Intermediate Care Assessment Bed Operational Policy

This is an official Northern Trust policy and should not be edited in any way Intermediate Care Assessment Bed Operational Policy Reference Number: NHSCT/12/480 Target audience: Intermediate care co-ordinators, Community Rehabilitation Teams/Home from Hospital Rehabilitation Teams (IRST), GPs participating in the Intermediate Community Care Scheme, Medical Director, Hospital Consultant staff, Heads of Service, Hospital Social Work Teams, Hospital Pharmacy, Multidisciplinary team members in Community Services, Community General Managers, Multidisciplinary members of Acute Services, Trust information staff, Northern Trust Senior Management Team, Managers and staff of Northern Trust Residential Units, Community hospital staff. Managers and staff of Private Nursing Homes. Service Users and carers. Sources of advice in relation to this document: Fiona O Neill, Team Manager, Home from Hospital Team Pamela Craig, Deputy Director Replaces (if appropriate): N/A Type of Document: Trust Wide Approved by: Policy Committee Date Approved: 9 January 2012 Date Issued by Policy Unit: 27 January 2012 NHSCT Mission Statement To provide for all the quality of services we would expect for our families and ourselves Updated 29/11/11

Intermediate Care Assessment Bed Operational Policy Intermediate, Rehabilitation and Stroke Service 1

Table of Contents INTRODUCTION... 3 PURPOSE OF ASSESSMENT BEDS... 3 TARGET AUDIENCE... 3 ASSESSMENT BED CRITERIA... 3 EXCLUSIONS... 4 LOCATION OF ASSESSMENT BEDS... 4 CHARGING OF ASSESSMENT BEDS 4 REFERRAL PROCESS FOR ASSESSMENT BED... 5 PROTOCOL TO BE FOLLOWED IN THE EVENT OF NO CAPACITY IN THE ASSESSMENT BEDS...5 OUTLINE OF STAFF RESPONSIBILITIES... 5 INTERMEDIATE CARE COORDINATORS... 5 REFERRING AGENCY... 6 MULTIDISCIPLINARY TEAM MEMBERS IN SUB ACUTE FACILITIES... 6 COMMUNITY INTEGRATED TEAMS... 6 INTERMEDIATE, REHABILITATION AND STROKE TEAM (IRST)... 6 STAFF IN RESIDENTIAL HOMES, NURSING HOMES AND COMMUNITY HOSPITALS... 6 ASSESSMENT BEDS IN NURSING / RESIDENTIAL HOME SETTINGS... 7 PROCEDURE FOR ADMISSION TO AN ASSESSMENT BED IN A RESIDENTIAL OR NURSING HOME SETTING... 7 MEDICAL COVER FOR RESIDENTIAL AND NURSING HOME BEDS... 8 ENABLEMENT PLAN FOR ASSESSMENT BED PATIENTS IN RESIDENTIAL / NURSING HOME... 9 ASSESSMENT BEDS IN COMMUNITY HOSPITALS...11 PROCEDURE FOR ADMISSION TO AN ASSESSMENT BED IN THE COMMUNITY HOSPITALS...11 MEDICAL COVER FOR COMMUNITY HOSPITAL ASSESSMENT BEDS...12 ENABLEMENT PLAN FOR ASSESSMENT BED PATIENTS IN COMMUNITY HOSPITAL...12 ASSESSMENT BEDS IN SUB ACUTE FACILITIES (WHITEABBEY AND MID ULSTER HOSPITALS)...15 PROCEDURE FOR ADMISSION TO AN ASSESSMENT BED IN SUB-ACUTE FACILITIES...15 MEDICAL COVER FOR ASSESSMENT BEDS IN SUB ACUTE FACILITIES...15 ENABLEMENT PLAN IN SUB ACUTE FACILITIES...16 GLOSSARY...18 APPENDIX 1...19 APPENDIX 2...20 APPENDIX 3...21 2

