Discharge Policy Discharge Team Page 1 of 73 Document Control Report Title Discharge Policy Author Pathfinder Urgent Care Team Lead Pathfinder Operational Manager Directorate Health and Social Care Department Pathfinder Team Version Date Issued Status Comment / Changes / Approval 1.0 2004 Final Approved by the Clinical Policy Sub Group in Jan 2004. 1.1 Oct 2007 Revision First draft circulated to key stakeholders for consultation and comments. 1.2 Nov 2007 Revision Revisions made in response to comments from stakeholders. 1.3 Jan 2008 Revision Submitted to discharge planning group for initial approval. Amendments made. 1.4 Apr 2008 Revision Submitted to the Discharge Planning group for approval in April 2008. Presented to the Clinical Services Executive Committee for approval in May 2008. 1.4 June 2008 Revision Ratified by the Trust Board. 2.0 June 2008 Final Published on Tarkanet 2.1 Dec 2008 Revision Amended to meet NHS LA Level 1 assessment recommendations. 2.2 Mar 2010 Revision Revision of Policy to incorporate the NHS LA requirements of a definition of patient groups. 2.3 May 2010 Revision Minor amendments by Corporate Affairs to document control report, header and footer, bookmarks and hyperlinks for appendices, and corrected the contents list numbering. Formatted for document map navigation. NHSLA text added. 2.4 Dec 2011 Revision Minor amendments made. Harmonised policy as a result of the merging of Northern Devon Healthcare NHS Trust and NHS Devon community services. A summary of key issues and differences is on page 3. The monitoring section has been strengthened as a result of revised NHSLA requirements. 3.0 Mar 2012 Final Approved by members of the Quality Assurance Committee via email on 23 March following consultation. 3.1 Mar 2012 Revision Minor amendments by Corporate Governance to document control report and formatting. 3.2 Sep 2012 Revision Rewritten by new author team. 3.3 Aug 2013 Revision Revision and addition of flowcharts. Compliance form added as Appendix K.
Transcript
Discharge Policy
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Document Control Report
Title Discharge Policy
Author
Pathfinder Urgent Care Team Lead Pathfinder Operational Manager
Directorate Health and Social Care
Department Pathfinder Team
Version Date
Issued Status Comment / Changes / Approval
1.0 2004 Final Approved by the Clinical Policy Sub Group in Jan 2004.
1.1 Oct 2007
Revision First draft circulated to key stakeholders for consultation and comments.
1.2 Nov 2007
Revision Revisions made in response to comments from stakeholders.
1.3 Jan 2008
Revision Submitted to discharge planning group for initial approval. Amendments made.
1.4 Apr 2008
Revision Submitted to the Discharge Planning group for approval in April 2008. Presented to the Clinical Services Executive Committee for approval in May 2008.
1.4 June 2008
Revision Ratified by the Trust Board.
2.0 June 2008
Final Published on Tarkanet
2.1 Dec 2008
Revision Amended to meet NHS LA Level 1 assessment recommendations.
2.2 Mar 2010
Revision Revision of Policy to incorporate the NHS LA requirements of a definition of patient groups.
2.3
May 2010
Revision
Minor amendments by Corporate Affairs to document control report, header and footer, bookmarks and hyperlinks for appendices, and corrected the contents list numbering. Formatted for document map navigation. NHSLA text added.
2.4 Dec 2011
Revision Minor amendments made. Harmonised policy as a result of the merging of Northern Devon Healthcare NHS Trust and NHS Devon community services. A summary of key issues and differences is on page 3. The monitoring section has been strengthened as a result of revised NHSLA requirements.
3.0 Mar 2012
Final Approved by members of the Quality Assurance Committee via email on 23 March following consultation.
3.1 Mar 2012
Revision Minor amendments by Corporate Governance to document control report and formatting.
3.2 Sep 2012
Revision Rewritten by new author team.
3.3 Aug 2013
Revision Revision and addition of flowcharts. Compliance form added as Appendix K.
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Distributed to stakeholders for consultation. Homeless information added as Appendix M.
3.4 Oct 2013
Revision Amendments as a result of consultation. Homeless information added as Appendix M.
4.0 Nov 2013
Final Offered for approval at Quality Assurance Committee
4.1 March 2017
Revision
Rewritten by Author and new team author. Addition of reluctant discharge procedure.
4.2 April 2017
Revision Distribution to stakeholders for consultation.
5.0 July 2017
Final Approval at Quality Assurance Committee.
5.1 April 2020
Extension This policy has been given an extended review date of six months due to the COVID 19 virus crisis
Main Contact Pathfinder Manager North Devon District Hospital Raleigh Park Barnstaple, EX32 4JB
Tel: Direct Dial – Email:
Lead Director Director of Nursing, Quality and Assurance.
Document Class Policy
Target Audience Ward staff Community Staff
Distribution List Senior Management Compliance Manager
Role of the Multi-Disciplinary Team (MDT) ................................................................ 9
Role of the Doctor responsible for the medical care ................................................. 9
Role of the Ward Manager ......................................................................................... 10
Role of the Nurse ....................................................................................................... 10
Role of the Ward Discharge Coordinator ................................................................. 10
Role of Acute Inpatient Occupational Therapy and Physiotherapy Team ............. 11
Role of the Pathfinder Team ..................................................................................... 11
Role of Head of Clinical Site Services ...................................................................... 12
Role of the Community Health and Social Care Teams, when patients known to them are admitted to hospital ................................................................................... 12
Role of the Rapid Intervention Centre (RIC) ............................................................ 13
Role of Care Direct Plus (CDP) ................................................................................. 14
Discharge planning processes and pathways ................................................................ 14
Pathway 1 Discharge Home ...................................................................................... 15
Pathway 2 Community Rehabilitation Bed ............................................................... 17
Appendix S: Stage 5 Formal Letter .......................................................................................... 67
Appendix T: Equality Impact Assessment Screening Form ......................................................... 68
Appendix U: Process for compliance monitoring (required for NHSLA)....................................... 72
Introduction
This document sets out Northern Devon Healthcare NHS Trust’s system for discharge of patients from hospital, and supports our statutory duties as set out in the NHS Constitution.
