Directorate of Operations DISCHARGE AND TRANSFER OF CARE POLICY Reference: OPP005 Version: 1.1 This version issued: 09/12/11 Result of last review: Minor changes Date approved by owner (if applicable): 28/11/11 Date approved: 22/07/10 Approving body: Trust Governance Committee Date for review: July, 2013 Owner: Director of Operations Document type: Policy Number of pages: 20 (including front sheet) Author / Contact: Graham Jaques, Operations Centre Manager SGH Northern Lincolnshire and Goole Hospitals NHS Foundation Trust actively seeks to promote equality of opportunity. The Trust seeks to ensure that no employee, service user, or member of the public is unlawfully discriminated against for any reason, including the protected characteristics as defined in the Equality Act 2010. These principles will be expected to be upheld by all who act on behalf of the Trust, with respect to all aspects of Equality.
Contents Section... Page 1.0 Purpose... 4 2.0 Area... 4 3.0 Principles / Objectives... 4 4.0 Duties and Responsibilities... 5 4.1 Chief Executive... 5 4.2 Consultant and Medical Team... 5 4.3 Ward Manager/Nurse in Charge... 5 4.4 Multi Disciplinary Team... 5 4.5 Discharge Liaison Nurses... 5 4.6 Social Care... 6 4.7 All staff... 6 4.8 PALS... 6 5.0 Policy and Guidance... 6 5.1 Discharge planning at or before admission... 6 5.2 Discharge planning following admission... 7 5.3 NHS Continuing Healthcare... 7 5.4 Social Care Assessment... 8 5.5 Delayed Transfer of Care... 9 6.0 Transfer of Patient Ward To Ward (Within NLAG Hospitals)... 9 7.0 Transfer of Patients Between Acute Trusts... 9 8.0 Transfer of Patients Out Of Hours... 10 9.0 Discharge of Patients... 10 9.1 Discharge of Patients to Care Homes... 11 9.2 Infection Control Arrangements on Patient Discharge... 11 9.3 Medications and Dressings... 11 Printed copies valid only if separately controlled Page 2 of 20
9.4 Involving patients and carers... 11 9.5 Information provision for patients and carers... 12 9.6 Transport... 12 9.7 Patients taking their own discharge against medical advice... 13 9.8 Discharging patients out of hours... 13 10.0 Discharge/Transfer Requirements of Specific Patient Groups... 14 10.1 People with mental health problems... 14 10.2 People with learning disabilities... 14 10.3 Patients with complex needs... 14 10.4 Fast track discharge of patients... 15 10.5 Vulnerable Adults... 15 10.6 Homeless... 15 10.7 Principles of Maternity Discharge Policy... 16 10.8 Paediatric Services... 16 10.9 Child Protection... 16 10.10 Children s Community Nursing Team... 16 11.0 The Mental Capacity Act 2005... 16 11.1 Introduction... 17 11.2 Independent Mental Capacity Advocates (IMCAs)... 17 11.3 Lasting Power of Attorney (LPA)... 18 11.4 Advanced Decisions... 18 12.0 Monitoring Compliance and Effectiveness... 18 13.0 References... 18 14.0 Definitions... 19 15.0 Ratification Process... 19 Appendix A... 20 Printed copies valid only if separately controlled Page 3 of 20
1.0 Purpose A discharge policy is necessary to ensure safe, timely and effective discharge and transfer of care for all patients admitted to hospital. It should be an ongoing process from or prior to admission actively involving patients, carers, trust and other health and social care parties. The policy is based on current legislation and recommendations taken from Discharge from hospital - pathways, processes and practice DOH 2003, The Community Care (Delayed Discharges etc) Act 2003, and the The National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care Revised July 09. 2.0 Area The contents of this policy will apply to all personnel working in wards and departments involved with in-patient episodes of care within Northern Lincolnshire and Goole Hospitals NHS Foundation Trust. 3.0 Principles / Objectives The principles/objectives on which the policy is based are that: Unnecessary hospital admissions are avoided Planning for hospital discharge is part of an ongoing process and should start prior to admission for planned admissions and at the earliest opportunity for other admissions The engagement and active participation of individuals and their carers is central to the delivery of care and in the planning of a successful discharge Staff should work within a framework of integrated multi-disciplinary and multiagency team working to manage all aspects of the discharge process The assessment for, and delivery of, continuing health and social care is organised so that individuals understand the continuum of health and social care services and their rights, and receive advice and information to enable them to make informed decisions about their future care. This should include information about their right to appeal against decisions reached Effective and timely discharge requires the availability of alternative, and appropriate, care options including intermediate care services or individualised home care support to ensure that any rehabilitation, recuperation and continuing health and social care needs are identified and met Patients who have been assessed as multi disciplinary fit/stable to transfer from acute care should not remain in an acute bed to wait for either assessment or service availability as set out in the Community Care (Delayed Discharges etc) Act 2003 and local Choice Directive Printed copies valid only if separately controlled Page 4 of 20
