infrmatin abut supprt ptins available fllwing transfer r discharge, in rder that jint and infrmed chices can be made. Ideally, leave and/r discharge planning shuld be cnsidered and cmmence as sn as the inpatient episde begins. Befre discharge, if apprpriate, phased leave shuld be cnsidered: 8.2: All patients shuld have an agreed leave and/r discharge plan which has been develped with the invlvement f: The Multi-Disciplinary Team (MDT) The patient. Carers r relatives (as apprpriate). Patient advcacy (as apprpriate) The relevant Cmmunity Services r Teams, including the Care Crdinatr. GP (as apprpriate). Other relevant agencies, e.g. scial services, cmmunity health services etc. If the persn is being discharged t a care hme, invlve the care hme managers and practitiners in care planning and discharge planning. 8.3: All pre-leave r pre-discharge MDT meetings require the fllwing standards f clinical practice and decisin making t be evidenced and recrded in the clinical nting: The inclusin f the cmmunity team-care crdinatr (r nminated representative)* fr key/agreed meetings (see Appendix 6 & Pathway 2) That leave and/r discharge** plans incrprate CMHT supprt/visitatin. If fr discharge that the 7-day fllw-up visit date is agreed and dcumented. Up-t-date clinical review & risk assessment/enablement status Review f frmal assessments/nursing & AHP clinical summary as part f the clinical decisin making prcess. With clear cmparisns against admissin clinical base-line. Clear explanatin and discussin f CPA status and assciated care requirements with the patient and carer/nk. O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 21

22 Linclnshire Partnership NHS Fundatin Trust Cmpletin f all clinical actins and nting as per Pathway checklist fr OA admissin/discharge: sectin 6: Pre-discharge planning: *inclusin des nt necessitate physical presence but indicates the requirement that the cmmunity team are fully aware f the leave/discharge plan and that input frm the cmmunity team has been included and cnsidered in this decisin making prcess. **discharge is cvered by the 7-day fllw-up requirement as a minimum service standard. The 7-day target is the maximum length f time allwed between discharge and cntact, best-practice wuld suggest cntact within 72 hrs. Best practice suggests that changes t patient medicatin related t the index presentatin shuld nt ccur immediately prir t cmmencement f a perid f leave f discharge unless a clear and rbust cmmunity care and management plan t mnitr the therapeutic utcme is agreed and dcumented. 8.4: The MDT leave and/r discharge agreements shuld be fully and accurately dcumented in a care-plan (see & belw) in rder that all parties relevant t the leave r discharge can clearly understand the arrangements and refer t these when needed. Ensure that there is a designated persn respnsible fr writing the care plan in cllabratin with the persn being discharged (and their carers if the persn agrees/lacks capacity). A cpy f the plan/key infrmatin shuld be sent/given t everyne invlved in prviding supprt t the persn at discharge and afterwards. 8.5:1: The discharge plan shuld: Be Persn Centred and reflect the patient s chices as far as pssible and be made available in a frm which can be read and understd by the patient (well-being plan & crisis cntingency plan) The patient shuld be encuraged t sign the agreed care-plan. If the patient is unwilling r unable t sign the plan f care reasns fr this shuld be dcumented in the clinical ntes. Be cnsistent with and develped within the Care Prgramme Apprach (CPA) framewrk (as per sectin 9 (Page 29) f LPFT Clinical Care plicy: als see Appendix 2) fr ensuring effective multidisciplinary, multi-agency, r acrss-team wrking. Be develped with the invlvement f advcacy services where patients request their help r lack capacity t engage in the prcess r decisin-making. Cnsider Statutry (Mental Health Act) prvisins, e.g. Sectin : The discharge plan shuld cver/cnsider/include (as required): Identify a named care c-rdinatr*. Clearly identify the rles and respnsibilities f peple invlved fr each part f the plan Management and/r enablement f risk crisis cntingency plans. a. Pssible relapse signs b. Recvery/staying well gals c. Wh t cntact in a crisis d. Details f medicatin O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 22

