Standard Operating Procedure 1 (SOP 1) Planned Care Community Discharge and Transfer of Care Why we have a procedure? This Standard Operating Procedure (SOP) has been developed to support the overarching Trust Discharge and Transfer of Care Policy to ensure an equitable quality and safe discharge and transfer of care from and across planned care community mental health services. It is an essential requirement of good patient care that discharge and transfer of care is person centred, planned and co-ordinated on a multi disciplinary and multi agency basis and that patients and carers are involved in making decisions and kept informed of their discharge or transfer plans. Early discharge planning with patients and carers through multi-disciplinary co-operation will promote flexibility and accessibility of services whilst supporting the individual s choice. Discharges and transfers of care should be managed as a coordinated process and not an isolated event. The individuals concerned and their carers should be fully involved in this process and kept fully informed by regular reviews and updates of their care plans and estimated date of discharge or transfer. This SOP recognises that many people need ongoing support whether they are leaving hospital, or are referred to different services and continuity of the right care in the right place is what matters most to them. Admission, discharge and other associated processes should now all be viewed are as a transfer of care process. Therefore this SOP has been developed to support the smooth and safe localised discharge and transfer of care processes and practices from and across Planned Care community services. This SOP provides the overall framework; within set principles, that ensures staff have the support and guidance they need to achieve good and safe discharge and transfer of care practices. The objectives of this SOP are as follows: To set out the roles and responsibilities of staff involved with discharge or transfer from services To provide continuous information sharing and communication with service users and carers regarding their needs To ensure early and effective discharge planning facilitated by a co-ordinated multiagency approach is embedded in the delivery of services To work with other providers, agencies and organisations proactively, to improve early and effective discharge planning and transfer of care Any individual s care that would be optimised by using a service that is not designated for their age group or they have needs that fall into more than one service should be able to have appropriate access to it irrespective of where their care is being managed Planned Care Community Discharge and Transfer of Care Page 1 of 6 Version 1.0 July 2017
Transition is to be viewed by staff as a continuous process rather than a series of assessments, interviews and reviews What overarching policy the procedure links to? Discharge and Transfer of Care Policy. Please note this policy should also be read in conjunction with the appropriate service operational policy. Operational Policies can be found on the Trust Intranet site: http://luna.smhsct.local/documents/operational-policies. If you cannot find the service you are looking for then please contact the relevant service manager. Which services of the trust does this apply to? Where is it in operation? Group Inpatients Community Locations Mental Health Services all Learning Disabilities Services all Children and Young People Services all Who does the procedure apply to? Clinical Directors (Lead) Clinical Directors are responsible for identifying and managing any risks in relation to standards for the discharge and transfer of care within their division. They will: Lead discussions on the practice of discharge and transfer of care at Divisional Quality and Safety Group meetings Oversee the completion of audits in respect of the discharge and transfer of care Monitoring the implementation of subsequent action plans to improve the discharge and transfer of care as required Provide updates on the practice of discharge and transfer of care within their division to the Quality and Safety Steering Groups Divisional Quality and Safety Groups (Monitoring) Divisional Quality and Safety Groups are responsible for monitoring the practice of discharge and transfer of care including any risks identified within their division: Membership is representative of the division as a whole multi-disciplinary in nature, with a mix of representatives from each of the service areas, professional and clinical leads All incidents in relation to discharge and transfer of care are reported via Datix, the trust s incident reporting procedure A report of all incidents is discussed at monthly meetings of each Divisional Quality and Safety meetings In addition, the group will receive the results and recommendations of all completed clinical audits and be responsible for monitoring action plans to implement changes to current practice until completion Divisional Directors and Divisional Managers Divisional Directors and Managers are responsible for ensuring that: All managers are aware of the SOP and promote good practice Provide support and guidance regarding resources to enable this SOP to be Implemented Planned Care Community Discharge and Transfer of Care Page 2 of 6 Version 1.0 July 2017
Staff implement safe systems of work in accordance with the procedures referred to in the SOP Service Managers/ Matrons The above named are responsible for ensuring that: They are familiar with this SOP and be responsible for adhering to the procedures referred to Staff attend training applicable to their role and for implementing the guidance across their areas of responsibility Staff work to the standards set out in this SOP Resolving in the first instance any disputes that may arise in the discharge or the transfer of care process Ensuring all incidents relating to patient discharges / Transfer of care are reported Clinical Staff Clinical staff are familiar with the SOP and be responsible for adhering to the procedures referred to within the document: All community / planned care services, regardless of profession or position, should work to the same discharge and transfer of care protocols with each individual's care managed by a single service Co-operation and flexibility, within all healthcare professions, services and departments should characterise a person centred coordinated care approach ensure a safe and smooth transfer of care / discharge from services. Ensuring that any deviation or errors arising from the discharge and transfer of care are dealt with in the correct manner, according to the Trust Incident Reporting Policy When should the procedure be applied? This SOP should be adhered to and followed for all patient discharges from and transfers of care across all Planned Care community services within the