4.0 Duties and Responsibilities 4.1 Chief Executive Has overall responsibility for ensuring that this policy is effectively implemented. 4.2 Consultant and Medical Team 4.2.1 Has the primary responsibility for patients care and discharge although this may be delegated to appropriately trained members of the multi disciplinary team following certain discharge criteria. The decision to discharge should be made in partnership with the multi disciplinary team. 4.2.2 Has the responsibility for the medical appropriateness for transfer/discharge out of acute care and estimating the length of stay and setting an expected date of transfer/discharge and develop a clinical management plan for every patient within 24 hours of admission. Decisions that the patient is clinically stable and safe for discharge should be made each day as part of regular senior reviews that take place outside the regular ward rounds. 4.3 Ward Manager/Nurse in Charge 4.3.1 Has overall responsibility for the transferring/discharging of patients from the acute care setting in a safe and timely manner. 4.3.2 Has responsibility for ensuring the appropriate multi disciplinary team are involved and discharge planning commences on admission ensuring timely referrals are made and nursing notes are accurate and up to date. 4.3.3 Responsible for ensuring that the Discharge and Bed Management Team are informed of any patients who are medically stable/fit and are a delayed transfer of care. 4.3.4 Responsible for ensuring that the patient and carer are involved throughout the transfer/discharge process and any information is given in an appropriate and timely manner. 4.4 Multi Disciplinary Team 4.4.1 Responsible for ensuring patients reach their optimum potential for transfer/discharge from acute care with the appropriate support and equipment required. 4.4.2 Integral part of the multi disciplinary team and need to ensure that all parties involved in the transfer/discharge of the patient are informed of any care needs of the patient and highlight recommendations to all MDT members, patient and carers. 4.4.3 Responsible for equipment and organising home adaptations in a safe and timely manner so as to prevent delayed transfers/discharges from acute care. 4.5 Discharge Liaison Nurses 4.5.1 Responsible for co-ordinating complex transfers/discharges from hospital and arranging timely delivery of health equipment. 4.5.2 Responsible for the training of ward staff in the discharge planning process. Printed copies valid only if separately controlled Page 5 of 20
4.5.3 Responsible for the assessment, supplying of services and equipment for patient who meet the NHS Continuing Healthcare criteria including fast track patients and coordinating an efficient and timely discharge for these patients. 4.5.4 Responsible for liaising with district nursing services and acute trust staff and dealing with problems/issues raised from partner agencies relating to the transfer/discharging of patients. 4.6 Social Care 4.6.1 Responsible for assessing a patient s needs (under the Community Care Act 1990) to enable an efficient, prompt and safe transfer/discharge of patients from acute care within the timescales of the Community Care (Delayed Transfer etc) Act 2003. 4.6.2 Commissioning services to meet the identified needs and involving patient and carer in the entire process of discharge planning. 4.6.3 Co-ordinating the appropriate level of care required, liaising with other members of the multi disciplinary team to ensure all needs are met on transfer/discharge from acute care. 4.7 All staff 4.7.1 Everyone involved in the patient s journey has a responsibility to actively plan the patients discharge and involve the patient, and carer when appropriate. 4.7.2 Responsible for ensuring any documentation is amended and up to date with any involvement of staff through the patient s admission and transfer/discharge process. 4.8 PALS The Patient Advice and Liaison Service (PALS) focuses on improving the service to NHS Patients. PALS acts independently and aims to advise and support patients, families and carers by listening to their concerns, queries and suggestions and providing information and support to help sort out problems as required. 5.0 Policy and Guidance 5.1 Discharge planning at or before admission 5.1.1 Elective Admissions: Pre admission assessment is routine for all elective surgical admissions. It provides an opportunity for patients and carers to understand how they can help themselves and plan for their return home. The discharge planning process commences at pre admission assessment stage All patients who attend for pre admission assessment will have a review of all their current health and social care needs and potential needs on discharge The patient and carer where appropriate, will be informed of the predicted length of stay in hospital at pre admission assessment Printed copies valid only if separately controlled Page 6 of 20