23 Linclnshire Partnership NHS Fundatin Trust e. Details f treatment and supprt plan f. Physical health care needs Further appintments with services r agencies, including fllw up within the first week. a. At discharge this requires the 7 day fllw-up appintment. Best practice wuld indicate that this shuld ideally ccur within 72 hrs f discharge. b. If initial purpse fr admissin and/r risk assessment at discharge review identified/identifies depressin and/r ptential suicide/self-harm risk then t fllwup in 2 wrking days. Cntact with services and agencies which will be invlved with nging care and supprt after discharge*. Scial care, including cnfirmatin f cntinuing r newly funded service prvisin. *where the service user s care is transferring/referred t anther service, pending that service actively engaging with the service user the current OA-care-crdinatr/primary wrker etc. will remain the allcated lead prfessinal and maintain cntact and supprt until the actual hand-ver f care. 8.6: Befre the persn is discharged: Let carers knw abut plans fr discharge Ensure that carers knw the likely date f discharge/edd well in advance. 8.6: At pint f discharge all actins as Pathway checklist f OA admissin/discharge: sectin 7: Upn discharge must be cmpleted. 8.7: Infrmatin/Dcumentatin t be prvided t the receiving healthcare prfessinal A cpy f the leave and/r discharge plan will be sent t the service user s GP, tgether with all thers invlved in the nward care f the service user, e.g. accmmdatin prviders, cmmunity teams, primary care services, prbatin, ther supprt services r agencies. 8.8: Delayed Transfer f Care (DTC): An acute/ nn-acute/ mental health delayed transfer f care ccurs when a patient is ready t depart frm acute/ nn-acute/ mental health care and is delayed. A patient is ready fr transfer when: a. A clinical decisin has been made that patient is ready fr transfer AND b. A multi-disciplinary team decisin has been made stating that patient is ready fr transfer AND c. The patient is safe t discharge/transfer. A case can nly be declared a delayed transfer f care when all f these three cmpnents are in place and evidenced in the healthcare recrd. Ward managers are respnsible fr ensuring that the prcess is fllwed fr identifying and reprting delayed transfers f care. A number f reasns fr delayed transfers f care can be identified and these shuld be cnsidered and anticipated, s that apprpriate actins can be taken befre the service user becmes a DTOC when these are identified. Where a DTC has been identified there shuld ccur: Weekly MDT review f DTC status and assciated recrding/reprting updates. O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 23

24 Linclnshire Partnership NHS Fundatin Trust Pr-active multidisciplinary/multi-agency engagement t prgress and reslve the delay (See > LPFT Clinical Care Plicy: Appendix 12.2: Delayed Transfer f Care (DTC), (Page 142). Liaisn and supprt with/by the Admissin and Discharge Pathway Crdinatr t supprt DTC reslutin. See als > standards and requirements fr CMHT fllw-up fllwing leave and/r discharge frm in-patient services see > OAD Cmmunity Mental Health Teams (CMHT) Operatinal Prtcl. See als > NICE guideline ng53 (2016): Transitin between inpatient mental health settings and cmmunity r care hme settings. O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 24

25 Linclnshire Partnership NHS Fundatin Trust Appendix 1: Mental Health Clusters Criteria fr admissin fr Functinal Mental Illness will include the fllwing cluster grups. Super Cluster A: Nn-Psychtic: Cluster 4: Severe depressin and/r anxiety and/r ther increasing cmplexity f needs. They may experience disruptin t functin in everyday life and there is an increasing likelihd f significant risks. Cluster 5: Severe depressin and/r anxiety and/r ther symptms. They will nt present with distressing hallucinatins r delusins but may have sme unreasnable beliefs. They may ften be at high risk fr nn-accidental self-injury and they may present safeguarding issues and have severe disruptin t everyday living. Cluster 6: Over Valued ideas - Mderate t very severe disrders that are difficult t treat. This may include treatment resistant eating disrder, OCD etc. where extreme beliefs are strngly held, sme persnality disrders and enduring depressin Cluster 7: Enduring nn-psychtic disrder - mderate t severe disrders that are very disabling. They will have received treatment fr a number f years and althugh they may have imprvement in psitive symptms cnsiderable disability remains that is likely t affect rle functining in many ways. Cluster 8: Nn-psychtic - a wide range f symptms and chatic and challenging lifestyles. They are characterised by mderate t very severe repeat deliberate self-harm and/r ther impulsive behaviur and chatic, ver dependent engagement and ften hstile with services. Super Cluster B: Psychsis: Cluster 10: First episde psychsis - with mild t severe psychtic phenmena. They may als have depressed md and/r anxiety r ther behaviurs. Drinking r drugtaking may be present but will nt be the nly prblem. Cluster 12: Onging r recurrent psychsis: with a significant disability with majr impact n rle functining. They are likely t be vulnerable t abuse r explitatin. O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 25