mental health Division. How to carry out this procedure Process for Discharges Discharges will take place through the Multi Disciplinary care team employing a collaborative process with client/carer and other relevant agencies. Service Users will be referred back to their GP from the Community Service team when they are recovered or their needs would be better served by other services. The Community service teams will ensure all members of the Service Users care team are fully involved with discharge planning. The Care Coordinators/ Lead Professionals will discuss all patient discharges at the multi-disciplinary team meeting before discharge. The care co-ordinator/ lead professional will review all care plans, Crisis plans, Risk assessments and Care Clusters prior to discharge. Relapse signatures and risk assessment/management information will be provided to all involved in the continuing delivery of the Service Users care plan including their GP. Planned Care Community Discharge and Transfer of Care Page 3 of 6 Version 1.0 July 2017
Discharge letters will be sent to the Service Users GP that are recovery focussed, comprehensive and indicate current treatment and pathways for additional support or re-referral. Younger adult services will not automatically discharge Service Users at 65 years old unless their mental health presentations becomes age related and their needs would be better served by the older adults team and their care would be transferred to older adults services. Discharge Following Non Attendance The discharge of service users following non attendance will follow the guidelines outlined in the Trust Discharge and Transfer of Care policy and individual community service DNA local protocols to ensure a collaborative and safe process is followed. The following actions will be completed for all discharges following non-attendance: Attempted telephone contact with service user (minimum standard) 3 week contact letter (minimum standard) Telephone contact with referrer where appropriate Further appointment where appropriate Discussion in MDT meeting Discharge back to referrer Transfer of Care Transfer of Service Users to other teams, (both within and outside of the organisation) will be in line with Trust Discharge and Transfer of Care policy. The service user s care will remain the responsibility of the Community team until transfer/handover of care is complete. The care of a service User, whilst experiencing a period of crisis, will not be transferred to another team or service. However, service users with a history of frequent crisis episodes will not be excluded from consideration of transfer of care. Such transfers would be collaboratively coordinated by the care coordinator or lead professional to ensure a safe and person centred transfer of care, through making direct contact with the receiving area and ensure safe transfer. A CPA review/ Transfer meeting should be arranged prior to a planned discharge or transfer between teams and services, both internal and external to the Trust. Where transfers across teams or services are agreed, the Care Coordinator/ Lead Professional is responsible for initiating and coordinating the transfer arrangements. Responsible Clinicians responsibility in the transfer arrangements should be made clear to the Care Coordinator. A representative from the receiving team/ service should be invited to attend and participate in the CPA review / Transfer meeting. The review will identify the new team/ service and if known, the identified Care Coordinator the user will be working with. The service user and carer if appropriate should be provided with information on the new team/ service/ Care Coordinator prior to transfer and this should be reflected in the review notes and documented in the user s notes. Planned Care Community Discharge and Transfer of Care Page 4 of 6 Version 1.0 July 2017
Where possible, a handover period should be agreed in collaboration with the service user which includes introduction of a new Care Coordinator and significant others as good practice. The handover period should be agreed by the receiving service. The exact length of the handover period will be agreed to meet individual need; depending on the service users transfer destination/ referral point, risks present or other complexities of the case. An updated care, crisis and contingency plan should be developed to reflect the new team/ services contacts and local resources available, where known, to support and meet the users needs. Relevant documents should be made available to the receiving team where known, including transfers into Trust Services from out of area placements such as: Referral form or referral letter for out of area Assessment and risk assessments CPA review / SAP documentation CPA care plan Crisis and contingency plans Other significant reports and documents as specific to service users care, e.g. recent outpatient clinic letters The transfer period can increase the service users vulnerability. the care plan, crisis, risk management and contingency plans must therefore be robust to reduce any risk to their presentation and well-being. Training Staff may receive training in relation to this procedure, where it is identified in their appraisal as part of the specific development needs for their role and responsibilities. Please refer to the Trust s Mandatory & Risk Management Training Needs Analysis for further details on training requirements, target audiences and update frequencies Monitoring / Review of this Procedure In the event of planned change in the process(es) described within this document or an incident involving the described process(es) within the review cycle, this SOP will be reviewed and revised as necessary to maintain its accuracy and effectiveness. Equality Impact Assessment Please refer to overarching policy (Discharge and Transfer of Care Policy). Data Protection Act and Freedom of Information Act Please refer to overarching policy (Discharge and Transfer of Care Policy). Planned Care Community Discharge and Transfer of Care Page 5 of 6 Version 1.0 July 2017
Standard Operating Procedure Details Unique Identifier for this SOP is State if SOP is New or Revised BCPFT-CLIN-SOP-17-1 New Policy Category Executive Director whose portfolio this SOP comes under Policy Lead/Author Job titles only Committee/Group Responsible for Approval of this SOP Month/year consultation process completed Clinical Executive Director of Nursing Community Matron Mental Health Nursing Board June 2017 Month/year SOP was approved July 2017 Next review due July 2020 Disclosure Status B can be disclosed to patients and the public Review and Amendment History Version Date Description of Change 1.0 Jul 2017 New SOP for BCPFT to support Discharge and Transfer of Care Policy Planned Care Community Discharge and Transfer of Care Page 6 of 6 Version 1.0 July 2017