The Newcastle upon Tyne Hospitals NHS Foundation Trust Patient Choice Directive Policy & Guidance Version No.: 2.1 Effective From: 26 August 2014 Expiry Date: 26 August 2016 Date Ratified: 17 June 2014 Ratified By: The Newcastle upon Tyne Hospitals NHS Foundation Trust Newcastle upon Tyne Adult and Cultural Services Directorate 1 Introduction Most people return home after a period of acute care, some after a period of intermediate care. Increasingly, in line with the policy of supporting independent living, those who are unable to return to their previous accommodation are re-housed in more appropriate extra care housing or other provision. Local policies and procedures and service provision should support maximum opportunity for rehabilitation and continued independence, which reflects the preferences of the great majority of patients. It should be recognised that when a transfer to a registered care home is the agreed outcome, proper opportunity for maximum rehabilitation has occurred. For a minority of patients transfer directly from an acute setting to a care home may be the plan agreed by all involved. Where a place is not available in the individual s preferred care home, remaining in an acute hospital setting is undesirable for the welfare of the patient. There are particular risks of increasing dependency and acquiring infections. In addition the acute care provision is needed for those with acute care needs. This policy is to be used in conjunction with the Hospital Discharge Policy and is for use by all staff with responsibility for arranging the discharge of patients. The policy should not be presented in the last stages of discharge but be part of the information routinely delivered to patients and their carers when all professionals involved in the assessment identify the need for the patients move to a care home following admission to hospital. This prevents the development of expectation that the person may stay in the hospital setting indefinitely. 2 Aims The aim of this policy is to offer guidance to those staff with responsibility for arranging the discharge from hospital of patients who have been assessed by the multidisciplinary team (MDT) as having the need to move into a care home thereby reducing the length of time the person waits to be placed appropriately. 3 Scope The 21 day choice directive applies to all patients who are moving from the acute healthcare setting to a long term 24 hour care placement. Where assessment has Page 1 of 11
shown and the decision agreed by all health and social care professionals along with patient, carers and relatives that the patients needs cannot be met at home or in an alternative supported living environment. 4 Duties (Roles and responsibilities) 4.1 Directorate Manager It is the responsibility of the Directorate Manager to convene a Final Review Meeting if a placement has not been identified within 21 days of the assessment. If, following this Final Review Meeting it is evident that the patient/relative/advocate does not intend to find a placement immediately, it is the Directorate Managers responsibility to advise that the Trust will instigate legal proceedings to ensure that the patient is discharged to an appropriate placement. The Directorate Manager will organise a meeting with the Legal Services Officer, Executive or their deputy and the Adult Services Team Manager to assess the risk and plan the patients discharge. 4.2 Discharge Nurse Specialist The Discharge Nurse Specialist should be notified immediately of any MDT fit patients who have had a delay in their transfer. The Discharge Nurse Specialist will work with the ward and Social Services to expedite the transfer of the patient. If a placement has not been secured within 14 days following the completion of assessment it is the joint responsibility of the Discharge Nurse Specialist/Ward Manager to organise a review meeting with the patient/relative/advocate to agree a discharge plan. If a placement has not been identified within 7 days of the review meeting, the Discharge Nurse Specialist will be invited to a Final Review Meeting by the Directorate Manager to advise on the final discharge plans of the patient. 4.3 Social Worker It is the Social Workers responsibility to organise a best interest discussion where a patient lacks capacity. If no agreement is reached at this meeting it is the responsibility of the Social Worker to organise a formal best interest meeting within 7 days. Following a patient being deemed MDT fit, the Social Worker has the responsibility of providing the patient/relative/advocate with a list of suitable homes, complete the financial assessment and provide the Your Move leaflet explaining the 21 day choice directive. If, after 14 days a home has not been identified the Social Worker will notify the Discharge Nurse Specialist / ward manager to arrange review meeting with the patient and family Once a home has been identified by the patient/ family/advocate the social worker will invite the manager of the home to assess the patient and agree a Page 2 of 11