26 Linclnshire Partnership NHS Fundatin Trust Cluster 13: On-ging r recurrent psychsis: histry f psychtic symptms which are nt cntrlled. They will present with severe t very severe psychtic symptms and sme anxiety r depressin. They have a significant disability with majr impact n rle functining. Cluster 14: Psychtic crisis. Acute psychtic episde with severe symptms that cause severe disruptin t rle functining. They may present as vulnerable and a risk t thers r themselves. Cluster 15: Severe psychtic depressin - acute episde f mderate t severe depressive symptms. Hallucinatins and delusins will be present. It is likely that this grup will present a risk f Nn-accidental self-injury and have disruptin in many areas f their lives. Cluster 16: Psychsis and affective disrder - Mderate t severe psychtic r biplar affective symptms. With unstable, chatic lifestyles and c-existing prblem drinking r drug taking. They may present a risk t self and thers and engage prly with services. Rle functining is ften glbally impaired. Cluster 17: Psychsis and affective disrder difficult t engage: Severe psychtic symptms with unstable, chatic lifestyles. There may be sme prblems with drugs r alchl nt severe enugh t warrant care assciated with cluster 16. This grup have a histry f nn-cncrdance, are vulnerable & engage prly with services Super Cluster C: Organic: Cluster 19: Cgnitive Impairment r Dementia Cmplicated (Mderate Need): Peple wh have prblems with their memry, and r ther aspects f cgnitive functining resulting in mderate prblems lking after themselves and maintaining scial relatinships. Prbable risk f self-neglect r harm t thers and may be experiencing sme anxiety r depressin. Cluster 20: Cgnitive impairment r Dementia Cmplicated (High need): Peple with dementia wh are having significant prblems in lking after themselves and whse behaviur may challenge their carers r services. They may have high levels f anxiety r depressin, psychtic symptms r significant prblems such as aggressin r agitatin. The may nt be aware f their prblems. They are likely t be at high risk f self-neglect r harm t thers, and there may be a significant risk f their care arrangements breaking dwn. O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 26

27 Linclnshire Partnership NHS Fundatin Trust Cluster 21: Cgnitive Impairment r Dementia (High Physical r Engagement): Peple with cgnitive impairment r dementia wh are having significant prblems in lking after themselves, and whse physical cnditin is becming increasingly frail. They may nt be aware f their prblems and there may be a significant risk f their care arrangements breaking dwn. O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 27

28 Linclnshire Partnership NHS Fundatin Trust Appendix 2: Assessment & Care Planning Flw Chart Referral Accepted (based n service eligibility & FACS) Initial Assessment fr Clinical Care & Treatment undertaken Risk Assessment & Health & Scial Care assessment if apprpriate YES Carers Identified And ffered an assessment f their wn NO Identify CPA Care Crdinatr t Crdinate Care Is Supprt Under CPA Indicated? Identify lead prfessinal t Crdinate Care Mre detailed Health and Scial Care & Risk Assessment if required Pre-leave and/r discharge MDT Plan r Statement f Care r treatment cmpleted Wellbeing Plan this incrprates care plan, staying well plan and review details. Planned Review f Care, including cnsideratin if Supprt fr CPA indicated. Cntinue treatment Update assessments Planned Review f Care including Review if supprt frm CPA indicated YES Is supprt frm CPA indicated? NO YES Is n-ging supprt frm CPA indicated? NO Discharge r cntinue treatment update assessments & statement f care Fr all OA SIA s patients cmmencing leave and/r discharge required t fllw CPA clinical prcess Discharge Surce: LPFT Clinical Care Plicy: Sectin 9/Appendix 9.3: O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 28

29 Linclnshire Partnership NHS Fundatin Trust Appendix 3: Admissin Infrmatin/Standards Frm Cmplete fr all lder adult admissin referrals Date Time Referred by: Jb Rle/title: Patient name: D.O.B. Gender Male Female Address: Cmmunicatin needs / difficulties: Knwn t service: (If yes, hw lng, care crdinatr details, NHS/Silverlink n) Yes N Diagnsis: (Include primary, secndary and icd10 cdes if knwn) Presenting prblem: (including any funding r placement issues) Purpse / bjective f admissin: Prvide assessment measures t supprt and prjected discharge threshld related t current assessments. Treatment and discharge plan: Including; anticipated length f stay anticipated date f discharge O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 29