The Trust encompasses three different Inpatient Units where discharge takes place. This policy describes a standard process for all inpatient units so that all Staff and patients moving through more than one unit can be confident there is a common process for discharge.
For the majority of patients, discharge from hospital is simple and uncomplicated. Those patients whose needs are more complex however, need to be confident that policy and procedure ensure that their discharge is planned and as uncomplicated as their circumstances allow.
Discharge planning with clear procedures is an essential component of quality health care. It can be a major life event for patients, their families and carers and may also have substantial implications for the use of health and social care resources, as well as for the voluntary sector and other support services.
Efficient discharge planning also ensures effective bed management so that in coming patients can be admitted to the most appropriate ward, avoids multiple patient moves within the Acute Unit thus prolonging hospital stays because of a lack of continuity in care. See the Bed management policy.
For particularly vulnerable people, such as those with Dementia consideration to the time of day to transfer or discharge patients may be key to reducing stress and disorientation to avoid exacerbation of symptoms and risk of harm.
Purpose
The purpose of this document is to ensure adherence to good practice and legislation. This policy is written in accordance with; The Care Act (Department of Health 2014); Ready to Go? Planning and transfer of patients, from hospital and intermediate care 2010; The Community Care Act (Delayed Discharges) 2003; Health and Social Care Act 2012; Achieving Simple, Valuing People Now (DOH 2009).
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This policy describes the process and pathways for timely discharge of all patients from any hospital setting in NDHT.
The policy applies to staff caring for inpatients and day surgery, whilst including Community Health and Social Care Teams with responsibility to track and expedite discharge, for patients known to them.
Implementation of this policy will ensure that the risk to patients from a prolonged hospital stay i.e. infection (see Standard Infection Control Precautions Policy), loss of autonomy, increased dependence or loss of skills is minimised. The policy aims to place patients, relatives and carers (link to Carers Policy) at the centre of planning and discharge from hospital, whilst promoting independence and improving the patient experience .
Definitions
ADL
Activities of daily living
CAD
Community Assisted Discharge
CCD
Clinical Criteria for Discharge: The minimum physiological, therapeutic and functional status the patient needs to achieve before discharge. It should be agreed with the patient and carers.
CCG
Clinical Commissioning Group
CDN
Complex Discharge Nurse, working with multi-disciplinary teams to facilitate discharge for patients with complex needs.
CDP
Care Direct Plus
CHC
Continuing Healthcare; funding source where people are assessed, as having a primary health need.
CRD
Clinically Ready for Discharge.
DCC
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Devon County Council
DILIS
Devon Independent Living Integrated Service
DST
Decision Support Tool – assessment format for establishing eligibility for continuing health care funding (CHC funding)
EDD
Expected Date of Discharge
GP
General Practitioner
H&SCT
Health and Social Care Community Team; multi-agency teams, locality based to manage complex needs within the community.
HOOF
Home Oxygen Order Form
LOS
Length of Stay (in hospital)
MDT
Multi-Disciplinary Team. The generic multidisciplinary team includes ward nurses, discharge planning nurses, doctors and therapists but may also include specialist staff e.g. diabetes, tissue viability and others. Effective MDT working is essential to the discharge process to achieve safe and timely discharge.
OT
Occupational Therapist
RIC
Rapid Intervention Centre: Act as a single point of access for rapid response to prevent unnecessary hospital admission and facilitate timely discharge, coordinates community nurse referrals and rapid response care
SCA
Social Care Assessor in Social services, working in hospital and community settings
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SCR
Social Care Re-ablement
TEP
Treatment Escalation Plan to establish future medical management including resuscitation status.
TTA
To Take Away (medication or other medical items) prepared for the patient to take away with them on discharge.
Responsibilities
Role of the Multi-Disciplinary Team (MDT)
This refers to all the staff involved in the management of patient’s care from admission to discharge.
The MDT must ensure that the patient is the focus of care planning and patient and their carers are involved in discharge planning early in the patient’s stay.
This will: • Clearly communicate the discharge planning arrangements & how treatment
will be managed. • Communicate when the patient should be discharged, ensuring that this is
before midday wherever possible.
Communicate arrangements which need to be put in place for when they
leave hospital.
• Promote confidence that the hospital admission will be kept to a minimum. A crucial factor in this is good communication. Therefore: • All conversations between the MDT and/or patient and/or carers MUST be
recorded in the Multi-disciplinary shared record from A&E through to the ward/s.
• Patients and carers are given an expected date of discharge (EDD) within 48 hours of admission. (Appendix A) The Clinical Criteria for Discharge should be set in conjunction with the MDT for all patients within 24 hours of admission (Appendix A)
Role of the Doctor responsible for the medical care
This Doctor is responsible for: • Identifying (at the earliest opportunity) with the patient and carer the purpose,
expected outcome and anticipated length of stay (LOS). • Establishing a clear documented management plan with the MDT, agreed
with patient, family and/or Carer. • Undertaking regular review of the patient and expected date for being
medically fit for discharge. • Attending MDT meetings as appropriate or daily Board reviews. • Identifying and documenting when the patient is medically fit for discharge, or
transfer of care to another hospital setting. • To refer patients appropriately for onward care either by General Practitioner
or Consultant.
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• Complete discharge summary and prescribe discharge medication (TTAs). Patient Summaries should be written by a doctor who has seen the patient. TTA,s must be written in a timely manner, to ensure they are available prior to expected time of discharge. At the time of discharge, all patients must be provided with a hard copy of the discharge summary ,to include current medications and copied to their GP, Community Health and Social Care Team and receiving hospital .This must be filed and clearly documented in the patient record and will include all patients (including those transferring to a care home)
‘Providers of Health and Social Care services send a discharge summary, including details of the persons medicines, with a person who comes to and from a care home.’(NICE Quality Standard 85).