Introduction As part of the Modernisation and Reform Strategy, it has been agreed that the trust will reduce the number of people going into permanent care by 468 people by April 2012. The Assessment Bed model proposes that no one will be placed directly into permanent care from an acute bed and that instead they will be placed in an Assessment Bed where a decision can be made on whether these service users definitely require long term care. The beds will be used by people whose initial assessment indicates the need for placement in a permanent setting. When placed in the Assessment bed the individual is assessed by a multidisciplinary team with re-ablement being the central theme to this process. Definition of assessment bed An Assessment bed is a bed that can be in a residential or nursing home, a community hospital or a sub acute hospital that will provide time and support for the patient and their carers/families to consider options to enable their return home. Purpose of Assessment beds To enable service users who may have otherwise required permanent placements in residential and nursing homes to have their care needs met in their own home To offer service users more choice in relation to meeting various aspects of their long term care needs To maximise service users rehabilitation and enablement potential To offer service users, carers and their families the appropriate environment, support and time to undertake the decision making process with regard to long term care needs To offer carers an opportunity for assessment of their needs to enable them to continue in their caring role To undertake the enablement process within a 21day time frame Target Audience Intermediate care co-ordinators, Community Rehabilitation Teams/Home from Hospital Rehabilitation Teams (IRST), GPs participating in the Intermediate Community Care Scheme, Medical Director, Hospital Consultant staff, Heads of Service, Hospital Social Work Teams, Hospital Pharmacy, Multidisciplinary team members in Community Services, Community General Managers, Multi-disciplinary members of Acute Services, Trust information staff, Northern Trust Senior Management Team, Managers and staff of Northern Trust Residential Units, Community hospital staff. Managers and staff of Private Nursing Homes. Service Users and carers. Assessment Bed Criteria Service users must be: - adults - an in-patient in an acute or sub acute setting 3

- able to have their needs met safely in the identified assessment bed environment - must be placed in a bed that meets with the registration criteria for their need - must be medically stable In addition The assessment beds should only be used for those people whose initial assessment indicates the need for a placement in a permanent care facility. Therefore the initial professional assessments must evidence that permanent care is the only viable option as all other community based options have been exhausted and excluded in conjunction with appropriate community staff. Service users and relatives should be informed that the purpose of further assessment is to assess if the service user s abilities improve when out of the acute environment. Exclusions - Service users with end of life needs - Service users referred from A&E department (other than short stay unit where alternative options for discharge to community settings must have been fully considered) - Service users who have already undergone an extensive rehabilitation programme in any setting and it has been determined by the acute and community team in conjunction with the Intermediate care Co-ordinator that the pathway for discharge will not be altered by further intervention. Referrers should discuss individual cases with the Intermediate Care Co-ordinator where there is ambiguity in the appropriateness of referral and if there is a difference of opinion a joint case discussion should be held to agree the appropriate pathway. If a placement is agreed where there is requirement for any significant assistive technology package or additional staff this must be agreed with the relevant Programme of care, who will accept funding responsibility for any additional expenditure to facilitate the placement. Permanent placements in nursing or residential homes must not be suggested as the only option with the patient and their family while they are still in an acute or sub acute setting, outside the assessment bed environment. The community named worker from the relevant community team e.g. Physical Disability, Mental health, Learning Disability, Integrated teams for Older People will fund and place the service user in a permanent care placement if it is determined that this is appropriate after a period in an assessment bed. 4

Location of Assessment beds A variety of Assessment beds are located throughout the Northern Trust as outlined in Appendix 1 Assessment beds are available in residential homes, nursing homes and community hospitals. Charging for Assessment Beds There will be no charge to the service user during the period of their assessment in an Assessment bed as per DHSS guidance for Intermediate care. Once the period of assessment has been completed normal charging as per Trust procedures will apply. Referral process for Assessment bed Referral for an Assessment bed should be made to Intermediate care Co-ordinators during the hours of 9am to 5pm Monday to Friday excluding bank holidays. Intermediate care co-ordinators can be contacted at the following contact numbers Localities Causeway Tel No: 028 7034 7860 Fax No: 02870347874 Antrim/Ballymena Tel No: 07525897215 Fax No: 02825635547 Mid Ulster Tel No: 07789082701 Fax No: 02825635547 Whiteabbey Tel No: 07841970676 Fax No: 02825635547 Larne/Carrick Tel No: 07841970676 Fax No: 02825635547 Protocol to be followed in the event of no capacity in the Assessment beds If there is no available capacity in the assessment beds at the time of referral, the patient s name and details will be placed on a waiting list held by the Intermediate care co-ordinator however the responsibility for the patient remains with the referring agent. If there is pressure to facilitate hospital discharge it will be the referring agent who will be responsible for putting arrangements in place to facilitate this if required. It will be the responsibility of the referring agent to escalate the delayed discharge in the acute hospital as per acute escalation procedures. Outline of Staff Responsibilities Intermediate Care Coordinators The Intermediate Care Co-ordinators are responsible for screening patients using the Intermediate care Screening form, authorising access to the assessment beds, the arrangement of medical cover for patients during their time in the Assessment bed, the arrangement of multi-disciplinary meetings and reviews and monitoring the implementation of exit plans. They are also responsible for the escalation of any delays in discharge from the Assessment beds. Intermediate care-coordinators must also retain information 5