Where pre admission assessment of a patient identifies that a patient is likely to require social care support at the point of transfer from an acute hospital bed, the pre admission assessor has the responsibility for ensuring that Social Services are sent a request for assessment (Section 2 notification) giving a maximum of 8 days notice to admission 5.1.2 Emergency Admissions: Emergency admissions are admitted to Northern Lincolnshire and Goole Hospitals via GPs, the emergency department and outpatient clinics Planning for discharge will begin on admission to hospital with the holistic assessment of the patient. This will take into account the health and social needs of the patient and involve their carer as appropriate 5.2 Discharge planning following admission 5.2.1 A thorough assessment of the patients needs is undertaken at the point of admission. The assessment process should identify the reasons for the admission, including any social care issues and any recent changes in these. It may be appropriate to involve the family/carer as part of this assessment, at this time, to ensure that the assessment is fully informed. Relevant multidisciplinary team referrals should be made at this time. This should give a clear reason for the referral. 5.2.2 The initial assessment is a good opportunity to underline expectations about a person s stay in hospital and help them think about transport home, access to property and moving on from the acute setting as soon as they are well enough. Contact details and names of key individuals should be obtained at this point. These details, if overlooked, will cause distress and delay in the discharge process. 5.2.3 It is important to find the underlying cause of the problems that will need to be addressed to avoid a further referral and/or avoidable deterioration in health. 5.2.4 If on assessment the patient s level of need indicates that a social referral is required, the patient s need should be assessed against the discharge liaison/social care referral guideline. This is to ensure that the patient s health need has been considered as per The Community Care (Delayed Discharges etc) Act 2003, and the The National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care Revised July 09. 5.2.5 The referral guideline will ensure that the referral is to either, Discharge Liaison/Continuing Healthcare Co-ordinator for further assessment for eligibility for fully funded NHS care or Section 2 referral to social care. 5.3 NHS Continuing Healthcare 5.3.1 NHS continuing healthcare is the name given to a package of care which is arranged and funded solely by the NHS for individuals outside of hospital with ongoing healthcare needs. Anyone assessed as having a certain level of care needs may receive continuing healthcare. A patient should be eligible if their overall care needs show that their primary need is a health need. Printed copies valid only if separately controlled Page 7 of 20
5.3.2 The patient (and carer if appropriate) should be fully involved in this process and informed of all decisions. Patients should be given a copy of Continuing care information leaflet for patients and carers. Patients should be included in the process throughout and given written confirmation of any assessment outcomes. Patients have a right of appeal if they are unhappy with the process. 5.3.3 The process is managed by Discharge Liaison (NHS North Lincolnshire and North East Lincolnshire Care Trust Plus) or Continuing Care Co-ordinator (East Yorkshire) for in-patients in Northern Lincolnshire and Goole Hospitals. 5.3.4 Further information about the National Framework for fully funded NHS care is available at: http://nww.nlg.nhs.uk/documentmanagement/display.asp?department=bed+management 5.4 Social Care Assessment 5.4.1 When is has been identified that a patients level of need requires a social care assessment to support their needs on transfer out of acute care a social care referral should be completed (Section 2 notification). 5.4.2 Patient s (or family) consent should be obtained before making the referral to Social Care. It should be clear on the referral as to what is being asked and what the patient s abilities are at the present time. 5.4.3 Patients should be given the right care right place leaflet and documented in the nursing notes. 5.4.4 Social Care will need to complete an assessment of the patients needs to ensure safe transfer out of hospital to an appropriate setting. 5.4.5 The Social Care worker will need to be involved in assessments of patients at an early stage, in consultation with other appropriate members of the multidisciplinary team, to ensure the appropriate and timely arrangements can be made for discharge 5.4.6 When the patient is MDT fit/safe to transfer and agreed, a SECTION 5 should be sent. 5.4.7 The assessment for discharge is part of the Community Care Assessment, but not necessarily all of it. The assessment for discharge covers the services needed to transfer from an acute bed. 5.4.8 For a Community Care Assessment, a range of disciplines is likely to be involved in the assessment process. Social Care will gather information from appropriate people; consultant, nurses, therapist, patient/carer. This should not delay the discharge process. Reports can be obtained verbally. (Paper copies to follow). 5.4.9 The patient/carers wishes will be taken into account. The patient has the right to make decisions for him/herself (even against medical advice) and this may mean them taking risks. The Mental Capacity Act to be taken into consideration. Printed copies valid only if separately controlled Page 8 of 20
