Powys teaching Local Health Board and Powys County Council COMMUNITY HOSPITAL DISCHARGE POLICY AND PROCEDURES

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1 Powys teaching Local Health Board and Powys County Council COMMUNITY HOSPITAL DISCHARGE POLICY AND PROCEDURES Document Code PtHB / GNP 042 Date Version Number Planned Review Date Dec 2014 Version 2 01/12/2017 Document Owner Approved by Date Director of Nursing Strategic Nursing and Midwifery Team 15/12/2014 Clinical Effectiveness Committee 19/01/2015 Document Type Policy & Procedure Bwrdd Iechyd Addysgu Powys yw enw gweithredol Bwrdd Iechyd Lleol Addysgu Powys Powys Teaching Health Board is the operational name of Powys Teaching Local Health Board Page 1 of 25 Review Date: 2016

2 Contents Page Validation Form 3 Consultation 3 Equality Assessment 5 Relevant to 6 Purpose 6 Policy Definitions 12 Responsibilities 15 Policy Process 17 Training 23 Monitoring compliance and audit 23 References 25 Appendices For Reviewed &/or Updated Policies Only: Relevant Changes Inclusion of requirements for Mental Capacity Act, Welsh Government (2005) Inclusion of requirements for Carers Measure (Welsh Government (2010) Inclusion of requirements for Passing the Baton - A Practical Guide to Effective Discharge Planning, NLIAH (2009) Date August 2013 August 2013 August 2013 Page 2 of 25 Review Date: 2016

3 VALIDATION FORM To be completed by the Author no policy, procedure or guidance will be accepted without completion of this section which must remain part of the policy Title: Procedures Author: Jason Crowl, Locality Lead Nurse and Professional Lead for District Nursing Directorate: Nursing and Midwifery Reviewed/Updated by: Jason Crowl (PtHB), Mick Collins (PSS) and Sue OGrady (PSS) EVIDENCE BASE Are there national guidelines, policies, legislation or standards relating to this subject area? If yes, please include below: Mental Capacity Act, Welsh Government (2005) Carers Measure (Welsh Government (2010) Passing the Baton - A Practical Guide to Effective Discharge Planning, NLIAH (2009) PtHB/CP012 Managing Policies, Procedures, Guidelines and Protocols DOING WELL, DOING BETTER - STANDARDS FOR HEALTH SERVICES IN WALES Please state which Health Services Standards this policy will support / link to: 1. Governance and accountability framework 2. Equality, diversity and human rights 3. Health Promotion, Protection and Improvement 5. Citizen Engagement and Feedback 7. Safe and Clinically Effective Care 8. Care Planning and Provision 9. Patient Information and Consent 10. Dignity and respect 11. Safeguarding Children and Safeguarding Vulnerable Adults 15. Medicines Management 18. Communicating Effectively 20. Records Management CONSULTATION Please list the groups, specialists or individuals involved in the development & consultation process: Name Date Powys Teaching Health Board April 2013 Powys Social Services April 2013 Powys Carers Group May 2013 Powys Association Voluntary Organisations May 2013 Powys Senior Sisters Forum July 2013 Page 3 of 25 Review Date: 2016

4 Powys Board of Directors August 2013 Strategic Nursing and Midwifery Team December 2014 Implications Please state any training implications as a result of implementing the policy / procedure. Locality lead updates on the Policy and Procedures. Please state any resource implications associated with the implementation. Locality based resources linked to update sessions. Please state any other implications which may arise from the implementation of this policy/procedure. Improvement in discharge process. Page 4 of 25 Review Date: 2016