regarding the admission and discharge of patients for audit purposes. Intermediate care coordinators are responsible for communicating the date of admission to Assessment bed to the Intermediate, Rehabilitation and Stroke Team (IRST). Referring Agency Multi disciplinary members of the referring team are responsible for forwarding up to date assessments, medical forms and treatment plans to the Intermediate care Co-ordinator, IRST and Multidisciplinary Team members as outlined in this policy. Nursing staff in the referring multi-disciplinary team are responsible for ensuring that a 28 day supply of medication is transferred with patients transferring to an Assessment bed in a Residential / Nursing Home and agreed pharmacy provision of medication for Community Hospitals together with a 3 day supply of any dressings, urine drainage systems, stoma products, continence pads etc. Multidisciplinary Team members in sub acute facilities Multi-disciplinary Team members in the Whiteabbey Hospital and the Mid Ulster Hospital will be responsible for the assessment of patients in ring fenced Assessment beds, development of enablement plans and subsequent time limited intervention. The Hospital Social Worker will be responsible for coordinating the comprehensive assessments and making the referral to the appropriate Community Team when it is agreed the patient requires permanent domiciliary or residential and nursing home care. Community Teams Named workers in the Community Teams will be responsible for arranging the permanent placements for those clients who following their period of assessment are unable to return home. The appropriate community team will be responsible for communication with the client and family regarding suitable placement and for all documentation required for placement and for CBPU. Other multi-disciplinary community staff will be engaged as required. Intermediate, Rehabilitation and Stroke Team (IRST) Multi-disciplinary Team members in the IRST will be responsible for the assessment of patients in the Assessment beds in Residential homes, Nursing homes and Community hospitals, the development of enablement plans and subsequent time limited intervention. They will also be responsible for the arrangement of services/support to facilitate the patient s discharge home. Staff in Residential Homes, Nursing homes and Community hospitals Staff in Residential Homes, Nursing homes and Community hospitals are responsible for the implementation of care plans and Enablement plans. They must also ensure that no discussion takes place with the client or their family regarding long term care needs outside the multidisciplinary meetings. 6

Assessment Beds in Nursing / Residential Home Settings Procedure for Admission to an Assessment bed in a Residential or Nursing Home setting Once a multidisciplinary assessment has identified that a patient is appropriate for an Assessment bed the hospital Social Worker will contact the Intermediate Care Coordinator (ICC) re availability of bed. The ICC will advise re availability of beds and complete a screening process (Appendix 3). Once agreement has been given the hospital Social Worker will then proceed with the admission process. The ICC will contact the receiving home and secure the bed. In complex cases a case discussion prior to discharge to an assessment bed may be required with involvement from the relevant Community Team. This will be arranged by the ICC as required. If the patient does not meet the criteria, the ICC will suggest a more appropriate pathway for the patient. If the patient is not accepted for an Assessment bed this will be recorded in the patient s notes in conjunction with the ICC. Information that will be required by the Intermediate Care co-ordinator at the time of referral is attached as Appendix 3. Other multi-disciplinary assessments should be forwarded to the relevant professional in the IRST by each profession in the acute setting. It is the responsibility of the Ward Manager to ensure that a medical form is completed by a Medical Officer in the acute/sub acute hospital (appendix 2) and forwarded to the Intermediate Care Co-ordinator prior to the patient s discharge. The Intermediate Care Coordinator will arrange the medical cover in consultation with a designated GP and confirm with the referrer that GP cover has been secured. It is the responsibility of the Intermediate care Co-ordinator to ensure that the medical form is faxed to the relevant General Practitioner who is assuming responsibility for the patient ensuring that trust s data protection procedures are adhered to. Agreement from the GP must be secured before the patient can be admitted to the identified facility. The Intermediate Care co-ordinator must provide the Home Manager with the details of the designated GP. The Hospital Social worker will complete a care plan for patients transferred to residential homes. The ward nurse will be responsible for completion of the Community Nurse Liaison Form and care plans for nursing care. Once the appropriate documentation is received and medical cover secured the Intermediate Care Co-ordinator will inform the Hospital Social Worker of the bed location and admission date. The Intermediate Care Co-ordinator will also inform the Team Manager of the IRST of the patient s admission to the assessment bed. It is the responsibility of the Hospital Social Worker to liaise with the patient/carer and families, provide them with an Assessment bed Guidance leaflet and gain consent for 7