transfer day. If the assessment takes place after the 21 days then the transfer date should be within 24 hours. If within the 21 days then should be within 48 hours to allow family to personalise the room. 4.4 Ward Manager The Ward Manager has joint responsibility with the Discharge Nurse Specialist to organise a review meeting with the patient/relative/advocate to agree a discharge plan following 14 days of the patient being issued with the 21 day choice directive. The Ward Manager should also organise a MDT meeting if they assess the patients needs to be complex and they feel that finding a suitable placement will be difficult. If, after 21 days from assessment a suitable placement has not been identified, the Ward Manager is responsible for notifying the Directorate Manager of the situation. 5 Process (assessment and planning) The 21 day choice directive is commenced as soon as the MDT, local authority, patient and / or family has agreed that a care home is required for discharge. The 21 day choice directive sets out the agreement with the trust and local authority to support patients and relatives to choose a care home which can meet the patient s needs. Key principles: The needs of patients in relation to any protected characteristics will be taken into account The patient will not be deemed as MDT Fit until the following have been completed A capacity assessment in relation to discharge destination should be carried out and documented An IMCA should be appointed when patients lack capacity and there is no one identified who can represent the patient. Contact Your Voice Counts 0191 4786472 If a patient lacks capacity then a best interest discussion should be organised by Social worker and documented. If as a result of the discussion all parties agree that a care placement is required the patient will be considered MDT fit. However, if no agreement is achieved then a formal best interest meeting will be arranged by the social worker ( within 7 days ) and the patient will not be counted as MDT fit until after the meeting. Considered for Continuing healthcare eligibility and complete a checklist Once patient is agreed as MDT fit Page 3 of 11
At this point the patient becomes delayed in their transfer of care and should be reported to discharge nurse specialist and declared in the weekly delayed transfer of care survey by telephoning patient services 37294 Social worker will provide patients with list of suitable homes, complete a financial assessment and provide the leaflet Your Move and explain the 21 day choice directive. The patient will be asked to make a choice of a home. If this home has no vacancies the patient will be asked to choose another alternative. If this too has no vacancies, the local authority will offer an interim placement, until a placement becomes available at one of the first choice homes Patient should be encouraged to choose a home as soon as possible and understand that this should not exceed 21 days (14 days to identify a care home with a further 7 days for managers to assess and accept and discharge the patients ) After 14 days if a home has not been identified, Social worker and the ward staff will inform the discharge nurse specialist. 6 Guidance to be followed if a placement has not been secured within 14 days following completion of assessment Discharge nurse specialist / ward manager will organise a meeting with the family to discuss progress and agree: o The patient remains MDT fit o That the patient / carers have been given all the necessary information and support to enable an appropriate choice can be made. o If the home of choice has no vacancies or family have not identified a care home, confirm with the social worker that 2 homes with vacancies which can meet the patients needs are available with the area. o Ensure the patient and carers are aware of the risks associated with prolonged hospital stays o Explain to the patient and carers that a further period of up to seven days from the date of the meeting is available to find an appropriate placement (See Appendix 1 for case conference guidance) If an appropriate placement is not available and adult Services have funding responsibility for the patient, then the reimbursement process should be instigated 21 days following the MDT fit date. Non local authority funded patients who will be funding their own placement are the responsibility of the NHS and reimbursement process does not apply. Page 4 of 11