5 Equality Assessment Statement Please complete the following table to state whether the following groups will be adversely, positively, differentially affected by the policy or that the policy will have no affect at all Equality statement No impact Adverse Differential Positive Do you believe that they are adequately controlled? N/A Comments Age Y All groups supported in accordance with legislation Disability Y All groups supported in accordance with legislation Gender Y All groups supported in accordance with legislation Race Y All groups supported in accordance with legislation Religion/ Y All groups supported in accordance with Belief legislation Sexual Y All groups supported in accordance with Orientation legislation Welsh Y All groups supported in accordance with Language legislation Human Y All groups supported in accordance with Rights legislation Risk Assessment Are there any new or additional risks arising from the implementation of this policy? None Are there any Information Governance issues or risks arising from the implementation of this policy? Sharing of information across the Multidisciplinary Teams as per current arrangements. Page 5 of 25 Review Date: 2016

6 Procedures 1. Relevant to: This policy covers all adults in general care beds in the Community Hospitals in Powys. This document clarifies roles and responsibilities for each professional group including responsibilities for coordinating all staff involved in the discharge process. Local audit arrangements, as outlined later in this document, will be used to ensure that this discharge policy and supporting are consistently and effectively implemented and applied. This includes user feedback and will be considered within the context of continuous improvement and the wider clinical governance responsibilities of Powys teaching Local Health Board (PtHB). 2. Policy Purpose This policy has been developed in response to WHC (2005)035 Hospital Discharge Planning Guidance and the need to ensure Powys Local Health Board and Powys County Council share an up-to-date, robust and clear process for planning patient discharges. The document has been developed between the partner agencies reflecting that joint working, communication and collaboration are fundamental to planning patients discharges. This policy is consistent with Welsh Government policies and guidance on hospital discharge and the statutory requirements for partnership working between the NHS and local authorities operating from April Specifically, this includes: Local policies related to discharge planning comply with the requirements of the guidance and reflect multi-agency and multi-professional planning, development and implementation, with explicit implementation and monitoring strategies to support this. Multi-agency policies and supporting protocols utilise and reinforce a joint approach to assessment and care planning for effective discharge arrangements for adults, and subsequent arrangements to meet ongoing care needs. All relevant staff are fully conversant with the requirements and receive training appropriate to their needs related to assessment and the discharge planning process. Information in an appropriate format is developed and provided specifically for patients, carers, relatives and those staff who will be providing ongoing care on discharge from hospital. Page 6 of 25 Review Date: 2016

7 3. Policy Definitions The following terms are used within this document: Assessment The process whereby the needs of and risks to/from an individual are identified and their impact on independence, daily functioning and quality of life is evaluated, so that appropriate action can be planned. Assessment involves both professionals and those with the needs thinking through different explanations for how the needs have arisen, and how different needs interact with each other. Assessments could cover the following three systems: the service user, the informal care network system, and the formal care network system. Assessment starts from the first of these and moves outward. Further information is obtained within the Guidance WHC(2002)32/NAFWC 09/2002: Creating a Unified and Fair System for Assessing and Managing Care. Clinically Fit for Discharge A judgment made by the clinician responsible for the in-patient care, in consultation with all necessary colleagues in the multi-disciplinary and multi-agency team, that a patient is able to be transferred safely to the next stage of care required. Complex When the patient s needs are complicated, due to the interaction of multiple factors that require frequent assessment and / or review. Continuing NHS Health This describes a package of health care arranged and funded solely by the NHS. WHC(2004)54/nafwc 41/2004: NHS Responsibilities for Meeting Continuing NHS Health Care Needs: Guidance and Framework for Implementation in Wales provides further information. Intermediate Care A range of usually time limited services, involving cross professional and agency working, provided on the basis of a comprehensive assessment, which have a planned outcome of maximizing independence, targeting those who would otherwise face a prolonged hospital stay or inappropriate admission. WHC(2002)128/nafwc 43/2002: Intermediate Care Guidance provides further detail. Page 7 of 25 Review Date: 2016

