Care Coordination and Care Programme Approach Practice Guidance Note Learning Disability Admissions Urgent Care Only V02 Date issued Issue 2 Dec 15 Issue 3 Dec 17 Author/Designation Responsible Officer / Designation Planned review October 2018 CC-CPA-PGN-06 Part of NTW(C) 20 CC/CPA Policy Denise Pickersgill Associate Director Executive Director of Nursing and Chief Operating Officer Learning Disability Urgent Care, North and South of Tyne Assessment and Treatment In-Patients Service Contents Section Description Page No 1 Introduction 1 2 Aims of the Service 1 3 Referral Criteria 1 4 Forms of Admission 3 5 Bed Management 3 6 Admission Process 4 7 Available Assessments and Interventions 5 8 Transfer of Patients between Hospital Sites 5
1. Introduction 1.1 The Learning Disability Services of Northumberland, Tyne and Wear NHS Foundation Trust (the Trust/NTW) provides a total of 24 acute admission beds across two hospital sites Belsay at Northgate and Rose Lodge at Hebburn. Both areas have flexibility in relation to the male / female bed usage depending upon need. 1.2 Admissions will be supported by the Trusts Bed Management Team and allocation to a bed will be arranged depending upon availability, however it is always favoured to have care provided as close to home as possible. 1.3 Beds within this service are often at a premium and access to specialist Learning Disability Assessment and Treatment beds can pose a recurring challenge for the service. 1.4 Wherever possible alternatives to admission should be considered and only those who require assessment and treatment of Mental Health should be admitted. 1.5 Many people with a learning disability can/should be supported within mainstream services and this should always be considered when a hospital based treatment is required taking into account the principal reason for admission being treatment of a mental health condition not the persons learning disability (Green Light Tool Kit). 2. Aims of the Service 2.1 The Learning disability In-patient service aims to provide short term, multidisciplinary assessment and treatment for adults with learning disabilities and mental health problems and for individuals with learning disabilities who display severely challenging behaviour. However, admission solely because of a challenging behaviour or Autism Spectrum Disorder, should wherever possible be avoided and alternatives to maintain well being identified. (Best Practice evidence identifies that admission can result in an increase in challenging behaviour due to raised anxiety and unfamiliar carer staff/surroundings) 2.2 The service does not seek to be a substitute for assessment and treatment by mainstream mental health services where that is appropriate nor for high quality community responses / home treatment approaches. 3. Referral Criteria 3.1 Admissions will only be considered for adults (over 18) with a learning disability. 1
3.2 In this case the following features must be present: Significantly impaired cognitive abilities / presentation (IQ of below 70) Impaired social functioning A history of onset before the age of 18 years 3.3 In addition to having a learning disability the individual would be expected to have either: i) A mental illness (or signs and symptoms requiring further assessment) meeting the diagnostic criteria of ICD 10/DSM IV that results in substantial disability such as an inability to care for themselves independently or to sustain relationships, and be currently displaying symptoms or are suffering from a chronic enduring psychiatric condition. and / or ii) Severe and enduring psychological dysfunction such that their everyday functioning is significantly affected. and / or iii) Challenging behaviour of sufficient severity, frequency or intensity as to seriously jeopardise the safety of the individual or others, or as to seriously limit access to community facilities. 3.4 Clinical indicators of the need for an assessment of any of the above can also trigger admission, however all suitable alternatives should be explored prior to admission. 3.5 It should be noted that where community resources are available and home assessment/treatment is safe and/or practicable this is the first option. 3.6 Where admission to mainstream mental health services is safe and/or practicable (if need be with scaffolding and advice from learning disability staff /Multi-Disciplinary Team (MDT)) this is the preferred option. 3.7 The service is not appropriate for individuals where offending behaviour is the main cause for concern. Referral to Forensic Services should be made in such circumstances. 3.8 Autistic spectrum disorders are not in themselves an appropriate reason for admission, accompanying learning disability and challenging behaviour would make admission possible, however, a referral to the Trusts Specialist Autism services should be considered. Best practice guidance would advise that assessment of challenging behaviour should take place in the home environment. 2