5.5 Delayed Transfer of Care 5.5.1 A delayed transfer of care is defined as a patient who is medically, MDT fit and safe to transfer out of acute care or there is undue delay in achieving MDT fit. If a delay is solely attributable to social care assessment or service provision then this may incur a reimbursement from the responsible local authority. 5.5.2 It is the responsibility of the nursing staff to notify the Discharge and Bed Management Team of any medically fit/stable patients whose transfer out of acute care is delayed. 5.5.3 Any patient who requires a care home setting to meet their current level of need should be managed through the Home of Choice Directive which can be found on http://nww.nlg.nhs.uk/service_dev_modernisation/home_of_choice/default.htm 6.0 Transfer of Patient Ward To Ward (Within NLAG Hospitals) 6.1 Internal transfer of patients is often necessary to ensure that a patient is cared for in the most appropriate clinical setting or to create more capacity in a specific clinical setting. 6.2 If a patient is to be transferred to another clinical setting within the hospital then there needs to be an in depth discussion between the referring and receiving ward to ensure that the transfer of care is seamless and does not impact on length of stay or the patient s treatment plan. This should be evidenced in the nursing documentation. 6.3 If a patient is transferring to an alternative speciality there should be an agreement to transfer and handover of clinical details between the speciality medical staff before any arrangements are made via the Bed Management Team. 6.4 All medical, nursing and other documentation should be up to date and accompany the patient on transfer. Notes should be tracked on the computerised system to the new location. 7.0 Transfer of Patients Between Acute Trusts 7.1 Transfer of patients between acute trusts is necessary if a patient needs speciality input that is not provided within NLAG Hospitals or to repatriate patients that have ongoing medical care needs from other acute trusts. 7.2 It should be determined that a patient requires ongoing input from acute care before any agreement to transfer a patient into NLAG Hospitals. A transfer should not take place if a patient is medically and multi disciplinary team fit or purely for the convenience of the Local Authority to complete an assessment. 7.3 Guidance can be provided by the Bed Management Team on the repatriation of patients and advice on local service protocols to support discharge to alternative settings rather than transfer to acute care unnecessarily. 7.4 When a patient is to be transferred to another hospital there should be an agreement to transfer and handover of clinical details between the speciality medical staff before any arrangements are made via the Bed Management Team. Printed copies valid only if separately controlled Page 9 of 20
7.5 All diagnostic investigations and results should be reviewed by the transferring medical team to ensure an in depth medical handover can take place with the receiving team. 7.6 There needs to be an in depth discussion between the referring and receiving ward to ensure that the transfer of care is seamless. This should be evidenced in the nursing documentation. 7.7 All medical, nursing and other documentation should be up to date and accompany the patient on transfer. Notes should be tracked on the computerised system to the new location. 8.0 Transfer of Patients Out Of Hours 8.1 If there is a clinical urgency for a patient to be transferred to an alternative health setting, this should be arranged at the earliest opportunity regardless of the time of day if this is in the interest of the patient s wellbeing. 8.2 All medical, nursing and other documentation should be up to date and accompany the patient on transfer. Notes should be tracked on the computerised system to the new location at the earliest opportunity. 9.0 Discharge of Patients 9.0.1 Arrangements for discharge must be checked against the discharge checklist (contained in the nursing notes). 9.0.2 The documentation that should be completed in preparation for discharge includes: 9.0.3 Multidisciplinary Discharge Summary where there is ongoing social or health care needs to be met. This should be a detailed plan of how the patient s current needs are being met and any details of ongoing follow up arrangements. 9.0.4 Discharge letter detailing the medical discharge summary and prescription is sent to the GP electronically and a copy is given to the patient. Details of medication; type, dose, frequency, route, side effects (TTO) should accompany any prescription provided. 9.0.5 Details of any specific requirements following input from any specialist service including any health educational literature and contact details of the service. 9.0.6 It is the responsibility of any discipline involved in planning a patient s discharge to provide any relevant information e.g. specialist nurse input/ongoing therapy plans to relevant community disciplines involved. 9.0.7 The person/s completing the discharge documentation must ensure that the information is accurate, understandable, without abbreviations and medical terminology where possible and legible on all copies. 9.0.8 The nurse will explain the contents of the discharge documentation to the patient. Every effort will be made to ensure that the patient understands the information given. The nurse to document in the nursing notes that this has happened. Printed copies valid only if separately controlled Page 10 of 20