8 NHS Funded Nursing Care The funding by the NHS of the care by a registered nurse in a care home providing nursing. WHC(2004)024/nafwc 25/2004: NHS Funded Nursing Care in Care Homes Guidance provides further detail. DPA Data Protection Act 1998 HRA Human Rights Act 1998 SSD Social Services Department Health Bodies NHS Trusts, Local Health Boards and Primary Care Personal Information in this guidance the term personal information should be taken to include, where appropriate, sensitive personal information (e.g. health information). Those terms have the same meaning as personal data and sensitive personal data in the DPA. Care Management a process whereby an individual s needs are identified and evaluated, eligibility for services is determined, Personal Plans of Care are drafted and implemented, and needs are monitored and re-assessed. ( Case management is an alternative term). Care Co-ordination this is undertaken by a named professional when a person has needs that require the input of a number of professionals. It ensures that assessment and subsequent action is joined-up. Care Planning a process based on an assessment of an individual s needs that involves determining the level and type of support to meet assessed needs, and the objectives and potential outcomes that can be achieved. Carer for the purposes of the Carers and Disabled Children Act 2000 the term carer includes people (age 16 and over who may or may not be a relative and who may or may not be living with the person for whom they are caring. The 2000 Act excludes from the definition of a carer, paid care workers and volunteers from a voluntary organization. Children and young people affected by caring situations should be considered and assessed as children in need under the Children Act Comprehensive Older Person Assessment this refers to assessments in which most or all of the domains of the unified assessment process have been triggered and explored through the use of specialist/in-depth assessments. All people entering care homes or in receipt of intermediate care services should have received a comprehensive older person assessment. It will include medical assessment. Page 8 of 25 Review Date: 2016

9 Contact and Overview Assessment this refers to a first assessment involving the older person and professional, and establishing the nature of the presented problem and whether or not there are potential wider health and social care needs. Basic personal information will also be collected or verified if previously collected, at contact assessment. The overview assessment refers to situations where all or most of the domains of the unified assessment process are explored. Overview assessment may be able to fully identify and describe needs; if not, it should indicate or trigger where specialist assessment is required. Diagnosis the act of distinguishing one disease from another. Domain/Sub-domains these refer to the content of the unified assessment process. Eligibility Criteria describe the full range of eligible needs that will be met by local authorities having taken their resources into account. Eligible Needs those presented needs for which local authorities will provide help because they fall within the local authority s eligibility criteria. Outcomes Approach to Assessment an approach that emphasis the relevance of establishing intended outcomes in the assessment process in order to proved clearer links between both assessment and the resulting personal plan of care, and, as a basis for clear information to providers. Outcomes can be described as the changes and effects that the service user requires resulting from service provision and the support network available to them. Plan of Care a record that sets out, for people who are to be provided with help, the objectives of that help, preferred outcomes, services to be provided, a review date, and other details. All people who receive community care services should receive an appropriate Personal Plan. Presenting Needs the needs or issues that are identified when an individual contacts agencies seeking support. Reliable generally speaking, this refers to the Local Health Board that can be placed on an assessment tool when used to score the needs of an individual by different assessors, or over time. For an assessment tool to be reliable there should be evidence of a measurement of reliability of a scale s use in at least one similar population and that this was an acceptable degree. Reliability refers to the degree of agreement that is achieved between different raters (or assessors) using the same scale at around the same time on the same person, or between different ones. Review this refers to re-assessment of people s needs and issues, and consideration of the extent to which services are meeting the stated objectives and helping to achieve the desirable outcomes. Social Services review the Personal Plan of Care for people receiving community care services within 6 weeks after their commencement and thereafter no less than annually. Page 9 of 25 Review Date: 2016

10 Scale this is a means of identifying the presence and or severity of a particular problem, such as depression or difficulties with personal care. Service User this refers to a person who is in receipt of either health or social care services. It includes patient of the NHS. Page 10 of 25 Review Date: 2016