• NB for patients transferring to Community hospitals Drs should be aware of the limited medical cover and ensure that prescription charts are current for at least 72 hours or more.
Role of the Ward Manager
The Ward Manager is responsible for ensuring: • That practice and effective discharge planning process operates within the
ward/Dept. • That each patient has a discharge plan that is documented in the shared
record and this will be monitored and evaluated from admission. • Full nursing assessment is completed and MDT assessment to determine
care needs where appropriate. • That the holistic plan is agreed with the patient and/or Carer.
Role of the Nurse
The Named nurse each shift is responsible for: • Ensuring effective handover, communication and documentation of patients’
assessment and identified needs and for day to day coordination of discharge. ensuring the clinical criteria for discharge has been set in conjunction with the MDT for all patients within 24 hours of admission. (Appendix A)
• Acting as a point of contact for effective communication for all members of the MDT.
• Confirming on the day of discharge there is no reason why the patient cannot be discharged to another care setting, if appropriate, e.g. infection risk to others (see Outbreak of Infection Policy).
• Coordinating referrals to other hospitals or teams e.g. Community Hospital, Care Home, Practice Nurse and Community Nurses. For Community Hospital Transfer process (Appendix D) and transfer form to be completed, (Appendix E). For Residential or Nursing Home transfer process, (Appendix H)
• Ensuring that the discharge checklist in the Ward Patient Admission, Information and Assessment booklet is used as a record of discharge planning.
• Ensuring that once the patient has been discharged their vacant bed (if it is not in isolation) will be washed by ward staff following the bed washing policy and ready for incoming patient within 30 minutes.
Role of the Ward Discharge Coordinator
- Assess the patients home needs on admission - Plan discharge from day 1 - Facilitate a timely discharge - Act as Key link between pathfinder teams, health and social care teams and
the acute and community nursing and medical teams
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Role of Acute Inpatient Occupational Therapy and Physiotherapy Team
The Inpatient Therapy Team is an integrated team of Occupational Therapists, Physiotherapists and Therapy Clinical Support Workers who are based on all Medical, Surgical and the Orthopaedic Wards. This includes the Medical Assessment Unit and Intensive Care. The Team also receive referrals from the Paediatric Ward, Special Care Baby Unit, Maternity and the Emergency Department for Respiratory patients, hand therapy (Trauma) and Neuro patients. The Therapy Team provide supported discharge services for Neurology, Orthopaedic and the Medical patients. The inpatient Team assess and treat patients who have difficulty with everyday activities e.g. mobilising, stair mobility, getting on – off bed, toilet, chair, washing and dressing, making meals to enable patients to be discharged as safely as possible. • Attend daily board rounds for referrals and to set estimated dates of discharge
with MDT. • Start assessment and treatment prior to patients being medically fit. • Assess and treat patients in pre – operation clinics to start discharge planning
prior to hospital admission. • Patients to have active participation in setting treatment goals linked to
estimated date of discharge. (Patient’s wishes taken into account re discharge plans following clinically fit for discharge guidelines)
• To liaise and work with families and carers. • Complete access visits and home assessment. • Assess and order appropriate equipment for discharge including Respiratory,
Activity of Daily living and Mobility equipment. • Fit collars and braces and teach carers how to help patients manage these in
the community. • Assess for short term or on-going care needs and refer to appropriate agency. • (Therapy representative attend morning tactical meeting.) • Liaise with appropriate and refer onto appropriate agencies and specialist
teams. • Work across wards and community to support patients post discharge.
Role of the Pathfinder Team
Pathfinder is a fully integrated multi-agency team which includes nurses, therapists, social workers, support workers and social care assessors,
Urgent Care Stream:
This stream carries out comprehensive geriatric assessments, including physical, cognitive and social care assessments, for: Complex patients who are expected to be discharged within 48 hours of admission (two-hour response time) Patients attending the emergency department (one-hour response time) They assist and promote the planning, commissioning and co-ordination of services for people over 18 years of age.
Complex Discharge Stream:
The complex discharge stream works with ward multidisciplinary teams to gather information and to establish care needs. Complex Discharge Nurses and Social Care support patients and their relatives/carers throughout the transfer of care process. Assessing, planning and organising the setting up of care and
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placements, for those patients who require face-to-face contact. The team co-ordinate the planning, commissioning and co-ordination of services to enable patients to be transferred to the most appropriate place for them, as seamlessly as possible
• Assist the MDT with complex discharges. • Coordinate assessments for CHC eligibility, fast track, assessment for short
term health funding to expedite discharge from acute setting and advice on completion of CHC checklist, where appropriate.
• Attend case conferences where appropriate. • Timely intervention where support required, within Mental Capacity
assessment and best interest decision making, safeguarding adults and homelessness.
• Reporting delays in transfers of care and validating the CRD SitRep. • Escalating problems with discharge appropriately including Choice of
Accommodation and Reluctant Discharge Policy.
Pathfinder Discharge Nurses: • Co-ordinate community hospital beds, • Assist with inter hospital transfers of care in NDHT and outside North Devon.
Role of Head of Clinical Site Services
The Trust Lead for Patient Flow has overall responsibility for ensuring adherence to this policy and for escalation of any capacity pressures to the appropriate Specialty or Clinical Division. Head of Clinical Site Services – lead for patient flow – is responsible for daily operational management across the site and fulfils a crucial role; fostering excellent communications and working relationships within teams and stakeholders, being the key representative on site for the Director of Operations and Strategy and the Director of Nursing in respect of daily operational management. The role requires expertise in the dynamics of patient flow and an understanding of the inter-relationships of the various teams, professions and departments within the healthcare system; and ensures decisions are patient-focused and have a clinical oversight.
Role of the Community Health and Social Care Teams, when patients known to them are admitted to hospital
The Community Health and Social Care teams are responsible for community assisted discharge.