30 Linclnshire Partnership NHS Fundatin Trust Current medicatin: (Surce/verified by) Assessments: (Identify any ther specific assessments that may have already been cmpleted such as MADRS, ACE III, Waterlw etc.) Risk assessment cmpleted? (must be cmpleted befre admissin agreed) Yes N IF NO, why? Wellbeing plan cmpleted? Yes N IF NO, why? Crisis and cntingency plan in place? Yes N IF NO, why? Dctr authrising admissin: Silverlink ntes up t date? Yes N Out f hur s admissin: (Identify why the admissin culd nt take place in nrmal wrking hurs and infrm ward cnsultant f admissin at earliest pprtunity) Cmmunity supprt prvided ver the last 7 days: (CMHT, GP crisis team, family etc.) Yes N Cnsent t admissin status: (Frmal capacity assessment must be cmpleted befre admissin) Des the patient have capacity relating t the need fr admissin and treatment if nt, hw will they be cnveyed (bi/capacity act) and has MHA review been cnsidered? Is the patient n CPA: Yes N Cmpleted by SIGN, PRINT NAME AND DESIGNATION O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 30

31 Linclnshire Partnership NHS Fundatin Trust Appendix 4: Pathway checklist fr OA admissin/discharge: 1.PERSONAL DETAILS Evidence Base Assurance Activity Signature Date LPFT Plicy Admissin is in accrdance with Admissin Criteria - as per the service prtcl recrd any discrepancy in the clinical ntes AIMS 13.2&3 In rare circumstances this maybe unmet. If unmet please state reasn in the clinical ntes Cmplete Demgraphic Details Sheet & recrd in Silverlink 2. IMMEDIATE TO BE COMPLETED WITHIN 4 HOURS OF ADMISSION > back t sectin 6.1.6: AIMS 15.1 Recrd reasn fr referral NICE CG136 and QS14 AIMS 21.1 NICE CG136 and QS14 AIMS 15.1 DH NICE CG136 and QS14 AIMS 15.1/15.2 DH NICE CG136 and QS14 AIMS 14.1/14.4 NICE CG136 and QS14 AIMS 14.7 NICE CG136 and QS14 MHA & MCA AIMS NICE CG136 and QS14 AIMS 14.4 NICE CG136 and QS14 AIMS AIMS NICE CG136 and QS14 MCAct NICE CG136 and QS14 AIMS CPA NICE CG136 and QS14 Qual Schedule/ EWS/Bi-mnthly care audit Qual Schedule/ EWS/Bi-mnthly care audit Trust exit survey Qual Schedule/ EWS/Bi-mnthly care audit Qual Schedule/ EWS/Bi-mnthly care audit Discuss expectatins with family/carers & recrd estimated discharge date within 72 hrs f admissin PART A Dctr ntified f admissin and attends ward within 4 hrs t cmplete Inpatient Medical Psychiatric Healthcare Assessment (see tlkit sctn:1) Cmmence PART B Nursing health screen within Inpatient Medical Psychiatric Healthcare Assessment (see tlkit sctn:1) Welcme service user and accmpanying parties t ward Offer relevant infrmatin leaflets/welcme pack t service user/carer Cmplete Mental Health Act checklist if admissin is Frmal Cnsider Mental Capacity Act and Deprivatin f Liberty (DLS) if admissin is infrmal Intrduce service user t staff, shw arund ward and bed area Recrd service user details n Fire bard, Bed bard, Named Nurse bard, PSAG Infrm Next f Kin f admissin (If cnsent given) Infrm CMHT f admissin via referral facsimile frm and recrd date/time in diary Allcate Named nurse and explain the rle t service user. Recrd n Silverlink Care Netwrk Any service user wishes and preferences expressed in an Advanced Statement have been cnsidered and are incrprated int their care plan (Advance Statement see plicy MEN65) The service user has an DNACPR/ r Advance Decisin t Refuse Treatment (ADRT) in place. (see plicy MEN65) Care Plan initiated/reviewed with service user if pssible Recrded nt Silverlink printed, signed & scanned (NB: include the stated bjectives fr admissin and utcmes see sectin Admissin Infrmatin ) Cpy given t service user/carer as apprpriate and dcumented n care plan r indicate why nt given Scan back page f care plan int Silverlink O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 31