transfer. The patient must be made aware by the Hospital Social Worker that when the period of assessment has been completed there may be financial implications if they are required to remain in a residential or nursing home setting. It is the responsibility of the Hospital Social worker to inform the members of the hospital multidisciplinary team of the patient s planned admission to the Assessment bed. It is the responsibility of the referring multidisciplinary team to forward up to date assessments to the IRST and to ensure that the residential and nursing home has information regarding the patient s needs and care required. The ward nurse is responsible for ensuring a 28day supply of medication is transferred with the patient as per pharmacy procedures. It is the responsibility of ward staff to supply 3day supply of dressings, stoma products, urine drainage systems, continence pads etc. It is the responsibility of the relevant member of the acute multi-disciplinary team to ensure that any equipment required for discharge e.g. pressure relieving equipment, moving and handling equipment etc is in place prior to the patient s admission. It is the responsibility of ward staff to arrange transport for the patient and to ensure that staff in the Residential or Nursing Home and the patient s family are aware of admission time and date. It is the responsibility of the Hospital Social worker to complete a RF1 form for admissions to all Assessment beds in Nursing home beds for the Central Bed Procurement Team (CBPU) and forward as per Trust procedures. The Hospital Social work staff should complete this for the period of 21 days and forward a copy to the Named Worker in the IRST. An amendment is required on the RF1 forms to ensure CBPU direct future enquiries to the Intermediate Care co-ordinator or Named Worker. The Hospital Social Work team must record the admission on the ADPC system as per trust procedure. It is the responsibility of the Named Worker in the IRST to complete documentation for CBPU for any further extensions. It is the responsibility of the ward staff to ensure the Patient s GP discharge letter is transferred with the patient. The staff in the residential or nursing home must ensure that this is given to the designated GP. Medical Cover for Residential and Nursing Home Beds (outline of responsibilities for designated GP) The designated GP will be required to: - Accept medical responsibility for a patient admitted to an Assessment bed in a community facility following a review of the medical form. - Give a timely response to the Intermediate Care Coordinator s request for medical cover. - If there are concerns regarding the patient s medical condition prior to discharge the designated GP will be responsible for linking directly with medical staff in the referring hospital - Review the patient if requested by the members of the multi-disciplinary team - Prescribe/review medication as required 8

- Communicate with the multi-disciplinary team in order to facilitate the enablement of the patient - Make onward specialist referrals as appropriate - Link with the patient, their family and carer as required - Provide medical reports for case discussions if required - Ensure arrangements for medical cover are in place during periods of leave If the patient was not previously known to the designated GP, the designated GP will then be responsible for communicating with the patient s own GP to: - Request information regarding the patient s medical history - Request an up to date list of the patient s medication - Ensure any intervention or change to medications / treatment is documented Provide a discharge summary for the patient s own GP on the patient s discharge from the Assessment bed Enablement Plan for Assessment Bed Patients in Residential / Nursing home A Multi-disciplinary Enablement plan will be devised within the first 5 days of the patient s admission to the Assessment bed outlining the patient s goals, review dates and plans/dates for discharge. This must be agreed and signed by the patient. The Intermediate Care co-ordinator will be responsible for ensuring that the most appropriate member of the Multi-disciplinary Team completes this in conjunction with the client. The Enablement Plan must show that options such as the following have been considered: - Respite plan - Rehabilitation needs have been addressed - Day care - Use of Assistive technology - Use of Voluntary sector - Step down residential with rehabilitation - Domiciliary care with rehabilitation - Carer s assessment offered/undertaken Once the patient has been admitted to the Assessment bed it is the responsibility of the Intermediate care Co-ordinator to monitor the patients progress in consultation with the IRST ensuring case discussions are held as appropriate and that discharge plans are being implemented in a timely manner. Each client on admission to an Assessment bed will be allocated an IRST Named worker. It will be their responsibility to engage the relevant Community Team as appropriate. Reviews must be undertaken in accordance with the Enablement plan. If an extension to the placement is required it is the responsibility of the Named worker in the IRST to complete a RF5 form for Central Bed Procurement Team. Following the period of assessment /intervention if a reablement domiciliary care package is required it is the responsibility of the Named worker in the IRST to make the referral to 9