• Having a duty of care to known patients when they are admitted to an acute or
community hospital to follow them through their hospital journey and expediting timely discharge. Collaborative discharge planning should be undertaken between hospital and community staff and commence within 48 hours of admission.
• H&SC Coordinator or Community Case Manager should make 1st contact with Ward Discharge Coordinator, for known patients, within 48 hours of patient’s admission.
• Information about known patients should always be passed onto the hospital from admission and throughout the patient’s hospital journey. This can be communicated via the Community Nurse and Therapy transfer of information forms found on BOB, H&SC Coordinator updating TrakCare, telephone or face to face contact from Community Professionals. Any direct contact must be recorded in the patient’s notes.
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Community Assisted Discharge (CAD) is appropriate for those patients who are already known to a Health and Social Care Community Service, or they have been known to a H&S Care team, within the past 8 weeks (this includes those waiting assignment of Case Manager) CAD is where there is a need for active community involvement and intervention, which expedites timely and appropriate discharge and reduces length of stay. This involves a proactive approach by Health and Social Care Teams, to interact with hospital staff to facilitate discharge, through sharing of information, joint assessment and planning and where appropriate, providing effective alternatives to inpatient stays.
Role of the Rapid Intervention Centre (RIC)
Rapid Intervention Centre (RIC): Act as a single point of access for rapid response to prevent unnecessary hospital admission and facilitate timely discharge. The RIC coordinators accept referrals over the telephone from 7:00am – 10:30pm from health or social care professionals, such as GPs and Social Workers. The service is able to provide:
Care Home sourcing including obtaining daily capacity of all care homes within North Devon and being the point of contact for all health professionals requiring a care home placement.
Hold Contingency Plans for those vulnerable and frail people who live at home and will utilise these in the event of crisis for that person to prevent unnecessary hospital or care home admission.
End of life coordination of care packages for fast track applications that have been verified by the CHC team.
Community Nurse e-referral coordination from North Devon District Hospital, Community Hospitals and Care Direct Plus. •
Step Up or Step Down Placements – this is a medium term service for up to 6 weeks for people who are recovering from an acute illness or injury, whose conditions would be exacerbated by remaining at home or being discharged home. The care and support is sourced from a local care home as an alternative place to hospital admission.
Rapid Response Care at Home – this is a short term service for up to 7 days. Care at home can be provided for up to 4 times a day and overnight if required, while the next stage of your care is planned and put into place. The care will be provided by skilled Rapid Response Support Workers employed by Northern Devon Healthcare NHS Trust or by care staff provided by local agencies. All areas of Northern Devon are covered from 7:00am to 10.00pm, seven days a week. This service is free of charge to the patient.
Rapid Response Placement – this is a short term service for up to 7 days and offers care and support sourced from a local care home as an alternative place to hospital admission. This service is free of charge to the patient
Night Sits – this is a short term service, only a single night is booked at a time and is provided by local agencies. Further nights can be booked on review of the night sit report and is on individual need of the patient to support someone in crisis as an alternative to hospital admission. This service is free of charge to the patient. For further information regarding the role of Devon Cares – ( http://devoncares.co.uk/ )
Care direct plus is the point of contact for referrals for adults over 18 years old who may need some support on discharge from hospital. This is one of the teams that are part of Adult Social Care services.
The team will be able to give advice on how support could be arranged which may include options for how people can make their own plans or in some circumstances it may be that support will need to be arranged for them.
Care Direct Plus can be contacted via NDDH Switchboard or 01392 381208
0900hrs to 1700hrs Monday to Thursday, Friday 0900hrs to 1600hrs and Saturday 0900hrs to 1700hrs
Social Care Re-ablement (SCR) are able to offer support to people who have recently had a period of illness or injury to help them regain confidence and learn, or relearn skills such as washing, dressing and meal preparation and regain a level of independence. For patients who meet this criteria, a referral should be made via Care Direct Plus. For further information regarding the role of Devon Cares
(http://devoncares.co.uk/)
Discharge planning processes and pathways
The Trust expects that patients will be discharged in a timely manner “right place right time, right care” to minimise the risks associated with prolonged hospital stays and improve the patient experience. Discharge planning with clear procedures is an essential component of quality health care for patients (Dept. of Health Ready to Go? Planning the transfer of patients from hospital and intermediate care 2010). It can be a major life event for patients, their families and carers and may also have substantial implications for the use of health and social care resources, as well as for the voluntary sector and other support services.
Where possible, on or before admission (e.g. at Pre assessment clinic) a Clinical Criteria for discharge (CCD) and predicted Length of Stay (LOS) will be discussed and documented in the patient’s records. Estimated date of discharge (EDD) is the date it is predicted that the patient will be discharged from hospital, based on the average length of stay for this condition or procedure, taking into account any particular needs. During the patients stay this will be reviewed on a regular basis and updated if necessary.
Pathway 1- Home
Discharge Policy Appendix C
Pathway 2 – Community Rehab bed
Discharge Policy App D&F
Pathway 3- Complex assessment
Discharge Policy Appendix H
Patient no longer has care needs that can only be met in Acute Hospital
Patients with simple discharge needs make up at least 80% of all discharges (DoH, 2010) NHS Choices 2013. They are defined as patients who:
Return to their usual place of residence
Involves minimal disturbance to the patient’s activities of daily living
Patient’s needs can be met safely at home.
Unable to return home and patient requires further rehabilitation/reablement.
Unable to return home – patient has complex care needs and may need continuing care.
Reablement service up to
4 weeks
Supported discharge by Acute or Community Rehab Teams.
Community Step Down
Bed.
Discharge Policy App
F
Community Hospital specialist
services/rehab.
Discharge Policy
Appendix D
Care Home short term offer.
Discharge Policy
Appendix H
NHS Community, Social Care or CHC assessments.