If, due to the complexity of patient needs a suitable placement is difficult to identify a multi- disciplinary meeting should be convened by the ward sister or social worker. 7 Action to be taken if a placement is not identified within 7 days of the review meeting. (21 Days from assessment) If, after the extended time period there are no indications that discharge is imminent, the ward manager should inform the Directorate Manager or their deputy. The Directorate Manager should convene the Final Review Meeting and invite the patient, family or advocate to attend in order to finalise the discharge plans with the Directorate Manager. This should be confirmed in writing and posted by recorded delivery. This meeting should take place within 2 working days of the expiry of the extended period (maximum 21 days from completion of assessments). The Hospital Adult Services Team Manager (if Social Services are involved) and The Discharge nurse specialist may be invited to attend. It is recommended that a minute taker be appointed. If it becomes apparent at this meeting the patient/relative/advocate, do not intend finding a placement immediately, the Directorate Manager must advise that the Trust will instigate legal proceedings to ensure that the patient is discharged to an appropriate placement. The details of this meeting must be sent to all attendees and include the Consultant and relative/carer/advocate. 8 Action to be taken if a placement is not identified within 7 days of the directorate managers final review meeting A meeting should be convened to discuss, assess risk and plan the patients discharge to a care facility which meets their assessed need. Attendees should include the; Directorate Manager Adult Services Team Manager N.U.T.H Legal Services Officer N.U.T.H Executive/Deputy 9 Training No specific training defined for this policy. Page 5 of 11
10 Equality and Diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This document has been appropriately assessed. 11 Monitoring compliance Standard / process / issue Monitoring and audit Method By Committee Frequency This policy will be monitored by an ongoing programme of weekly audit of the delayed discharges reported by the ward staff as being delayed due to awaiting placement in care home or patient or family choice Emergency Care Facilitator and the Discharge Liaison Facilitator on behalf of the Patient Services Manager Discharge review group These will be reported on a weekly basis by the Social Services Team Leaders and presented on a quarterly basis at the Discharge Review Group 12 Consultation and Review The Discharge Review Group have been consulted in this policy review and have agreed all changes and amendments. 13 Implementation (including raising awareness) The Discharge Review Group will disseminate any changes through their user groups. 14 References This policy is based on direction given by the Department of Health in the document, Discharge from Hospital: Pathway, process and practice (2003) and NHS Responsibility for meeting Continuing Health Care Needs (HSG (95)5) NHS Choices: www.nhs.uk/pages/homepage.aspx 15 Associated documentation Hospital Discharge Policy Page 6 of 11
Guidelines for Management of Case Conferences (NHS Staff) Appendix 1 Pre Case Conference Planning Agree at M.D.T the need for a case conference Agree who is to be chair person Agree the persons required to attend Role of Chair person; to arrange the date/time and venue of the case conference. The Chair person will then issue the invitations to the professionals and appoint a minute taker. Case Conference Introduction of attendees Apologies received/(minutes from any previous meetings) Outline the purpose of the case conference Views of the patient (may be given by an informed person) Views of the main carer (may be given by an informed person) Views/reports from professionals involved Outcomes and actions agreed Any other business Any further meetings needed to be arranged by Chair Person Page 7 of 11
YOUR MOVE (To be used in conjunction with the Patient Choice Directive Policy) Moving on from hospital Appendix 2 This leaflet is for you, your relatives and carers. It supports the information you need to make your decision once you are ready to be discharged to a Residential or Nursing care Home. Since you were admitted to hospital, you and the team involved in your care have been working together, with you to assess your needs for health and social support when you leave hospital. It is now agreed by all that your needs may be best met in a Residential or Nursing Care home. We understand that this decision is a major one and one that involves important and significant changes for you, your family and carers. Advice and Guidance for choosing a home Social Workers will offer you advice and guidance about planning your discharge from hospital. This will involve discussing your care needs with you and your family or carers and giving you written information about the homes that can meet those needs. Social workers will also advise you regarding any questions related to funding your placement that you may have. Timescales You will, of course continue to receive care and support while making your choice of home but we must stress the importance of finding a care home which will meet your needs without undue delay. Therefore we will ask you and your family or carers to make a choice of two care homes that are both suitable and available within 14 days of the date it was agreed your care needs could only be met in a Residential or Nursing Care home. We will allow another 7 days for the manager of the care home to make their assessment and arrange transfer of care. Page 8 of 11