11 4. Policy Principles of Community Hospital Discharge The following are the key policy principles of discharge planning for Powys Local Health Board and Powys County Council and are reflected in the local multi-agency outlined later in this policy: Planning for hospital discharge must begin at, or in the case of elective admissions before, admission to hospital. It should be considered as a process not an event. The process of planning discharge from hospital needs to operate concurrently with clinical care. This helps to ensure that patients who are clinically fit for discharge (as determined by the clinician responsible for their inpatient care, in consultation with all necessary colleagues in the multidisciplinary and multi-agency team) are able to be transferred to the next stage of care in an appropriate and timely manner. Effective multi-agency, multi-professional partnership working is essential to ensure the successful management of discharges from hospital. Decisions on further care requirements following hospital discharge are based upon professional assessments of health, social care and other related needs, taking into account the patient s views and consideration of the views of relatives, advocates or others who know the patient well. It is essential that the input from professionals and others to these assessments is coordinated effectively and in a timely and responsive manner. Similarly, it is important to deliver services in accordance with the joint protocol to ensure there are no gaps in services or duplication of efforts. A whole systems approach to assessment, commissioning and delivery of services will facilitate effective hospital discharge arrangements. Implicit within this is an ethos of multidisciplinary and multi-agency working, to include housing, support and other needs which relate directly to the individual s health and well-being. Hospital admission and discharge are an opportunity to support the patient in developing improved lifestyle choices in relation to smoking, alchol, diet and self management of frailty issues. Hospital discharge planning is a continuous process that takes place seven days a week. Whilst not all members of the multi-agency team may be available on this basis, communication, co-ordination and planning can and should continue. This will be particularly significant in planning simple discharges. All patients should be provided with an Estimated Date of Discharge on admission, or for elective patients at pre-admission, reviewed and amended as necessary. Predicting the length of stay is fundamental to timely discharge. The provision of a documented estimated discharge date also helps families and carers to plan for discharge. The individual s interests and wishes are central to the hospital discharge planning process and must be taken into account when considering future care options. The assessment and discharge process must be person centred and involve regular Page 11 of 25 Review Date: 2016

12 consultation with the patient and his / her family / carer / advocate, and where appropriate paid care staff or providers of services. Patients and their families and / or carers will be provided with written and verbal information in a range of formats appropriate to them, taking into account any sensory or spoken language needs. The information should include details of arrangements and any relevant information regarding their future treatment and care. A named responsible person who has responsibility for co-ordinating all stages of the patient s journey must be identified to co-ordinate the hospital discharge process. The further development of integrated care pathways will facilitate and support the management of discharge arrangements as an ongoing process. The ability to discharge appropriately and effectively can be dependent upon the availability of a range of services to meet ongoing or longer-term care needs. A check should be carried out to ensure that all arrangements are in place on the day of discharge. This should include ensuring that needs for equipment, transport, medication and ongoing service requirements have been identified, planned for and met in a timely manner. The ability of the patient to manage their medication at home must have been assessed and arrangements made as appropriate to ensure ongoing compliance. Many patients who are discharged home will need the support and assistance of their family and / or other carers in addition to any health and social care. Effective communication and partnership with carers is key to many successful discharges. Hospital discharge is not merely about the fitness of the patient for discharge, it is about ensuring that carers are available and willing to continue to provide care, that they are clear about and comfortable with any new caring tasks which will become necessary post-discharge, that the timing of the discharge is suitable for them and that any services which the cared for person will need are immediately in place e.g. equipment, district nursing, and home care. Carers who provide regular and substantial care are entitled to a carer s assessment, and this should establish what care they are able and willing to provide and what support, e.g. respite, needs to be provided for them. The responsibility to provide clear information and to work closely with carers lies with both health and social services staff, and the specific responsibility to provide or arrange a carers assessment is placed in statute upon social services. Page 12 of 25 Review Date: 2016