the Community Integrated Team to secure funding and engage a Named Worker as required. There will be no requirement for the Community Integrated Team to commence further assessments prior to discharge. Once the IRST have agreed a discharge plan and date from the Assessment bed it is the responsibility of the Community Teams to provide the funding to support the discharge on this date. It is the responsibility of staff in the IRST to arrange all domiciliary services/support which facilitate the patient s discharge home. This includes the moving and handling risk assessment and other risk assessments as appropriate. If the patient is unable to return home it is the responsibility of the relevant Community Team to arrange the discharge from the assessment bed to a permanent residential or nursing home placement. A referral will be sent to the Team Leader of the appropriate community team along with any assessments completed by the IRST. It is the responsibility of the Named worker in the relevant community team to liaise with the client and their family, source funding, forward relevant documentation to Central bed procurement Team and arrange discharge and transfer to permanent placement. Once assessments have been forwarded to the relevant Community care Team the IRST will have no further intervention with the client. If a delay in discharge occurs from the Assessment beds it is the responsibility of the Intermediate Care Co-ordinator to escalate the delay using the End of Intermediate Care Episode template. All reasons for delay must be recorded for the purpose of audit by the Intermediate Care Co-ordinator. Prior to the patient s discharge the Intermediate care Co-ordinator must ensure that all various professionals involved in the patient s care including the designated GP have an agreed discharge date and discharge arrangements are in place. Once the patient is discharged from the Assessment bed intervention from the IRST will cease. The IRST will refer to colleagues in the Community Integrated Teams for ongoing intervention/monitoring as required. 10

Assessment Beds in Community Hospitals Procedure for admission to an Assessment bed in the Community Hospitals Once a multidisciplinary assessment has identified that a patient is appropriate for an Assessment bed the hospital social worker will contact the Intermediate Care Coordinator (ICC) re availability. At this point the ICC will check the patient meets the criteria, advise re availability of beds, and advise the hospital Social Worker to proceed with the referral process. The ICC will carry out a screening process (Appendix 3). The ICC will notify the nurse in charge in the community hospital of client s admission if accepted for Assessment bed and give information regarding the patient s needs. In complex cases a case discussion prior to discharge to an assessment bed may be required with involvement from the relevant Community Team. This will be arranged by the ICC as required. If the patient does not meet the criteria, the ICC will signpost a more appropriate care pathway. If the patient is not accepted for an Assessment bed this will be recorded in the patient s notes in conjunction with the ICC. The hospital Social worker will contact the Community Hospital Nurse in charge who will identify from the rota, the GP covering that day. The hospital Social Worker will relay this information to the hospital medical officer who is responsible for contacting the GP. If the GP accepts and agrees to the transfer of the patient, the medical liaison form (appendix 2) following completion be acute medical staff should be faxed to the GP and the original copy sent with the patient to the Community Hospital. The GP will then contact the nurse in charge of the community hospital giving relevant information. If the GP is not happy to accept transfer of the patient he/she has responsibility to refuse the request if, in their view the referral is inappropriate. Should there be any concerns regarding suitability for managing the patient within the unit, the nurse in charge should discuss this with GP currently providing medical cover and the Intermediate care Co-ordinator. Once accepted for admission to the Community Hospital the ward clerk of the community hospital will contact the patient s own GP and request a summary of the notes to be faxed. If the patient was not previously known to the GP, the covering GP is responsible for arranging information regarding the patients past medical history to be faxed to the community hospital. The ward clerk will contact the ICC to inform of the agreed admission date. The ICC will inform the Manager of the IRST of the patient s admission to the assessment bed. It is the responsibility of the referring hospital Social Worker to liaise with the patient/carer and families, provide them with an Assessment bed guidance leaflet and gain consent for transfer. 11