Once your choice is made If it seems that the wait for a bed in your initial choice of home will be longer than one week we will support you in choosing an alternative accommodation until a vacancy becomes available in the home of your choice. If you are unable to identify a choice of care home within the time period or refuse the temporary accommodation available, the Trust will be required to take the necessary steps to arrange your discharge to an appropriate place of care. A summary of the hospitals discharge process used in these situations is included in this leaflet. A copy of the Trust policy, The Patient Choice Directive can be accessed via the internet or the ward staff will be able to give you a paper copy on request. Trust staff will do their best to support and help you to move smoothly from hospital to Residential or Nursing Home within these timescales. The Discharge Process and Timescales Your medical condition has resolved, all assessments which are essential prior to discharge are complete ( some assessments may be carried out after discharge ) and the Consultant and staff involved in your assessments agree, along with your relatives and carers that your care needs can best be met in a residential or nursing home. The Trust requires you to choose accommodation as soon as possible which will be available within two three weeks of agreeing your care needs. If you are unable to make a choice within these timescales, the ward team will work with you to help you find an alternative, interim placement. Discharge Review Group January 2014 Page 9 of 11
Appendix 3 Dear ------------------ Re; -------------------- Your ------------ was admitted to ----- on date and is currently an in-patient on ward X at -- ----------- hospital. Your ------ was assessed as medically fit for discharge on date and I understand that there has been an on-going dialogue with you to establish the most appropriate nursing care home to which to admit her. It does appear that this dialogue has become somewhat protracted and I would therefore strongly urge you to resolve this matter as a priority as your --------- no longer requires a bed in hospital. I would therefore be grateful if you would contact Sister ----------, on ward x at -------------- ---- hospital who will be able to provide you with further advice and guidance in order to ensure that - - - - - - is safely discharged from hospital. Yours sincerely Page 10 of 11
Dear date Regarding. Following the Case Conference which was held on at ward Hospital which you attended, it was agreed by the Multi-disciplinary team who have been working with that he/she was fit to be discharged from hospital and all in attendance including yourself agreed with this decision. At this meeting you were made aware of the process the Trust expects you to follow and failure to support in finding an appropriate placement may result in the Trust being forced to pursue the Patient Choice Directive Policy. As it is now 14 days since this agreement was reached we would like to invite you to meet with the same team as on date, time and location to discuss the progress you are making in your selection of a suitable care home for. Please contact on telephone no; on receipt of this letter to confirm your attendance on date, time and location We look forward to hearing from you Yours Sincerely, Page 11 of 11
The Newcastle upon Tyne Hospitals NHS Foundation Trust Equality Analysis Form A This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. PART 1 1. Assessment Date: 15/08/14 2. Name of policy / strategy / service: Patient Choice Directive 3. Name and designation of Author: Dot Kyle, Patient Services Manager 4. Names & designations of those involved in the impact analysis screening process: Dot Kyle, Patient Services 5. Is this a: Policy X Strategy Service Is this: New Revised X Who is affected Employees X Service Users X Wider Community 6. What are the main aims, objectives of the policy, strategy, or service and the intended outcomes? (These can be cut and pasted from your policy) The aim of this policy is to offer guidance to those staff with responsibility for arranging the discharge from hospital of patients who have been assessed by the multi-disciplinary team (MDT) as having the need to move into a care home thereby reducing the length of time the person waits to be placed appropriately. 7. Does this policy, strategy, or service have any equality implications? Yes No X If No, state reasons and the information used to make this decision, please refer to paragraph 2.3 of the Equality Analysis Guidance before providing reasons: The assessment for the requirement of 24 hour care placement is based on the health and social needs of the patient and must be agreed by all health and social care professionals along with the patient, carer and relatives so there is no