13 Assessment and Care Management During the stay of a patient in hospital their needs may be assessed by a range of professionals including doctors, nurses and allied health professionals. Also, assessment is often a continuous process recording the changing needs of the patient. The various professionals concerned are the multi disciplinary team (MDT). The MDT may identify that a patient will require ongoing community care and refer them to Social Services (if they are not already involved). The Social Services care manager will commence their assessment on receipt of the referral or as soon after admission if already known to the service. This will help inform the hospital discharge plan which the hospital care coordinator will develop as well as the personal plan of care which will specify the health and community care services which will be provided. Assessing Mental Capacity The MDT must be clear whether or not the patient being discharged has the mental capacity to understand and agree their discharge arrangements. Capacity to be able to give consent to discharge should be assessed by considering whether the client has the capacity to: Make this particular decision Understand and retain the information relevant to the decision Understand the consequences of the deciding one way or the other Communicate the decision they have made. Assessment of Mental Capacity must be recorded in an appropriate format so all practitioners have access to the evidence of the process undertaken and the outcome. The outcome of any assessment must also be recorded within the notes of the MDT meeting. Where an individual does not have the capacity to make an informal decision then Best Interest decisions need to be taken by the professional/s concerned, unless another person has legal authority to act on the client s behalf (e.g. a person with Power of Attorney). Decisions to discharge must be made taking into account the person s Best Interests, ensuring that safe, appropriate discharge is initiated. Advice from a manager should be sought in cases of uncertainty. This process of assessing capacity and, where appropriate, making best interest decisions must be documented. If a patient who lacks capacity has been admitted from the community, has no relative or friend to speak on their behalf and is being considered for a place in a care home, they must be referred to the Independent Mental Capacity Advocacy (IMCA) Service, (managed by the local Community Health Council). Page 13 of 25 Review Date: 2016

14 Best Interest Notification The risks to the patient from taking their own discharge should be evaluated and their permission should be sought to notify others such as family and healthcare professionals. If consent for this is not received this should be fully documented. If a patient has mental capacity it is their decision whether or not anybody is to be informed of their discharge. However, if they do not have mental capacity to make this decision the MDT may need to evaluate what is the best interest for the patient and this decision should be fully documented. Discharge of Vulnerable Adults The main categories of people who should be considered as vulnerable when planning hospital discharge include those with a learning disability, those who have a physical or sensory disability, people who have a mental illness, including dementia, those who are old and frail, those who abuse substances and the homeless. When arranging discharge for people in these vulnerable groups the following additional considerations need to be taken into account:- The early involvement of specialist workers / specialist teams. The demands on carers and the importance of a thorough assessment of the carer s needs must be considered in order to avoid unrealistic discharge planning. Vulnerable Adults at Risk of Abuse A vulnerable adult may be admitted to hospital because they have been abused and suffered an injury. Alternatively, abuse or the risk of abuse may come to light during the person s hospital stay, and this may include more subtle kinds of abuse e.g. neglect or financial abuse. Possible abuse must reported in accordance with the Wales Interim Adult Protection Policies and Procedures Abuse allegations are investigated following multi-agency Strategy Meetings. The Chair of the Strategy Meeting (Designated Lead Manager) may ask for the co-operation of the Local Health Board to retain a patient in hospital until an allegation is investigated and/or if it is confirmed that the person can be discharged safely back to their home or care home. Such investigations are a high priority and are conducted urgently and so delayed discharge should not be a common consequence. Page 14 of 25 Review Date: 2016

15 Homeless People If an inpatient is identified as homeless with their consent, a social worker will be allocated to them to assist with the discharge planning who can liaise with Council Housing Department colleagues. Continuing Health Care Funding If the assessment of the patient identifies that they may be eligible or Continuing Health Care funding the procedure must be followed. 5. Responsibilities Health and Social Services Staff All Health and Social Services staff involved in hospital discharge have a responsibility to ensure they are aware of and conversant with this policy and the and that their actions accord. The Role of the Multi Disciplinary Team (MDT) It is the role of the MDT to ensure that a patient centered assessment is used on an individual basis, managed by the MDT. A MDT approach is essential to ensure safe and effective discharge practice. The multidisciplinary team for each patient should consist of health and social care professionals caring for the patient and may include representatives of other services required on discharge. The MDT must ensure, through the assessment process that they understand enough about the patient to make the decision that the patient is safe to discharge. This should include a clear picture of the patient s circumstances prior to admission, progress and recommendations of ongoing treatment during admission and what will be required on discharge, and an understanding of the services and support available in the community and in other settings. Therefore it is important to ensure that the contributions of all members involved in the patient s assessment/ treatment are taken into account to ensure the appropriate package of care can be provided. (NB this should include consideration of eligibility for Continuing Health Care). The Role of the Care Coordinator/ Named Responsible Nurse Some patients admitted to community hospitals are already known to social services and / or to community nursing. However, whilst in a hospital setting there will also be a named professional identified as being responsible for care coordination, the hospital care coordinator, usually a named responsible nurse. Page 15 of 25 Review Date: 2016