Self-Care
Self-Funded
Home Care
Funded Home Care
Self-care at home
Pathway 1
Discharge policy
App C
LA funded care at home
Self-funded care at home
Long Term Care
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Does not require a significant change in support offered to the patient or their carer in the community
Where on-going care/support needs or discharge destination are not in dispute
Time in hospital does not determine whether a patient has simple discharge needs. The key criterion is the level of on-going care required
Efficient processes in which discharge occurs for this large group of patients will have a major impact on patient flow and effective use of the bed capacity.
Where the MDT has agreed that the patient is ready for discharge and that their needs can be met safely at home, follow Pathway 1 (Appendix C.)
Pathway 1 Discharge Home (Appendix C)
Assessment of needs by MDT completed and agreed by patient/carers. Consider equipment needs and refer via DILIS. Consider rehab needs.
MDT agrees patient is ready for discharge.
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Pathway 2 Community Rehabilitation Bed
Patients who no longer have care needs that require acute hospital admission, may still be unable to return home, as they require further rehabilitation/reablement. The MDT should assess and identify patients requiring specialist services of a Community Hospital or rehabilitation services in a step down bed, as early as possible and agree appropriate EDD from acute bedded unit.
For Community Hospital, transferring ward, to refer appropriate patients to Pathfinder Bleep 121 or Pathfinder Office, via NDDH switchboard. Pathfinder Discharge Nurse
Need is the same as before
Yes
No
No need for formal care
Need for formal care. Medically fit for discharge planning/further
rehabilitation
No change to existing
Ring Care Direct Plus on 01392 381208 to restart 72 hours’ notice
Discharge checklist (TTA’s,
discharge summary, transport, referrals)
Discharge
Increase or new (simple)
Consider Acute/Community rehab support required.
Social Care re-ablement as appropriate.
Refer to Care Direct Plus on 01392 381208 giving 72 hours’ notice for care.
Complex discharge planning refer to Pathway 3. Unable to return home due to rehab needs .Refer to Pathway 2
See Appendix D
and F.
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identifies community hospital beds that will become available the same and next day using TrakCare plus/speaking to the community hospitals.
Pathfinder Hospital Discharge Nurse identifies the priority patients on the Community Hospital transfer list to move and liaises with the acute and community wards. Community Hospital Transfer of information form to be completed by transferring ward.
Community Hospital transfer process: see Appendix D and E
MDT to identify suitable patients for step down beds with rehabilitation/reablement needs. Referral made by Ward therapists to the Band 7 OT Therapy lead, to agree appropriateness of patient for step down bed .Once agreed as appropriate, Ward Therapist to telephone Rapid intervention Centre to complete referral.
Step Down Bed Process: see Appendix F
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Community Hospital Transfer (Appendix D) NDDH staff:
MDT identifies patient requiring specialist services of a Community Hospital (as early as possible).
Note Check patient meets criteria for community hospital.
Has patient been identified and agreed with Pathfinder Complex Discharge Nurse (bleep 121) and on waiting list.
Waiting list updated daily on shared drive.
When appropriate fax pre-admission transfer form (appendix H) to appropriate CH
.EDD TrakCare.
NDDH staff – to discuss with patient and obtain consent.
Ward SHO/Consultant referral to care of the elderly staff grade for appropriate handover
Consultant bed.
G.P bed.
Ward SHO/Consultant to give verbal
handover to GP and arrange transfer of
care.
Relative aware.
Daily (Monday – Friday)
Pathfinder Discharge Nurse identifies community hospital beds that will become available the same and next day
using Trakcare plus/speaking to the community hospitals.
Pathfinder Hospital Discharge Nurse identifies the priority patients on the CH transfer list to move and liaises with the Acute and community wards
Ward Dr does discharge summary
and reviews medicines. Clear medical and rehabilitation plans
documented in notes. Up to date TEP
completed for transfer.
Receiving community hospital nurse agrees
transfer with acute ward. Acute ward nurse ensures
verbal handover
Note: Do not transfer patient unless CH has confirmed acceptance
by phone.
Patient transferred with healthcare records, new completed drug chart, at least 4 4 days TTA’s and
any equipment.
New Drug chart sent to pharmacy so that non-stocked items can be
supplied asTTAs.
Transport booked by NDDH staff.
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Patient identified on ward by Therapist for step down placement
(Including project beds and
Moreton Court Pathway)
Referral made by ward therapist to Band 7 OT Therapy Team
Lead to assess appropriateness of patient (Bleep 054 or 022)
Ward therapist to contact locality Complex Care Team
and verbally hand over patient and ensure patient can be
managed on caseload
After assessed as appropriate, ward Therapist/Nurse to telephone
Rapid Intervention Centre to complete referral and alert to placement required.
Placement sourced by Rapid Intervention Centre and most cost effective options that meet patient needs given to ward
therapist to discuss with patient and choose most appropriate.
RIC to produce letters to patient, provider and Complex Care Team.
Therapist to inform RIC of most appropriate care home and contact care home to verbally hand over patient.
If care home then increase price from original amount RIC to pass case to brokerage team to negotiate cost. If negotiation
required Rapid Intervention Centre to the contact ward therapist to inform of final cost and authorisation to continue with step down
discharge.
If query over rehab potential of patient;
community therapist to review patient on the
ward within an appropriate timescale
Step Down Process (Appendix F)
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Pathway 3 Complex Assessment .
Unable to return home, patient has complex care needs and requires a more detailed assessment of needs. Resources and funding may be necessary and this may require referral to other agencies and teams. The person may be discharged to a place other than their usual residence i.e. different domiciliary residence e.g. supported living, sheltered housing, residential home or nursing home .It should only be in exceptional circumstances that a person is placed into a permanent residential placement from an acute setting, unless it is for end of life care.
Complex health and social care needs require detailed assessment, planning and intervention by the multi-professional and multi-agency teams.
Communication is central to the process of managing hospital discharge, commencing as early as possible, throughout a patients stay and following discharge.