32 Linclnshire Partnership NHS Fundatin Trust TRUST POLICY AIMS 45.1/45.12 NICE PSG01 GP cntacted fr current medicatin list and medical histry btained (see tlkit sctn: 46) 3. TO BE COMPLETED WITHIN 12 HOURS OF ADMISSION BY ADMITTING NURSE/NAMED NURSE > back t sectin 6.1.6: Evidence Base Assurance Activity Signature Date TRUST CLINICAL Qual Schedule Cmplete Falls Screening Tl n Silverlink and if indicated Falls CARE POLICY Assessment NICE CG161 and HSCIC/Safety PH56 thermmeter audit (See Clinical Care plicy) AIMS 26.2/ TO BE COMPLETED WITHIN 24 HOURS OF ADMISSION BY NAMED NURSE > back t sectin 6.1.6: TRUST INFECTION CONTROL POLICY AIMS 29.1 NICE QS61 and PH36 TRUST CLINICAL CARE POLICY *NICE CG32, CG4 & CG189 and QS24 and PH25 & PH53 NHS Five Year Frward View and Public Health England s (PHE) 19.1/19.2/19.8/19.9/ TRUST CLINICAL CARE POLICY MHAct AIMS NICE CG179 NICE QS3 & QS29 NICE CG49 & 171 Qual Schedule/ EWS Qual Schedule/ EWS Physical Healthcare Audit HSCIC/Safety thermmeter audit Undertake MRSA screening (If apprpriate see MRSA pathway Clinical Care plicy) Cmplete Nutritinal screen (MUST tl n Silverlink) Recrd diet/fluid mnitring fr 3 days where indicated Cmplete Cnfidentiality statement Cmplete Waterlw assessment recrd n Silverlink Cmplete Bdy Map & SSKINS (repsitining) Cmplete VTE assessment recrd n Silverlink Cmplete Prperty sheet Cmplete PEEP plan Cmplete Track & Trigger (cmmenced fr 3 days) Cmplete Disability questinnaire recrd n Silverlink Cmplete Cntinence assessment recrd n Silverlink Cmplete Oral health assessment recrd n Silverlink NICE CG42 and QS1/QS30 5. TO BE COMPLETED WITHIN 72 HOURS OF ADMISSION BY NAMED NURSE: > back t sectin 6.1.6: AIMS TRUST CLINICAL CARE POLICY AIMS Named nurse intrduces them self t service user Cmplete Older Adult Risk Prfile& Management Plan and recrd n Silverlink electrnically. (Assessment tl may be used see tlkit sctn: 4) Cmplete Mving & Handling Assessment & Plan if required, & recrd n Silverlink O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 32

33 Linclnshire Partnership NHS Fundatin Trust AIMS 19.1 AIMS 15.2/19.2 NICE CG42 and QS1/QS30 AIMS Clinical Care Plicy NICE CG42 and QS1/QS30 NATIONAL AND TRUST SAFEGUARDING POLICY AIMS 5.25/5/27 NICE AIMS 47.1/47.17 NICE CG42 Qual Schedule/ EWS/Bi-mnthly care audit Qual Schedule Cmplete Initial PBR Cluster & recrd n Silverlink Cmmence/review/update MANCAS 65 with any necessary detail and recrd n Silverlink Make referral t OT Physi Psychlgy where apprpriate Cmmence Dementia/functinal pathway The carer has been given infrmatin that a carer assessment is available and has been signpsted t the apprpriate agency Offer declined (NB: if nt ffered then apprpriate agency shuld be cntacted) Cmplete Safeguarding child(ren) screening tl n electrnic clinical system Cmplete Safeguarding adult screening tl n Silverlink Life stry wrk initiated This is me/knwing yu cmpleted Individualised activity plan cmmenced 6.PRE DISCHARGE PLANNING: > back t sectin 8.3: Evidence Base Assurance Activity Signature Date Leave & Discharge plans incrprated int Care Plan, inc. Crisis Plan Update assessments (Risk) t supprt leave/discharge plans Schedule & cmplete Pre-Discharge CPA Review/ward rund (recrd n Silverlink in Wellbeing Plan) Cmplete discharge cluster Make any necessary transprt arrangements(recrd bking ref in patient s ntes) 7. UPON DISCHARGE: back t sectin 8.6: Trust Exit Survey/DEMQOL AIMS 21.18/21.32 NICE CG /QS = Guideline / Friends & Family questinnaire ffered Check ward safe, & sign fr returned prperty Sign fr and hand ver TTO s Update electrnic recrd recrd discharge, end care plan needs, end care netwrk rles/ assign unit CMHT discharge ntificatin cmpleted and faxed Details amended n: Fire bard, Visual Ward/ Patient at a Glance bard, Admissin/discharge bk (if used) Cmplete 24 hur discharge ntificatin (Including any physical health cnditins, Edmntn frailty scre) & FAX t GP CG179 Pressure Ulcer Preventin CG32/CG43/QS24 Nutritin Supprt in Adults /Obesity CG42/QS1/QS30 Dementia CG161 Falls CG49 Faecal Incntinence CG171 Urinary Incntinence QS61 Healthcare assciated infectins QS3/QS29 VTE NICE PSG = Public Safety Guideline NICE PH = Public Health Guideline PSG01 Patient Safety medicatin PH48 Smking Cessatin PH56 Vitamin D PH53 Managing Overweight & Obesity in Adults/PH25 Preventin f Cardivascular disea O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 33