16 The named responsible nurse should be identified on or before admission. They will be responsible for ensuring that the assessment process is completed which includes: The development and updating of the discharge planning integrated care pathway (discharge documentation). Making a referral to Social Services if there are any emergency social problems created by the patient s admission identified at this stage e.g. if the patient is also a carer. Involve and inform all patients about all aspects of their care planning. Keep documentation up to date. Liaise and work as an integral part of MDT. In some cases a Social Services Care Manager will already be involved in the care and an assessment will already have been completed. This assessment should be shared with the named responsible nurse in accordance with the Powys Information Sharing Protocol. If there is a Care Managers and / or community nurse already supporting the patient in the community, they should be kept informed by the named responsible nurse during the patients time in hospital and invited to any pre-discharge planning. On discharge, care passes back to the community staff. Where it has been identified that the patient/client will require a care manager or community nurse on discharge and there is no professional previously identified in this role, the patient s needs must be evaluated within the MDT, which should consider the level and types of support needed and identify the appropriate agencies to arrange provide the support. The named responsible nurse should make the referrals required to set these arrangements in place. Page 16 of 25 Review Date: 2016

17 6. Policy Process Discharge Planning Procedure Assessment and planning should be initiated as soon as possible after the decision to admit a patient has been made. All patients admitted to hospital, whether elective or non-elective admissions and for whatever duration, will need to have their discharge needs assessed and planned as part of their overall assessment. Information for patient Families and Carers On admission to hospital patients and their carers should be provided with written and verbal information in a format appropriate to them, taking into account any sensory or spoken language needs. The information should include details of information regarding their future treatment, care and discharge. The appropriate discharge information should be given to all patients and their carers within the first 24 hours of admission and the discharge poster should be displayed on all wards and clinical areas of the LHB. They affirm the expectation that patients should be discharged from hospital as soon as is practicable after their medical treatment is concluded. Discharge Pathway Planning for each patient must be facilitated and monitored with the use of the PtHB Discharge Planning documentation. The documentation will: ensure that all elements of the discharge planning process are taken into consideration; facilitate communication on discharge planning between all members of the multidisciplinary team; provide a standardised system for auditing discharge planning processes across all services provide a tracking mechanism which records the reasons for variance. The documentation does not replace clinical judgment. However its completion is mandatory. The discharge documentation is to be completed in black ink as indicated in the LHBs Record Keeping Policy. The patient s details and/or addressograph should be recorded at the top of each page. The discharge documentation is a working document with relevant sections being completed by appropriate members of the patient s MDT. Each person who will be contributing to the discharge documentation will be required to record their name and designation. Page 17 of 25 Review Date: 2016