Once a patient has been identified as having complex needs and requiring Case Management, they should be referred, via Care Direct Plus, for face to face assessment from Pathfinder or Community Care Manager.
The MDT will interact with patients and/or their family/carers to offer support with any concerns, whilst reinforcing the message that everyone will work towards the patients discharge from hospital. Decisions to accept care or support at home or to live in nursing or residential care are major, and often made during a time of considerable change in personal circumstances including adjustment to disability, increasing dependence and the potential erosion of social networks. They should never be made without fully exploring what is important to the individual and what support may be available to the person, from within their own social and community networks.
For patients who are funding their own care (“self-funding”) they will be provided with the same advice, guidance and assistance on choice as those fully or partly funded by their Local Authority (LA)/Clinical Commissioning Group (CCG).
Any decision made on the individuals behalf by the MDT or a legal representative must be made in the patient’s best interest, in line with the Mental Capacity Act 2005.
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Appendix G Pathway 3 Complex Discharge
For advice/support contact Pathfinder
Complex Discharge Team
Patient needs are substantially different or not effectively met prior to admission
Management plan and MDT agree complex
needs and agree CRD / EDD
Identify need
Home For placement
Go to Appendix H
Increased or new package
of care
In an acute ward less than
48 hours – refer to
Pathfinder Urgent care or ward therapist.
Telephone referral to CDP
Devon Care for access care
package
Equipment need
To Pathfinder or Community Social
Services Manager for face to face assessment
of needs and funding eligibility
Funding application via DCC or CCG (consider
eligibility for 4 week health funding (acute) or CHC funding (community
hospitals))
Request to DILIS
Funding agreed by DCC or CCG
Package of care
confirmed/acceptance by Care Home.
Equipment delivered
Home oxygen need (HOOF)
TTA’s / transport / Referral to
Community Nurses etc.
Home
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Care Home Discharge: Appendix H
Continuing Healthcare
Multidisciplinary Teams (MDT) recommend patients requiring long-term health care, for screening for eligibility for Continuing Healthcare funding. The CHC assessment process
Residential or Nursing Home
discharge being considered
Referral to Pathfinder or
Community Care Manager via CDP
Consider self-funding
Support /Patient
information required -contact
Pathfinder.
Joint Health and Social Care Assessment
Acute unit assessment for 4 week Health
funding via Pathfinder
Social Care Funding
Application via Social Care
Manager
Community Hospital CHC Assessment via Checklist
and DST
1. RIC to source care home
2. Care Home assessment and agree acceptance (ensure patient/relatives involvement)
3. Appropriate panel process to agree funding/Brokerage process.
4. Ensure funding agreed
5. Discharge
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should be carried out in accordance with wider legislation and national policies including the National Framework for Continuing Healthcare Funding (Health and Social Care Act Nov 2012) the End of Life Care Strategy 2008, Long-Term Conditions Policy, Valuing People 2009, and the Mental Capacity Act 2005.
Good practice suggests that assessment for CHC eligibility is not undertaken in an acute hospital setting. If eligibility is indicated the Clinical Commissioning Group (CCG) may agree to four weeks health funding to enable further assessment in a more appropriate care setting for possible CHC funding.
For advice please contact the Complex Discharge Nurses Pathfinder Team.
Within the Community Hospitals, if a possible primary health need is indicated by CHC checklist, completion of the CHC Decision Support Tool is required; Eligibility for CHC funding and a recommendation made for eligibility. Should the patient be successful as eligible for in receiving 100% NHS funded care this will be commissioned and at this point the patient may be discharged to the appropriate setting.
Throughout this process the patient or patient’s advocate should be involved and all stages of the outcomes and communication recorded in the patient’s records.
Should the person be assessed as not meeting the eligibility criteria for CHC funding health funding not be granted, the discharging team will consult with the patient and their family regarding the outcome and the next course of action. A letter accompanies a copy of the Checklist to the patient and/or next of Kin to confirm that assessment for eligibility has taken place and confirming the outcome.
Where a full assessment for CHC is completed the CHC team is responsible for informing the patient of the outcome and process for appeal.
Fast track CHC
A fast track assessment is used to gain access to Fast Track Continuing NHS Healthcare funding, where an individual needs an urgent package of care/ support. This should only be used for individuals who have a primary health need ,through a rapidly deteriorating condition and who are entering a terminal phase .Terminal is used to describe active or progressive disease(s), for which curative treatment is neither possible or appropriate and from which death is certain. A Terminal Phase is when it appears that death is imminent and active treatment of the condition is rejected, in favour of symptom relief and therapy. See Appendix I
The Pathfinder Complex Discharge Nurses will facilitate the discharge of palliative patients to, nursing home or patient’s own home, working with the ward MDT to ensure appropriate community care and equipment in place. The Palliative Care Team and Hospice Nurses will offer advice and support and facilitate discharge to the hospice, where appropriate.
All documentation relating to CHC assessment and eligibility can be found on the Trust’s Intranet (See Continuing NHS Healthcare).
Identified by any clinical team as a person who ‘has a primary health
need arising from a rapidly deteriorating condition which may be
entering a terminal phase’
Care HomeHome
Identify home (NH or RH) Arrange assessment
Agree cost
Involve therapist and Pathfinder etc
RIC to:1. Access Care2. Identify care homes (assessment required to be arranged)
Refer to Pathfinder for discharge planning
Discharge only when: RIC or Pathfinder confirm
acceptance by home or care in place Relatives have been informed Ward have arranged TTA’s,
transport, discharge summary, community nurse referral, others as appropriate
Complete fast track pathway tool,
consent and care plan for NHS
continuing health care (On BOB)
Identify discharge destination with patient / family
Complete fast track tool. CHC team to agree: (Contact number:01769 575123):
Eligibility Funding
Fast Track CHC Flowchart
Discharge requirements, for specific patient groups
A significant number of patient groups will require special considerations when planning discharge. These include:
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Discharge for children on Caroline Thorpe Ward
The NSF for Children and Young People (2004) recognises that the hospital admission of children should be avoided wherever possible, and if admission becomes necessary discharge should be expedited to minimise the psychological impact on the child. Planning for prompt discharge and the prevention of unnecessary re-admissions should be the aim.