34 Linclnshire Partnership NHS Fundatin Trust Appendix 5: MDT Meeting Recrd Frm Multidisciplinary Meeting Recrd Frm Name Unit / Lcatin D.O.B MHA / DLS Status NHS number Date f MDM Type f Review 1 st Review (within 7 days f admissin) Full Assessment Meeting CPA Review Subsequent Review Best Interest Meeting Sec 117 Planning Pre Leave/Discharge Meeting Family Meeting Other Persns invlved in care & present at meeting: Patient Named Nurse Family/Infrmant Ward Rund Nurse Scial Wrker OT Diagnsis including ICD-10 cdes Cnsultant Medic Care C-rdinatr Others Persns Present Primary Reasn Fr Admissin: 1. Primary: 2. Secndary: 3. Medical c-mrbidities: 1: Presenting prblems and circumstances leading t admissin: 2: Presenting risk prfile (t be cmpleted n admissin) 1: Predispsing: 2: Precipitating: 3: Perpetuating: 4: Prtective factrs: 3: Review f last week s actins /care plan: Any utstanding actins? 4: Nursing summary / Reprt f Active Needs (last 7 days and cmparisn t admissin baseline) Objective Measures: (Clinical assessment scales: change frm baseline & last review / trajectry. Als, Clinical Risk Framewrk patient summary and PHC checklist) O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 34

35 Linclnshire Partnership NHS Fundatin Trust Clinical presentatin/prgress/needs: 5: Medical Reprt: including physical and psychiatric presentatin, investigatin/assessment results 6: Physical Observatins Date Date Date Date Date Weight: Bld pressure: Pulse: Temperature: Respiratins: BMI: O 2 saturatin (if required) 7: Other reprts: (OT, Psychlgy, Physitherapy, CPN/CMHT, SALT) 8: Carer views: 9: Patient interview and discussin / expressed needs: Mental State Examinatin: 10: Clinical Summary/Risk Frmulatin: (Current Trust Clinical Risk Framewrk Patient Summary Required) O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 35

36 Linclnshire Partnership NHS Fundatin Trust 11: Risk Assessment & management: Self-harm Lw Medium High Suicide Lw Medium High Harm t thers Lw Medium High Neglect Lw Medium High Prtective factrs: (i.e. insight, cmpliance, family/carers, etc.) Risk & cntributing factrs: (i.e. gender, age, substance misuse, nn-cmpliance, previus self-harm histry, frailty, scial islatin etc.) 12: Review f Care Plan/Management and Further Actins: Status (a) Sectin 17 leave Respnsible persn (b) T2/T3 frms (c) Observatin status/level & review: (d) MHA status/dls: (e) Mental Capacity: Specify tpic and date f assessment: (f) Safeguarding cncerns: (adults/children) O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 36

37 Linclnshire Partnership NHS Fundatin Trust (g) Cntinuing Health Care checklist/dst/dtc status/date agreed: (h) Medicatin Review: Side effects f medicatins explained? YES NO (why?) Leaflets f medicatin ffered? YES NO (why?) 13: Outcme/Actins frm meeting: Recrd Frm O l d e r A d u l t s D i v i s i n A d m i s s i n & D i s c h a r g e P r t c l Page 37