The Nurse in charge of the community hospital will contact the referring hospital to complete the Nursing Liaison form and Infection control Assessment Form. Once the transfer of the patient has been agreed it is the responsibility of the referring multi-disciplinary team to coordinate and ensure all the up to date multi-disciplinary assessments are forwarded to the relevant professional in the IRST. It is the responsibility of the ward staff in the transferring hospital to arrange the transport/ambulance for the patient. It is the responsibility of the ward staff in the referring hospital to always send the casenotes including medicine kardex at the time of transfer. The medical liaison form, the referring hospitals discharge letter and a copy of the medicine kardex should always accompany the patient. Medical Cover for Community Hospital Assessment Beds (outline of responsibilities for designated GP) The designated GP will be required to; - Accept medical responsibility for a patient admitted to an Assessment bed in a community hospital following a review of the medical form. - Give a timely response to the referring Doctor from the referring hospitals request for medical cover. - Promptly inform the nurse in charge of the community hospital the agreement for patient s admission. - Complete a medicine kardex for the patient, for admission to the community hospital. - Prescribe / review medication as required. - Review the patient once a week, and if requested by the members of the multidisciplinary team. - Make onward specialist referrals as appropriate. - Have direct contact with the patient s family and carer as required. - Provide medical reports for case discussions if required. - Ensure arrangements for medical cover are in place during periods of leave If the patient is not currently from the catchment area of the designated GP, the responsibility is with the designated GP to communicate with the patient s own GP to; - Request information regarding the patient s medical history. - Request an up to date list of the patient s medication. - Ensure any intervention or change to medications/treatment is documented. - Provide a discharge summary for the patient s own GP on the patient s discharge from the Assessment bed. Enablement Plan for Assessment Bed Patients in Community Hospital A Multi-disciplinary Enablement plan will be devised within the first 5 days of the patient s admission to the Assessment bed outlining the patient s goals, review dates and plans/dates for discharge. This must be agreed and signed by the patient. 12

The Intermediate Care co-ordinator will be responsible for ensuring that the most appropriate member of the Multi-disciplinary Team completes this in conjunction with the client. The Enablement Plan must show that options such as the following have been considered: - Respite plan - Rehabilitation needs have been addressed - Day care - Use of Assistive technology - Use of Voluntary sector - Step down residential with rehabilitation - Domiciliary care with rehabilitation - Carer s assessment offered/undertaken Once the patient has been admitted to the Assessment bed it is the responsibility of the Intermediate care Co-ordinator to monitor the patients progress in consultation with the IRST and Community hospital nursing staff ensuring case discussions are held as appropriate and that discharge plans are being implemented in a timely manner. Reviews must be undertaken in accordance with the enablement plan. Once the patient has been admitted to the Assessment bed it is the responsibility of the Intermediate care Co-ordinator to monitor the patients progress in consultation with the IRST ensuring case discussions are held as appropriate and that discharge plans are being implemented in a timely manner. Each client on admission to an Assessment bed will be allocated an IRST Named worker. It will be their responsibility to engage the relevant Community Team as appropriate. Reviews must be undertaken in accordance with the Enablement plan. Following the period of assessment /intervention if a domiciliary care package is required it is the responsibility of the Named worker in the IRST to make the referral to the Community Team to secure funding and engage a Named Worker as required. There will be no requirement for the Community Integrated Team to commence further assessments prior to discharge. It is the responsibility of staff in the IRST to arrange domiciliary services /support to facilitate the patient s discharge home. If the patient is unable to return home it is the responsibility of the relevant Community Team to arrange the discharge from the assessment bed to a permanent residential or nursing home placement. A referral will be made to the relevant community Team by the IRST named Worker and any assessments completed by the IRST forwarded. It is the responsibility of the Named worker in the relevant community team to liaise with the client and their family, source funding, forward relevant documentation to Central bed procurement Team and arrange discharge and transfer to permanent placement. 13

If a delay in discharge occurs from the Assessment beds it is the responsibility of the Intermediate Care Co-ordinator to escalate the delay to the Area Manager for Intermediate Care and Rehabilitation Services who will liaise with the Community General Manager. All reasons for delay must be recorded for the purpose of audit by the Intermediate Care Co-ordinator. Prior to the patient s discharge the Intermediate care Co-ordinator must ensure that all various professionals involved in the patient s care including the designated GP have an agreed discharge date and discharge arrangements are in place. Once the patient is discharged from the Assessment bed intervention from the IRST will cease. The IRST will refer to colleagues in the Community Integrated Teams for ongoing intervention/monitoring as required. 14