The Laming Inquiry (2003) highlighted the importance of discharge decisions and the vital role of thorough multi-agency discharge planning along with the potential disastrous consequences of inappropriate discharge for the child.
Prior to discharge all children must be assessed as clinically fit by a senior doctor. Any safeguarding concerns must have been addressed in full and the parents/carers must have received information to enable them to provide on-going care and the discharge care plan completed.
If a child requires referral to the Children’s Community Nursing Team this should be made prior to discharge, and the parent’s/carer’s consent obtained prior to the referral.
If a child requires referral to the Children’s Community Nursing (CCN) Team a “Community children’s nursing team” referral form must be completed. The parent’s/carer’s consent must be obtained prior to the referral. The parent/carer will be given an information leaflet.
If a child has complex needs a discharge planning meeting, involving all relevant professionals, must be held prior to discharge, allowing time to obtain equipment etc.
If there are any safeguarding concerns, a Strategy Meeting, involving all relevant professionals, must be held prior to discharge.
Effective communication with the child, family and other agencies involved with the child is essential to the achievement of a smooth transition from hospital to home or another location. The following documents must be completed at the time of discharge:
Entry by the discharging doctor in the medical records documenting the discharge decision
Electronic discharge letter (must ideally be completed by the doctor prior to the child leaving the ward. A copy will be given to the parent/carer (and health visitor and school if appropriate), and a copy put in the child’s notes.
nursing discharge documentation must be completed as per the checklist
provide information to the child and parent/carer about any discharge medication and check understanding
provide a telephone point of contact should the parent/carer have any concerns
provide appropriate patient information leaflet relating to the child’s condition and discuss the contents with the child and parent/carer
Health Visitor/ School Nurse (PHN) team can be contacted using the “Referral to Public Health Nursing” form; telephone contact should be made if urgent.
The discharging nurse must ensure that the parents/carers have the ward’s contact number and are aware that they can contact the ward for advice.
For children who have open access to the ward the discharging nurse should ensure that the parents/carers and child where appropriate, have received both verbal and written information regarding the process to follow if access is required.
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Children’s Outpatient Follow Up
It is the responsibility of the discharging doctor to decide whether a follow-up appointment is required and communicate the required follow-up with the nurse. Appointments made after the child has left hospital must be forwarded the family.
Discharge from Special Care Unit (Babies)
Discharge planning begins from the admission of the baby to SCU and onwards. Neonatal nurses begin completing the Neonatal Discharge checklist in the baby’s care plans. Health visitors are informed that the baby has been born and possible date for discharge. The family have regular discharge planning meetings to prepare for their infants’ homecoming. They meet with the Neonatal Outreach team who help them plan for discharge and arrange visits according to outreach criteria.. They are taught parent craft skills and observed in caring for their baby. Children’s centre staff visit weekly to meet and offer information and support that parents can access after discharge. If there are safeguarding concerns they are escalated appropriately and multi-agency strategy meetings held as required to plan and enable support and for the safe discharge destination of the baby.
Prior to discharge:
All clinical devices are removed unless medically indicated.
Parents/carers are encouraged to stay and care for their baby during the day and overnight
Parents/carers are confident with parent craft skills.
Parents/carers receive information and education on administration of infant medication.
Resuscitation training has been offered.
Baby is weighed and this is documented.
Hearing screening has been given (if baby is an inpatient for more than 48 hours).
All babies born less than 30 weeks or less than 1501g require an eye test. The first eye test must be prior to discharge. At discharge it is checked that eye tests are up to date and any necessary follow up arranged.
New-born Blood Spots are up to date. If the baby was 32 weeks gestation or less, a repeat should be taken at 28 days or at discharge whichever is sooner. If the baby is discharged before 6 days old then the first test will be arranged with a midwife.
Infant is up to date with relevant vaccinations.
Discharged examination has been completed by medical staff.
All expressed breast milk is taken home.
Red Health Care Record is completed with relevant details.
Medical staff perform baby discharge check and document.
Nurses check on discharge planning documentation that all requirements are completed and this is updated
If baby is discharged when less than 28 days old, the Community Midwife and Health Visitor will be contacted regarding home circumstances and the discharge plan.
If the baby is discharged when less than 28 days the Community Midwife is informed via Bassett Ward and will make direct contact to arrange follow-up/Midwifery discharge as indicated.
If the baby is discharged when older than 28 days just the Health Visitor is informed and will make direct contact to arrange follow-up. At discharge
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Discharge follows plans made at previous discharge planning/strategy meetings working closely with parents, midwives, health visitors, social workers etc.
Inform Midwives, health visitor, neonatal outreach nurse and social workers of discharge date as applicable.
For midwives complete a referral and leave in community midwives folder on Bassett Ward if the baby is under 28 days old.
Documentation The electronic discharge summary/badger discharge summary should be completed on the day of discharge and 4 copies printed; One placed in medical notes, 2 given to parent/carer (one for them and one for them to give to the Community Midwife or Health Visitor on their first visit) and one sent to the GP. If the baby is discharged under 28 days gestation the parents are given the purple post natal notes and a copy of this is placed in the medical notes.
Outpatient’s appointments will be made via the relevant Consultant’s secretary. This may be arranged prior to discharge or sent to the parents/carer via the postal system.
Identification of person collecting baby for discharge must be established and recorded in the nursing notes.
Parents/carers are given:
Medication
copy of infant’s medication
Purple post natal neonatal baby notes for Midwife if discharged at less than 28 days
2 copies of computerised Badger discharge summary (one for themselves and one for Community Midwife/Health Visitor)
Relevant contact details
Red health care record
Any relevant baby memorabilia e.g. cot card, old ID labels
Security tag and ID labels are removed baby’s identity is confirmed with the parents
Parents/carers are escorted to ward exit by nurse
Document discharge in:
Bed state
Admission/discharge book
Trust computer systems
Badger database
Medical notes
For babies that have been cared for on SCU including those who have had been cared for classed as Transitional care (BABTC) and have been discharged to Bassett ward, the same process is followed by the midwifery staff as above and the medical notes are returned to SCU.