9.0.9 Copies of the discharge summary to be distributed as per guidance on the form. 9.1 Discharge of Patients to Care Homes 9.1.1 If a patient is assessed as needing to be discharged to a care home, whether they are health or social care funded, the choice directive should be followed. 9.1.2 The patient may have a preference for one home rather than another. However, the patient should not wait in hospital for a vacancy in their preferred home to become available, as it is important that they move to somewhere tailored to meet their needs once they are well enough to transfer out of acute care. A suitable alternative to hospital will be identified whilst the preferred option becomes available. This may be a temporary placement in another care home: http://nww.nlg.nhs.uk/service_dev_modernisation/home_of_choice/default.htm 9.1.3 For patients being discharged to a care home the Multidisciplinary Discharge Summary should be detailed to such a level that the care home can compile their own care plan from this. 9.2 Infection Control Arrangements on Patient Discharge 9.2.1 Refer to the Trust Infection Control Policy and Guidance, on the Intranet, for specific issues relating to Specific Infection Control problems, or contact the Infection Control Team, or the Public Health/Community teams. 9.2.2 If a patient is being discharged with a known infection control problem/condition, e.g. MRSA, the patient s General Practitioner and, any other health care agencies should be informed prior to the patient s discharge/transfer from hospital. 9.2.3 If the patient is being discharged/transferred to a nursing/residential care facility, both the medical and nursing/community staff should be informed in advance. An Inter Healthcare Infection Control Notification Form will be sent on discharge with the patient: http://nww.nlg.nhs.uk/path/policies/operational_policies/intra.htm 9.3 Medications and Dressings 9.3.1 Patients will be provided with sufficient drugs for a minimum of 7 days (where appropriate) and dressing for up to 7 days (where appropriate) following discharge. Consideration should be given to providing extra drugs/dressings over a Bank Holiday period. Advice relating to take home medicines will be given by the ward, pharmacist, or a registered nurse. A patient s prescription to take home should be a planned integral part of the discharge process and should not delay a discharge/transfer from acute care. 9.3.2 Please seek further guidance from Pharmacy Department for specific controlled drugs and Policy for the Reuse of Patients Own Medicine and Self-administration (SAMPOD): http://nww.nlg.nhs.uk/documentmanagement/display_search_results.asp?keyword=csp008 9.4 Involving patients and carers 9.4.1 The engagement and active participation of individuals and their carers is central to the delivery of care and planning of a successful discharge. Printed copies valid only if separately controlled Page 11 of 20
9.4.2 Pre admission assessment helps the patient and carer plan for admission to hospital and to understand what to expect on returning home. In relation to emergency admissions, this cannot take place and it is therefore essential to explain on admission to patients and carers what to expect and how they will be involved in the decisions affecting their care. 9.4.3 All patients should have an estimated date of transfer/discharge date set either before admission to hospital or as soon as possible after admission. The patient and carer should be informed of this expected date of transfer/discharge and clearly documented in the nursing notes for discharge planning purposes. 9.4.4 There should be opportunity for the patient and/or carer to express any concerns about being discharged from hospital so that they can be addressed and any assessments can be achieved in parallel with the patient s recovery where appropriate. 9.4.5 Those elements of the carers assessment which relate to the patient s discharge should be undertaken in the same assessment timescales laid out in the NHS Community Care (Delayed Transfers etc) Act for patients. Just as assessment for discharge doesn t need to be a full community care assessment, carer s assessment related to a patient s discharge may be only part of a full assessment which continues after the patient is discharged. 9.4.6 Where a carer will be undertaking tasks that need training to ensure that the carer or patient is not put at risk, staff should ensure that appropriate training is provided. 9.5 Information provision for patients and carers 9.5.1 Information provision for patients and carers about discharge starts before admission whenever possible and continues throughout the patient s stay as above. 9.5.2 All staff must ensure that the patient and their carers are fully informed of the discharge arrangements. This requires a proactive approach to ensure the plan is progressing smoothly and to take immediate action to address problems with the multi disciplinary team. 9.5.3 On discharge a registered nurse will ensure the patient has all the information they require. They will fully explain ongoing care needs including out-patient appointments and any further service provision. Written information will be provided where appropriate. 9.5.4 Relevant information about patient and carer support groups and advocacy will be available on wards. 9.6 Transport 9.6.1 Patients will be discharged in the morning wherever possible. 9.6.2 All patient eligibility and transport requirements must be assessed before any non emergency transport is booked and re assessed at each subsequent visit. Printed copies valid only if separately controlled Page 12 of 20