Assessment Beds in Sub Acute Facilities (Whiteabbey and Mid Ulster Hospitals) Procedure for admission to an Assessment bed in Sub-acute facilities Once a multidisciplinary assessment has identified that a patient is appropriate for an Assessment bed the hospital Social Worker will contact the Intermediate Care Coordinator (ICC) re availability. The ICC will advise re availability of beds, screen patients and authorise admission. In complex cases a case discussion prior to discharge to an assessment bed may be required with involvement from the relevant Community Team. The ICC will be responsible for arranging the case discussion. If the patient does not meet the criteria, the ICC will suggest a more appropriate care pathway. If the patient is not accepted for an Assessment bed this will be recorded in the patient s notes in conjunction with the ICC. The coordinator will contact the admitting ward to book the bed and provide some information regarding the patient s needs. It is the responsibility of the Hospital Social Worker in the acute hospital to liaise with the patient/carer and families and provide them with an Assessment bed Guidance leaflet and gain consent for transfer to an Assessment bed. It is the responsibility of the Hospital Social worker to inform the members of the acute hospital multidisciplinary team of the patient s planned admission to the Assessment bed. It is the responsibility of the referring multidisciplinary team to fax up to date assessments and treatment plans to colleagues in the sub acute hospital as per current procedures. Procedures for admission to the sub acute hospital will be as per current acute/sub acute hospital transfer policies and procedures. Medical cover will be arranged by Consultant to Consultant as per current acute/sub acute procedures. Assessment and Intervention will be provided by the Hospital Social worker and Allied Health Professionals in the Sub-acute hospital Medical Cover for Assessment Beds in Sub Acute facilities (outline of responsibilities for medical staff) The designated medical staff member will be required to; - Accept medical responsibility for a patient admitted to an Assessment bed in a sub acute hospital following a review of the medical form. - Give a timely response to the referring doctor from the referring hospitals request for medical cover. - Promptly inform the nurse in charge of the hospital the agreement for patient s admission. - Complete a medicine kardex for the patient, for admission to the hospital. 15

- Prescribe / review medication as required. - Review the patient once a week, and if requested by the members of the multidisciplinary team. - Make onward specialist referrals as appropriate. - Have direct contact with the patient s family and carer as required. - Provide medical reports for case discussions if required. - Ensure any intervention or change to medications/treatment is documented. Provide a discharge summary for the patient s own GP on the patient s discharge from the Assessment bed. Enablement Plan in Sub Acute Facilities An Enablement plan will be devised by the multi-disciplinary team within the first 5 days of the patient s admission outlining patient s goals, review dates and plans/dates for discharge. This must be agreed and signed by the patient. The Intermediate Care co-ordinator will be responsible for ensuring that the most appropriate member of the Multi-disciplinary Team completes this in conjunction with the client. The Enablement Plan must show that options such as the following have been considered: - Respite plan - Rehabilitation needs have been addressed - Day care - Use of Assistive technology - Use of Voluntary sector - Step down residential with rehabilitation - Domiciliary care with rehabilitation - Carer s assessment offered/undertaken Once the patient has been admitted to the Assessment bed it is the responsibility of the Intermediate care Co-ordinator to monitor the patients progress in consultation with the hospital Multi-disciplinary team ensuring case discussions are held as appropriate and that discharge plans are being implemented in a timely manner. Reviews must be undertaken in accordance with the enablement plan. Following the period of assessment /intervention if a domiciliary care package is required it is the responsibility of the Hospital Social Worker to make the referral to the Community Integrated Team to secure funding and engage a Named Worker as required. There will be no requirement for the Community Integrated Team to commence further assessments prior to discharge. It is the responsibility of the Hospital Social worker to arrange and complete any documentation required for domiciliary services/support which facilitates the patient s discharge home. The sub acute multi-disciplinary team must ensure all arrangements are in place prior to the patient s discharge home. 16

If the patient is unable to return home it is the responsibility of the relevant Community Team to arrange the discharge from the Assessment bed to a permanent residential or nursing home placement. The Hospital Social worker will refer the patient to the relevant Community Team and forward all assessments completed by the multi-disciplinary team. It is the responsibility of the Named worker in the relevant community team to liaise with the client and their family, source funding, forward relevant documentation to Central bed procurement Team and arrange discharge and transfer to permanent placement. Prior to the patients discharge the Intermediate care Co-ordinator must ensure that all professionals involved in the patient s care have an agreed discharge date and that discharge arrangements are in place. If a delay in discharge occurs from Assessment beds it is the responsibility of the Intermediate Care Co-ordinator to escalate the delay using the End of Intermediate Care Episode template Equality, Human Rights and DDA This policy has been drawn up and reviewed in the light of Section 75 of the Northern Ireland Act (1998) which requires the Trust to have due regard to the need to promote equality of opportunity. It has been screened to identify any adverse impact on the 9 equality categories and no significant differential impacts were identified, therefore, an Equality Impact Assessment is not required. Alternative formats This document can be made available on request on disc, larger font, Braille, audiocassette and in other minority languages to meet the needs of those who are not fluent in English. Sources of Advice in relation to this document The Policy Author, responsible Assistant Director or Director as detailed on the policy title page should be contacted with regard to any queries on the content of this policy. 17