38 Appendix 6: Multidisciplinary Ward Rund Standards: Pre Ward Rund Standards Ward Rund Standards Pst Ward Rund Standards All patients/carers will receive a frmal invite t first ward rund: t ccur within 5 wrking days f admissin (t review suitability and/r purpse/bjectives f admissin). Carers (dependent f SU chice/capacity) will be invited t attend all MDT ward rund discussins. If carers are unable t attend ward runds then pre-mdt cmmunicatin shuld ccur t ensure that the views and infrmatin f and frm the service users carers are represented and recrded in the MDT meeting. Care Crdinatr will at minimum attend: Initial MDT t review suitability and/r purpse/bjectives f admissin, EDD; and identify ptential needs and utcmes t facilitate discharge. Pre-discharge/CPA review; t supprt and agree discharge plan and develp pstdischarge care-plan. CMHT will allcate care crdinatr at pint f referral t service CPA date will be set at first full ward rund: t ccur within 4 weeks f admissin Each service user is given the pprtunity, with their named nurse/agreed alternative, t prepare fr the ward rund, thrugh cmpleting MDT preparatin sheets. MDT templates will be fully cmpleted by clinical staff prir t ward rund: Medical Nursing AHP s Actins frm previus week will be checked and actined and escalated thrugh MDT if there are blcks Rbust assessment f service user will be reflected int MDT template (Appendix 4) as identified in clinical pathway fr cnditin Each service user shuld be given an appintment time and seen within 30-minutes f that time. Service Users shuld be seen at least nce a week t supprt active discharge planning. The service user shuld be given the pprtunity t discuss with their named nurse / agreed alternative, the presence r therwise f family members. The service user shuld be intrduced t everyne present wh he r she is, their designatin and what their rle is. With the exceptin f trainees and staff acting in liaisn rles in the absence f ther team clleagues, nly thse peple currently invlved, r with the ptential t be invlved in the future care f the service user, shuld be present at the ward rund. Each service user shuld be asked befre the ward rund whether they are willing t have trainees r students present. During the ward rund, the service user will be given sufficient infrmatin abut treatments and services available, t enable them t participate in the decisin making abut their care. Gals fr admissin shuld be reviewed and EDD Blcks t discharge planning shuld be identified at first review and DTC prcesses implemented Clear actins and peple respnsible must be identified Where service users are unwilling r unable t be invlved in decisins abut their care, the reasns fr this will be dcumented in the ntes relating t the ward rund. There is a written recrd f the meeting, clearly indicating the agreements made. MDT will have a senir nurse presence t supprt clinical decisin making prcesses Each service user is given the pprtunity, with their named nurse / agreed alternative, t discuss the ward rund and/r have a cpy f the ward rund recrd. Risk assessments and care plans shuld be updated pst ward rund with key bjectives Care Crdinatrs shuld check clinical system fr update actins and recmmendatins Band 6 nurses will be accuntable fr ensuring that all clinical actins are cmpleted in a timely manner

39 Appendix 7: Out f Area Treatment Referral frm: Referral fr Acute Out f Area Treatments [Mental Health and Learning Disabilities] Date f referral: Please cmplete all sectins if pssible & return by secure r fax t Patient s name: Date f birth: Mental Health Act status: Sectin Expiry date f sectin: Current lcatin f patient: Name f GP and GP practice: Name, address & phne number f referrer: Name address & phne number f lead cntact fr this referral, if different t referrer: Name & phne number f cnsultant psychiatrist: Name & phne number f care crdinatr: Name, address & phne number f next f kin: Has next f kin been made aware f this referral? - Yes - N delete t shw chice Is the patient aware f this referral? - Yes - N delete t shw chice Reasn fr referral Please give a cmprehensive summary f current needs and patient s presentatin ver past 24 t 48 hrs. Please als include current diagnsis and assessment f presenting risks. Type f interventin required & reasns why these cannt be met by lcal services: Prescribed medicatins r fax details at same time as submitting this frm t (01522) : Lcal bed availability - Yes - N delete t shw chice Lcal acute/ cmmunity ptins explred Yes - N Type f interventins explred? ***Please fax/pst/ any ther relevant supprting dcuments t assist this referral*** Please als submit cmpleted frm t the relevant LPFT service manager N.B. this frm will be circulated t the OATs Panel electrnically: Inadequate infrmatin may delay the prcess fr receiving a panel decisin. Please return t Cmplex Case Team, Suth West Linclnshire Clinical Cmmissining Grup, Gervas Huse, Lng Leys Rad, Lincln, LN1 7EJ; Telephne: : Fax N: swlccg.cct@nhs.net