9.6.3 A patient is eligible for provision of transport where the medical condition of the patient is such that they require the skills or support of PTS staff on/after the journey and/or where it would be detrimental to the patient s condition or recovery if they were to travel by any other means. 9.6.4 Further information is available: http://nww.nlg.nhs.uk/documentmanagement/display.asp?department=patient+transport+services 9.7 Patients taking their own discharge against medical advice 9.7.1 It is recognised the patient s have the right to discharge themselves from hospital unless they are detained under a section of the Mental Health Act 1983 or by a Court Order. 9.7.2 Any patient who is not detained as above and wishes to take their own discharge should be informed of the consequences and risks of discharge against medical advice. The risks associated with early unplanned discharge must be discussed with the patient and if appropriate their carer and the content of these discussions are to be documented in the patient s medical records. The patient must be asked to sign a disclaimer Discharge against medical advice form by a Doctor or other senior member of clinical staff and this should be witnessed. It is imperative that the appropriate people are informed of the discharge to ensure that the appropriate care is in place. The patient will be advised that self discharge does not preclude them from further treatment. Test results received following discharge will be communicated to the GP. It is the responsibility of the patient to arrange their own transport when the discharge is against medical advice (staff may use discretion with this). 9.7.3 If patients refuse to sign a disclaimer and/or listen to explanations with regard to risks or consequences, this should be documented clearly in the patient s medical notes and on the disclaimer. This should not preclude the patient s GP being informed or from the patient being offered follow up if necessary. Every effort should be made to ensure that there is appropriate care for the patient in the community. 9.7.4 Patients, who take their own discharge against medical advice, should be offered the same aftercare services as other patients. 9.8 Discharging patients out of hours Due to providing 24 hour a day services there is not a working definition of out of hours and the person organising the discharge/transfer of the patient should use their discretion ensuring the following issues have been addressed. The discharge should only take place when the needs of the patient, his/her relatives, and/or carers can be met. When community services are required patients can be discharged during or just before the weekend, late in the day or on public holidays, providing this is already arranged agreed and confirmed by the multidisciplinary team, services are in place and agreed with patient/carer. Planned discharges and transfer should take place over seven days to ensure delivery of continuity of care for the patient. Printed copies valid only if separately controlled Page 13 of 20
10.0 Discharge/Transfer Requirements of Specific Patient Groups 10.1 People with mental health problems 10.1.1 Patients with mental health problems may need additional support and input from specialist services including assistance with medications, activities of daily living, follow up health care and financial assistance. Discharge planning should take this into consideration from the start of the discharge planning process. 10.1.2 Some patients may already be known to mental health services. Mental Health Care Workers should be informed of their client s admission and potential length of stay, and subsequent discharge date. The Mental Health Care Worker should also be informed of any transfers between clinical areas or hospital sites. 10.1.3 The Mental Health Liaison Team will respond to referrals for mental health assessment, advice and communicate with other mental health services where appropriate. 10.2 People with learning disabilities 10.2.1 When planning the discharge of anyone with a learning disability it must be recognised that the patient may require more time or support to understand the implications of the plan. Carers needs must be considered as outlined in section 9.4 and 9.5. 10.2.2 The Learning Disability Service should be contacted to assist with the planning, agreement and transfer/discharge arrangements of a patient. This can be especially valuable if the patient is already known to the service. 10.2.3 A carer or social care worker involved with the patient would be able to assist by: Offering specialist information when discharge plans are being prepared Ensuring the patient with a Learning Disability has understood and is following discharge instructions including medication requirements, awareness of contraindications, follow up appointments, accessing other services such as practice nurse, GP and therapists Ensuring practical issues or difficulties are addressed and resolved when necessary Accessing other workers who may be able to assist patient/carers Assisting with the monitoring of a patients progress following discharge and provide feedback where appropriate 10.3 Patients with complex needs 10.3.1 When a patients level of abilities indicate that support will be required on discharge appropriate referrals should made so that members of the multi disciplinary team can assess to ensure the patients needs are met e.g. equipment, home care services, community health involvement to enable a safe transfer/discharge in a timely manner. Printed copies valid only if separately controlled Page 14 of 20