Glossary Enable to provide someone with adequate power, means, opportunity or authority (to do something) Homecare Re-enablement services for people with declining physical or mental health to help them self manage at home by learning and or re-gain the skills necessary for daily living and to maximise independent living Nursing Home care - a care home with qualified nurses permanently on site registered to provide nursing care Rehabilitation - The process of restoration of skills by a person who has had an illness or injury so as to regain maximum self-sufficiency and function in a normal or as near normal manner as possible. For example, rehabilitation after a stroke may help the patient walk again and speak clearly again Residential home care a care home providing 24 hour general care but with no registration to provide nursing care IRST Intermediate Rehabilitation and Stroke Team This team will pull together a range of services including, Multi disciplinary rehabilitation, Assessment beds, Early Supported Discharge for Stroke Services, Orthopaedic Service & Rapid Response Home Care Service. ICC Intermediate Care Coordinator 18

Appendix 1 Plan to Roll Out Assessment Beds Area Antrim / Ballymena Facility No. of Beds to be opened Sept 10 No. of Beds opened Oct 10 No. of Beds opened Nov 10 No of beds to be opened Dec 10 TOTAL BEDS TO BE OPENED Private Nursing Home Antrim Care Home 6 beds 0 0 0 5 6 Causeway Mid Ulster East Antrim MidUlster Whiteabbey Pinewood RH 6 beds 3 3 3 3 6 Brookmount PNH 2 Rathene PNH 2 4 4 4 4 4 Dalriada Hospital 2 beds 0 0 0 2 2 Rathmoyle RH 1 bed 0 0 0 0 1 The Roddens RH 2 beds 1 1 1 2 2 Westlands RH# 1 bed 1 1 1 1 1 Inver Hospital 2 beds 0 0 2 2 2 Lisgarrel RH 2 beds 0 0 2 2 2 Clonmore RH 2 beds 0 0 2 2 2 Midulster hospital 3 beds 0 0 0 0 3 Whiteabbey hospital 4 beds 0 0 0 0 4 TOTALS 35 beds 9 9 15 23 35 19

Appendix 2 20

Appendix 3 ICSC Admission Information Sheet Date: Name & Address D.O.B: Referrer Name & Number Tel No: N.O.K: Time Referred Reason for Referral Time Accepted Previously Independent Hospital/Ward Yes/No Named Worker Previous P.O.C. PMH Current GP Yes/No Provider Covering GP Service Required Rapid Response Am Pm Lunch Tea Total Hrs Assistance x 1/2 PC Mobility Aids Zimmer/Stick/etc Referrer/Advised Paperwork/ Ex Care contacted Ex Care phone 94482939 Ex Care fax 94482950 ISCS fax 25635547 Start Date Assessment Bed SUSD Referral CRT Admission Date Location Team Area Patient Information 1. Maintaining Safe Environment Behavioural issues i.e. agitation/aggression/wandering/infection status Other: Equipment needs i.e. cot sides 2. Communication Level of orientation/confusion Folstein Dementia diagnosis Psych Referral 3. Breathing O² Nebuliser/Inhalers Other 4. Nutrition Special Requirements 5. Medication i.e. Insulin/Injections Allergies D/N required 21

6. Elimination Continent Incontinent Catheter 7. Personal Care Assistance ½ Independent Skin integrity Braden Ordered by DN CRT Equipment Required i.e. mattress OT Assessment 8. Mobility Current Level Aids required: Zimmer/Stick/Other H/o falls Y/N Physio Assessment 9. Sleep Sedation required Wandering Other = Investigations pending/requested Medication 28 Day supply Medication from home Admission Date EOAE Date For office use Home contacted Date Contact details S/W contacted Comments ICSC signature Date RR/SUSD/Assessment Bed Accepted Yes/No Reason for not accepting 22