opportunity for one group to be discriminated against. 8. Summary of evidence related to protected characteristics Protected Characteristic Race / Ethnic origin (including gypsies and travellers) Sex (male/ female) Religion and Belief Sexual orientation including lesbian, gay and bisexual people Age Evidence, i.e. What evidence do you have that the Trust is meeting the needs of people in various protected Groups by all stakeholders. Interpreters available to support people with limited English by all stakeholders by all stakeholders. Chaplaincy team available for support if required by all stakeholders. Partnership work with MESMAC who work with LGB people and available for advice if required by all stakeholders Does evidence/engagement highlight areas of direct or indirect discrimination? If yes describe steps to be taken to address (by whom, completion date and review date) One problem with care homes that provide care for minority ethnic people is that they fail to adequately address the specific needs of black and minority ethnic older people (such as dietary needs, proximity to community or religious buildings. (Better housing update 2012) No further action The policy states that Social Workers will a list of suitable homes. Staff are not allowed to recommend specific homes where there may be bilingual and culturally sensitive services No Some people of faith may prefer to live in a home specifically relating to the faith they practise. For example 7 out of 10 Jews requiring long-term-care opt for Jewish voluntary sector residential or nursing homes.(religion, Culture and Institutional Care) No further action The policy states that Social Workers will a list of suitable homes. Staff are not allowed to recommend specific homes relating to a person s religion Many older gay people express considerable worries about the future about having to hide their sexual orientation, about having to move into a care home that is designed for heterosexual people and about a lack of opportunity to socialise with other older gay people.(stonewall Working with Older Gay People) No further action The policy states that Social Workers will a list of suitable homes. Staff are not allowed to recommend specific homes relating to a person s sexual orientation No Does the evidence highlight any areas to advance opportunities or foster good relations. If yes what steps will be taken? (by whom, completion date and review date) Social workers may advise on any 3 rd sector support that patients and cares can find; for example the Carers Centre, Health and Race Equality Forum Social workers may advise on any 3rd sector support that patients and cares can find; for example the Carers Centre Social workers may advise on any 3rd sector support that patients and cares can find; for example the Carers Centre; religious centres- available through the Chaplaincy Team Social workers may advise on any 3rd sector support that patients and cares can find; for example MESMAC Social workers may advise on any 3rd sector support that patients and cares can find; for example the Carers Centre
Disability learning difficulties, physical disability, sensory impairment and mental health. Consider the needs of carers in this section Gender Re-assignment Marriage and Civil Partnership Maternity / Pregnancy by all stakeholders Interpreters available to support people who are Deaf. Learning Disability Liaison Nurse available for advice if required by all stakeholders Partnership work with MESMAC who work with Trans people and available for advice if required by all stakeholders by all stakeholders The Winterbourne Review demonstrated that people with a learning disability going into care are more likely than the general population to experience poor care and abuse. No further action The policy states that Social Workers will a list of suitable homes. Staff are not allowed to recommend specific homes relating to a person s learning disability As Sexual Orienation No No Social workers may advise on any 3rd sector support that patients and cares can find; for example the Skills for People Social workers may advise on any 3rd sector support that patients and cares can find; for example the MESMAC 9. Are there any gaps in the evidence outlined above? If yes how will these be rectified? No 10. Engagement has taken place with people who have protected characteristics and will continue through the Equality Delivery System and the Equality Diversity and Human Rights Group. Please note you may require further engagement in respect of any significant changes to policies, new developments and or changes to service delivery. In such circumstances please contact the Equality and Diversity Lead or the Involvement and Equalities Officer. Do you require further engagement? Yes No x 11. Could the policy, strategy or service have a negative impact on human rights? (E.g. the right to respect for private and family life, the right to a fair hearing and the right to education? If patients are required to move to a care home far away from their next of kin, this may impact on their right to a family life.
PART 2 Name: Dot Kyle Date of completion: 15/08/14 (If any reader of this procedural document identifies a potential discriminatory impact that has not been identified, please refer to the Policy Author identified above, together with any suggestions for action required to avoid/reduce the impact.)