10.3.2 The referral guide should be completed to ensure that patients with a high level of need are referred for an assessment and further consideration for continuing health care funding. 10.4 Fast track discharge of patients 10.4.1 If a patient has rapidly deteriorating condition which may be entering a terminal phase, with an increasing level of dependency a Fast Track Pathway Tool for NHS Continuing Healthcare should be completed and signed by an appropriate clinician and referred to the Discharge Liaison Service or Continuing Healthcare Service: http://nww.nlg.nhs.uk/documentmanagement/display.asp?department=bed+management 10.5 Vulnerable Adults 10.5.1 Where there is suspected physical, emotional and/or financial abuse of an adult, the appropriate multidisciplinary, multi-agency referrals and discussions should take place before discharge occurs.(for further guidance on Vulnerable Adults, refer to: http://nww.nlg.nhs.uk/documentmanagement/display.asp?department=safeguarding+adults+team 10.6 Homeless 10.6.1 People who are homeless are entitled to an assessment of need for community care services, if they meet Adult Social Care eligibility criteria. Usual social service referral methods should be followed and completed at the earliest point following admission (Section 2 notification). Homeless people are the responsibility of the Local Authority to which they reside provide they have a care need identified. 10.6.2 Consent from the homeless person should be obtain before any contact with the Homeless Office is made as some people exercise their right of choice to be homeless. 10.6.3 It is vital there is good communication and liaison between hospital and service providers particularly around people in temporary accommodation. 10.6.4 People who are homeless should be offered the same level of aftercare as other patients, for example they should not be denied outpatient follow-up. 10.6.5 If a patient presents as homeless, and wishes to seek help then the patient can be directed to the local authority-housing department. 10.6.6 As far as long-term housing options are concerned, the role of the support worker means that an assessment must be carried out relating to a patient housing circumstance and the patients should not be given an impression that long-term accommodation is available or an option. 10.6.7 The patient may wish to deal with their own affairs/arrangements, in these circumstances the nurse should aid with providing contact numbers for information and reference. 10.6.8 If the person does not have connection with the local authority, then advice should be given and/or sought from the local authority area with which the patient does have connection. Printed copies valid only if separately controlled Page 15 of 20
10.7 Principles of Maternity Discharge Policy 10.7.1 The principle of the Northern Lincolnshire & Goole NHS Foundation Trust Discharge Policy is accepted by the maternity units which will also adhere to the following aims: To ensure safe physical transfer of mothers and/or babies between care settings To ensure effective transfer & communication of information between health professionals & any relevant agencies 10.7.2 Specific in-depth guidance can be obtained from the Guideline on the movement of Mothers or Babies between Care or Settings and/or Transfer of care between Health Professionals. 10.8 Paediatric Services 10.8.1 Electronic discharge should be completed, a copy provided for the family and one forwarded to the GP, for children with complex needs a written discharge letter outlining all details may need to also be completed and posted in addition to the electronic copy. 10.8.2 Non-urgent admissions and discharges are sent to the Health Visitor/School Nurse by routine post by the discharging nurse. If an urgent referral is requested it is the responsibility of the Named Nurse to ensure that the relevant Health Visitor/School Nurse is contacted in a timely manner. 10.8.3 The child s Social Worker is to be informed of discharge where appropriate. 10.8.4 Children with complex discharge needs may require a pre-discharge multidisciplinary meeting. 10.9 Child Protection 10.9.1 Where there are safeguarding children issues, the discharge procedure detailed in the safeguarding pathway must be followed by the discharging nurse. The Named Nurse must also complete a Child in Need assessment consent form. Children with safeguarding issues are not be discharged until all appropriate agencies are in agreement and are notified of date of discharge and destination: http://nww.nlg.nhs.uk/documentmanagement/display.asp?department=safeguarding+children+team 10.10 Children s Community Nursing Team The Children s Community Nursing Team is to be notified of all discharges requiring nursing input in accordance with the criteria for referral. If the Children s Community Nursing Team are involved during an inpatient episode, they should be informed of any transfers between clinical areas or hospital sites. 11.0 The Mental Capacity Act 2005 Listed below are the key points of the Mental Capacity Act (2007) that influence discharge planning. Printed copies valid only if separately controlled Page 16 of 20
11.1 Introduction 11.1.1 The Mental Capacity Act 2005 provides a statutory framework for acting and making decisions on behalf of individuals who lack the mental capacity to do so for themselves. The Act specifies the principles that must be applied by everyone who is working with or caring for adults who lack capacity. It also provides options for those who may choose to plan and make provision for a future time when they may lack capacity. 11.1.2 The Five Key Principles: 1. A person is presumed to have capacity 2. A person is not to be treated as unable to make a decision unless all practicable steps to help them to do so have been taken without success 3. A person is not to be treated as unable to make a decision merely because they make an unwise decision 4. An act done or decision made on behalf of a person who lacks capacity must be done or made in their best interests 5. Before any such act or decision is made the person making or taking it must consider whether the purpose for which it is needed can be effectively achieved in a way that is less restrictive of the person s rights or freedom of action 11.2 Independent Mental Capacity Advocates (IMCAs) 11.2.1 The Secretary of State is to make such arrangements as to enable IMCAs available to represent and support persons who do not have capacity and have no other appropriate representative to consent concerning what would be in their best interests. 