18 Before or within 24 hours of Admission In Powys hospitals, pre-admission assessment can take place at outpatients clinics, day hospital, pre-operation assessment unit, at presentation to minor injuries unit and in primary care such as in chronic disease management. Pre-admission assessment should be routine for elective admissions and undertaken by the designated community team or hospital based service. This should identify anticipated health and social care needs pre-admission thereby helping to ensure the patient s stay in hospital can be as short as possible. When a patient is admitted to hospital as a scheduled or un-scheduled admission an estimated date of discharge (EDD) will be identified immediately by the nurse in charge in liaison with the admitting Doctor and recorded on the Myrddin Patient Administration System and the appropriate discharge documentation in the medical notes by the admitting practitioner. If for any reason this should be amended, this should be recorded on the front of the assessment documentation. A Hospital Based Care Co-ordinator should be identified by the hospital nursing team leader. In many cases a social worker will already be involved in the care and an assessment may have already been completed. Relevant assessment information should be shared with the care coordinator /named responsible nurse in accordance with the information sharing protocol. The social services care manager should be kept informed by the named responsible nurse during the patient s time in hospital. Where necessary the patients advocate should be informed or arrangements commenced to secure the services of an advocacy service. The responsible nurse will ensure that the hospital assessment processes commence, which include the development and updating of the discharge documentation and the patient s treatment plan. At all stages of the assessment process the assessor should consider the 4 P s Previous/Present/Predict/Prevention Previous What the patient s circumstances were prior to admission? Present What is happening now Predict Any risk factors that may impact on discharge Prevention - What can be done to minimize risks on discharge Any urgent social problems created by the patient s admission should be referred to social services (e.g. the patient is also a carer in the community). It is necessary to ensure the General Practitioner (GP) details are correct, that the patient is registered with a GP or record the refusal in the clinical notes. In the case of homeless Page 18 of 25 Review Date: 2016

19 people it is often the case that they have no GP and the NHS Direct Information Team should be contacted for assistance. The County Council Housing Options Advisor should be contacted. Referrals for in depth assessments must be recorded in the coordination log by the person/s making the referral and date of commencement of assessment completed by those whom perform the assessment. Page 19 of 25 Review Date: 2016

20 During admission (24 hours onwards) Continue to follow and complete the discharge documentation ensuring: Assessment and review continues. As members of MDT become involved in the patient s care they should update the appropriate parts of the discharge documentation. Their specialist assessments once completed and their treatment plans should be kept within the patient s medical record to inform a multi disciplinary approach to care planning. The patient is reviewed daily by the appropriate members of the MDT. Any further actions are identified and care is altered accordingly, and progress along the patient s pathway is recorded. Completing the process should not cause unnecessary delays. The process should be robust enough to identify any potential issues that could affect the EDD and allow them to agree on an Actual Discharge Date (ADD). The patient is referred to the appropriate health and social care professionals If a patient is already, or needs to be, on a Clinical Pathway this should run in parallel with the discharge documentation. When a Patient is Ready for Discharge This will require that: A clinical decision has been made that the patient is clinically ready to be discharged from the ward AND A multi-disciplinary team decision has been made and recorded that patient s needs or agreed plan of care indicates that discharge will be as safe as possible These two criteria are not separate or sequential stages; all three should be addressed at the same time whenever possible. Also: Any continuing health and social care needs must have been identified and assessed and the appropriate referrals made. Individual patient needs will be assessed in relation to the intensity, complexity, stability, predictability of their needs and risks to their Page 20 of 25 Review Date: 2016

21 independence and ongoing health and social wellbeing identified in accordance with current Powys Health teaching Board Policy. If the patient changes ward prior to discharge it must be documented on the front page of the discharge documentation to and from which ward, the date and the name of the Hospital Care Co-ordinator. The reasons for this must be documented and a new EDD recorded on the discharge documentation. If the EDD is compromised established. for clinical or MDT reasons, a new EDD must be Where it has been identified that the patient/client will require a Care Co-ordinator on discharge, and there is no professional previously identified in this role, the patient/client s needs should be evaluated by the multi-disciplinary team, who should consider the level and type of support needed by the patient/client, and identify the appropriate agency to provide the Care Co-ordinator. e.g. district nurse or social services care manager. The MDT s agreed actions and services must be recorded. The Named Responsible Nurse should then take all necessary actions to implement what has been agreed. If the priorities of the patient/client s care needs alter this may also require the Care Coordinator to change. Page 21 of 25 Review Date: 2016