3.9 The service does not provide social care and cannot be considered an appropriate response to placement breakdown or under resourced community provision when there is no requirement for assessment and/or treatment, for example care provider/inability to provide care staff/tenancy agreement revoked due to challenging behaviour. 4. Forms of Admission 4.1 Admissions, wherever possible should be planned and take place within the hours of 9-5 Monday Friday: with the individual receiving support from care staff, community team / Responsible Clinician in order to ensure there is a robust transfer of care which is seamless and safe. b) Emergency admissions occur when there has been no early warning signs of deterioration and the person presents in crisis, the community MDT should ensure that all possible interventions to prevent relapse and maintain care at home are considered and admission to hospital is only considered when all efforts to maintain safety and well being at home have been explored/exhausted 4.2 Patients known to the community service should at the earliest opportunity receive a review of care by the supporting MDT/community team exploring strategies to maintain care safely at home. The In-patient Care team should be invited to attend all relevant MDT meetings where hospital care is being considered and / or consulted at the locality meetings when complex patients are known to be in a crisis situation. 5. Bed Management 5.1 The Trust operates a bed management system and all requests for admission should be made via the Initial Response Team, they will sign post the referrer to the most appropriate person/ service. 5.2 It is essential that the reason for admission, the aim of admission and discharge pathway are explored prior to any admission being agreed, the needs of the patient should be assessed by an NTW Clinician and RiO Core assessment data should be completed including FACE Risk Assessment, Capacity to Consent to Treatment/Admission and Mental Health Act/Deprivation of Liberty (MHA/DOLS) will be considered/documented. 5.3 If admission is required a bed will be allocated by the Bed Management team and the admission process will be commenced 5.4 Ultimately the responsibility for the safe management of a ward falls upon the Ward Manager and in their absence the nurse in charge. The Bed Management Team will liaise with the ward to discuss potential admission or use of a leave bed; at this point it is the responsibility of the ward staff to determine if facilitating admission can be achieved safely. Support required to facilitate admission should be explored and relevant resources obtained. 3
5.5 If no beds are available within the NTW Trust and the patient requires immediate hospitalisation to maintain his or her safety and/or the safety of others, an alternative hospital bed must be identified, this will be supported by the Bed Management Team within working Hours or the Initial Response Team out of hours. 5.6 The patient will be transferred to Northumberland, Tyne and Wear service when the next bed becomes available. 6 Admission Process 6.1 All patients will be formally admitted by a doctor with initial physical and mental state examinations undertaken (these will include capacity to consent to admission, MHA/DOLS) and outcomes documented on relevant RiO screens (Including Physical Health). 6.2 Medication reconciliation should be completed to ensure that the patient s current medications are prescribed on the medicine chart. Allergy status should be clearly documented. 6.3 Mental Health Act Documents will be clearly and accurately completed as per Trust Policy and all relevant data recorded on RiO. All relevant individuals will be informed of the detention. 6.4 All service users to whom CPA/Care Coordination framework and standards applies, will have a Care Coordinator who will co-ordinate their care support and treatment programme throughout all parts of the Trust. Consent must always be sought from a professional prior to them being identified as a Care Coordinator. Under no circumstances must any professional be stated as Care Coordinator without negotiation and agreement. Where only one professional is working with a service user, that person will be the Care Coordinator. 6.5 Care and treatment strategies will be developed by the MDT as outlined in the Trust s NTW(C)20 - Care Coordination and Care Programme Approach Policy 6.6 Care Coordination Meetings will be arranged as per Trust Policy and all relevant information will be recorded on RiO screens. The Patient will be actively involved in their care and treatment with involvement and support of their family and/or carers 7. Available Assessments and Interventions 7.1 Assessment, diagnosis, formulation and interventions are provided by the multi-disciplinary team using a bio-psychosocial and Positive Behaviour Support model of care. 7.2 The multi-disciplinary team will comprise all relevant disciplines required to assess the needs of the patient and develop care strategies. Referrals will be completed to relevant professionals as required to ensure the aims of admission can be fulfilled, the following maybe utilised depending upon need: 4
Psychiatric Assessment and Observation Review of medication Behavioural / Functional assessment. Positive Behaviour Support Plans Nursing and Psychology Assessments and interventions Occupational / Physiotherapy / SALT assessment and intervention Assessment of Daily Living skills Assessment of risk to self or others, devising of risk management plan MHA or Deprivation of Liberty (DOL) Assessment Formulation Based Approaches Discharge and Contingency Planning 8. Transfer of Patients between Hospital Sites 8.1 Patients will be admitted to a specialist learning disability bed, if required the patient may need to be transferred for safeguarding reasons, or to ensure care is delivered as close to home as possible. 8.2 The MDT will discuss the potential transfer of patients and coordinate the transfer of care informing all relevant parties including patient, family and carers. 8.3 If the transfer is contested discussions should take place to negotiate a desirable outcome however if required it is a management decision to transfer patients if maintaining safety is a concern. 8.4 When transfer is agreed all Care and treatment strategies will be communicated within teams and MDT will continue to undertake assessments and interventions to ensure discharge can be facilitated in a timely manner; Transfer should not delay discharge or compromise treatment options. 5