11.2.2 The appointment of IMCAs only relates to the provision of one of the following: Serious medical treatment by the NHS Change of accommodation in hospital or care home for the person by the NHS Change of residential accommodation by the Local Authority 11.2.3 The function of IMCAs is to: 1. Provide support to the person to ensure they participate as fully as possible in any relevant decision 2. Obtain and evaluate any relevant information in health records 3. Ascertain what the person s wishes were likely to be 4. Ascertain if alternative courses of action are available to the person Printed copies valid only if separately controlled Page 17 of 20
5. Obtain alternative medical opinion where treatment is proposed and the advocate thinks one is required 11.3 Lasting Power of Attorney (LPA) This replaces the Enduring Power of Attorney. The person who has LPA will be able to make decisions about the person s health and welfare should the person become incapacitated, if such a power is conferred. 11.4 Advanced Decisions These have also been known as Advanced Directives or Living Wills : Advanced Decisions can be withdrawn or altered at any time when the maker has capacity to do so Where it is clear that an Advanced Decision exists in writing, this should be attached to a patients file Advanced Decisions need not be in writing to be valid, withdrawal or partially withdrawal need not be in writing Alteration of Advanced Decisions need not be in writing unless it refers to life sustaining treatments The Advanced Decision has to be valid in that it must address current circumstances and current treatment http://nww.nlg.nhs.uk/riskmanagement/mental_capacity_act/default.htm 12.0 Monitoring Compliance and Effectiveness In order to ensure that this discharge policy is fit for purpose there will be at least an annual monitoring and audit of this policy either in full or in part in conjunction with the Nursing and Patient Services Directorate. Any omissions or actions required will be monitored and the policy updated in line with this. 13.0 References 13.1 Listed below are the documents that have informed the development of this policy. 13.1.1 Discharge from Hospital: Pathway, Process and Practice (DH 2003): http://nww.nlg.nhs.uk/documentmanagement/display.asp?department=bed+management 13.1.2 Mental Capacity Act (2005): http://nww.nlg.nhs.uk/riskmanagement/mental_capacity_act/default.htm 13.1.3 The National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care (revised July 2009): http://nww.nlg.nhs.uk/documentmanagement/display.asp?department=bed+management 13.1.4 Protection of Vulnerable Adults Policy and Guidance. Printed copies valid only if separately controlled Page 18 of 20
13.1.5 Ready to go? Planning the discharge and the transfer of patients from hospital and intermediate care (DH 2010): http://nww.nlg.nhs.uk/documentmanagement/display.asp?department=bed+management 14.0 Definitions Multi Disciplinary Team (MDT) Refers to a range of staff from both hospital and community e.g. Consultant, Nurse/Midwife, Mental Health Worker, Therapist, Discharge Liaison Team, GP, District Nurse, Social Care Worker or any other body of staff involved in the care and transfer/discharge of a patient. 15.0 Ratification Process This policy will be approved by the Governance Committee. The electronic master copy of this document is held by Document Control, Office of the Medical Director, NL&G NHS Foundation Trust. Printed copies valid only if separately controlled Page 19 of 20
Appendix A Admission Nursing Documentation Patient s normal activities prior to admission Family / Carer involvement / opinions Communicate & Record Medical / Surgical Team Estimate length of stay / Expected discharge date Involve patient/carer Consider MDT Involvement required Physio - transfers, reduced mobility, breathing OT - limited mobility to carry out ADL s, kitchen / washing/ dressing, home visit, equipment Others - SALT, Dietitian, etc CPN - confusion, if medical reason, patient s history,?known to CPN Consider capacity Consider CHC fast track Medical / Surgical Team Treating / investigations Complete Guide to Support Referral Is there 1 yes in box marked ** or 5 or more yes in total NO Obtain patient consent Send Section 2 (complete all form) Social Care to identify needs and appropriate care package Identify needs & equipment YES Contact Liaison Service on EXT To complete checklist To complete DST Identify needs and equipment Arrange care package If not CHC consider sending section 2 Medical / Surgical fit for transfer Document in patient s notes Check all MDT agree fit and safe to transfer / discharge from Acute care Section 5 timescales. Mon-Thurs before 5pm or Fri before 2pm for discharge next day. Fri after 2pm Mon discharge All health services/equipment must be in place prior to sending Invoke Home of Choice Policy if no vacancy in chosen home Inform Bed Management once med fit if not discharging Transfer / Discharge Patient TTO s Discharge paperwork Colour Key Code Continuous throughout stay Medical or Surgical process Liaison Service process Ward/Nursing staff process Printed copies valid only if separately controlled Page 20 of 20