22 At least hrs before Actual Date of Discharge At least hours before discharge this section of the discharge documentation should be completed ensuring the following;- Confirming that the patient/carer understands the diagnosis. Discharge arrangements have been agreed. Support services are in place and equipment supplied. The agreed LHB Transfer of Care Forms and The Discharge Summary completed. Personal Plan of Care completed and summarised. Transport has been arranged. Medication has been ordered and all other relevant pharmacy followed e.g. procedure for processing a TTO. Day of Discharge The following is required:- Ensure the discharge documentation is fully completed and signed off; The discharge check list complete, valuables returned. All information must be legible and in accordance with legal and organisational requirements. The General Practitioner is responsible for the patient s treatment in the community; therefore it is essential that a transfer of care/summary form is communicated to the General Practitioner within 24 hours of discharge and a comprehensive discharge summary within 14 days of discharge. All services resuming and newly provided services have received a copy of the Personal Plan of Care, subject to patient consent and have confirmed the service commencement as stipulated in that Plan. If manual handling is required a written copy of the Occupational Therapy assessment must go with the discharge documentation to the Community Care Coordinator. In all situations the full involvement of carers must be sought. Page 22 of 25 Review Date: 2016

23 7. Training Effective implementation of this policy will be achieved by all health and social care personnel involved in discharge planning adhering to the policy which will promote high quality discharge planning. The training and education departments should ensure that core curricula include input on discharge planning and other related policies. This should be part of any induction programme and linked to the knowledge and skills framework / Healthcare Standards. Wherever possible, multi-agency/multi-disciplinary training and education is preferred. 8. Monitoring Compliance/ Audit Implementation of this Policy both within the Local Health Board and Social Services will be the responsibility of Line Managers. It must be given high profile with visible support from senior managers within the partnership. Senior managers and all operational staff involved in discharge planning will require training in its application and in their roles and responsibilities in driving it forward across Powys The LtHB and Powys Social Services should work together to ensure the collection and collating of data which will be used to jointly evaluate the effectiveness of hospital discharge arrangements. The Regional Offices of the Welsh Assembly Government monitor delayed transfers of care performance as part of their wider performance management responsibilities related to the delivery of the Service and Financial Framework (SaFF) operating in Wales This policy and related practice will be jointly monitored by Powys Local Health Board with PLHB audit team taking the responsibility to audit as below, informing and involving Powys Social Services at all times. o PLHB Documentation Audit o Critical Incident reporting o A Datix report/concern form must be completed by clinician professionals if they have concerns regarding an individual discharge. o Informal/Formal Complaints Individual patients and/or their families where necessary should be enabled to use the Local Health Boards/Social Services Complaints Procedure. ο Patient Surveys ο Annual Passing the Baton Discharge Planning Audit Page 23 of 25 Review Date: 2016

24 Patient satisfaction will be audited by the Patient Experience Manager, using patient surveys. Page 24 of 25 Review Date: 2016

25 9. References WHC (2004)024/nafwc 25/2004: NHS Funded Nursing Care in Care Homes Guidance WHC (2004)54 /NAFWC 41/2004: Continuing NHS Healthcare Guidance and Framework for implementation in Wales pl-2-e.pdf WHC (2002)32 / NAFWC 09/2002: Creating a Unified and Fair System for Assessing and Managing Care WHC (2004)066 / NAFWC 46/2004: Guidance on National Assistance Act (Choice of Accommodation Directions 1993) WHC (2005) Welsh Government Discharge planning guidance Mental Capacity Act (2005) Mental Health Policy Guidance: The Care Programme Approach for Mental Health Service Users, A Unified and Fair System for Managing Care, February 2003 WHC (2005)013: Standard Procedure for the handover of Elderly Mentally Infirm Patients between NHS LHBs and the Welsh Ambulance Service Passing the Baton. A Practical Guide to Effective Discharge Planning NLIAH 2008 (Pdf File) Six Steps From DTOC to ETOC. Summary Report. National Self Assessment of Discharge Planning in Wales. Page 25 of 25 Review Date: 2016

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