Completed case notes are then sent to Clinical Coding following discharge.
Discharge Process in Maternity Services
Maternity services offer pregnancy care over a continuum of different clinical pathways,
including low risk and high risk complex pathways.
During pregnancy, women may be admitted many times during their pregnancy, labour and
postnatal to an in-patient bed.
The majority of women will be cared for largely in the community environment antenatal and
postnatal, with the majority of women having intra-partum care in hospital.
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For women who have all of their care in the community and give birth at home, the discharge
process will be no different to that of women in an in-patient environment.
The various pathways for ensuring on-going pregnancy and postnatal care are detailed in
the two attached guidelines, which describe the pathway for discharge.
Antenatal care (admissions and discharge) and continued follow up
Women and their babies are not discharged from an in-patient environment, they are
discharged from maternity and midwifery care at the point of a final health and well-being
assessment. This is generally postnatal – during the 28 days postpartum
The discharge process will include referral to the next appropriate health professional. i.e.
Health Visitor.
Homeless Patients
The Trust cannot be responsible for patients that have no home to return to. Therefore patients facing homelessness or who are homeless on admission are informed that Local Authorities may have a statuary obligation through legislation (Homeless Act 2002) to nominate people for housing in accordance with housing need.
Where eligible District Councils will work in partnership with the hospital to resolve the housing problem, but there will be times when suitable housing is not available and an interim solution may be needed. Pathfinder Team are available for support with discharge planning. Please ensure timely referral, identifying potential housing needs on admission. For further information and helpful contacts see Appendix J.
Patients with a Learning Disability
If a patient with a Learning Disability attends as an emergency admission, the Learning Disabilities Liaison Nurse should be contacted. They will offer advice and support during the admission and should be fully involved with the discharge planning process. Patients with a Learning Disability should be fully involved in the discharge planning process. (Valuing People Now DOH 2009). It is essential that the patient’s family or IMCA is part the patient’s discharge plan. Should a key worker or care staff, be it in a care home or supported living be available they should be involved too.
Discharge of patients for whom Mental Capacity, regarding discharge decision making, raises concern & use of Independent Mental Capacity Advocates
Mental capacity is the ability to make a decision.(Department of Health Mental Capacity Act 2005) The Act covers situations where someone is unable to make a decision because the way their mind or brain works is affected, for instance by illness or disability. It includes everyday decisions such as what to wear and more serious decisions, such as where to live.
For those patients it is believed may lack capacity to make decisions regarding discharge, please refer to the Trust’s Mental Capacity Act Policy and ensure documented mental capacity assessment has been completed as part of the discharge process. This should also involve a best interest decision involving relevant family, carers and/or friends. Please refer via Care Direct Plus 01392 381208 for support and further assessment, via Social Care, or contact the NDHT Safeguarding Lead for further information and guidance, via NDDH switchboard.
For patients who are un-befriended and have no one to act on their behalf, except paid carers and for whom a significant change is being considered post discharge (e.g.an accommodation move) an Independent Mental Capacity Advocate should be contacted to act on the patient’s behalf. See the Trust’s Mental Capacity Act Policy.
Discharge of Adults at risk of abuse and neglect
Any safeguarding concerns regarding Adults at risk of abuse or neglect must be referred to Care Direct Plus on 01392 381208 (See the Trust’s Safeguarding Adults Policy). When such patients are fit for discharge from a NDHT Hospital, they must be discharged to an agreed place of safety in conjunction with the person leading the safeguarding enquiry. If unsure who this is contact CDP as above or the Trusts Safeguarding adult lead. .
Discharge of Deprivation of Liberty Safeguard (DOLS) Patients
For any patient being discharged from acute/community hospital care, who has had a
deprivation of liberty safeguard authorisation in place, prior to discharge, staff should ensure
that this has ceased by contacting the supervisory body who is Devon County Council
(01392 381676) (see Trust’s DoLS policy). Placements receiving patients that may require a
DOLS, must apply for authorisation separately from the Supervisory body. The receiving
care home or placement must be made aware of the potential to need a DoLS authorisation
in place.
Safeguarding Children and Young People
When planning discharge, all staff involved in this process, should consider whether the
patient has responsibility for children and if they are able to Care for the child/children, on
their discharge home. Where this may be compromised and there is no other protective
carer available, the professional should act accordingly and share their concerns as detailed
in the Safeguarding Children Policy
Discharge of patients with mental health issues
There are arrangements for patients (discharged from a general hospital setting):
Already receiving support from a Community Mental Health Team.
Who develop mental health issues following admission.
With a known dementia.
The Psychiatric Liaison Team and Community Mental Health Team should be informed of a patient’s admission whether planned or emergency. This team should be involved in the discharge planning process. Patients with a Mental Health problem should be fully involved in the discharge planning process.
All patients should have a treatment plan within 24 hours of arrival.
An expected date of discharge should be set within 24 hours of arrival or in many case before admission for elective patients and communicated to the patient and all staff in contact with the patient.
The expected date of discharge should be proactively managed against the treatment plan (usually by ward MDT) on a daily basis and changes communicated to the patient.
Ward rounds and board rounds should be scheduled in a way that allows at least daily, a senior clinical review of all patients (Dept. of Health Ready to Go? Planning the transfer of patients from hospital and intermediate care 2010).
Purpose of Tactical Meetings – These are twice-daily, led by the Head of Clinical Site Services or Clinical Site Manager to capture the bed state and identify and challenge delays and actions. An action log is updated once daily to provide continuity of communication each day and ensure actions are followed up and completed. The meeting acts as a support for staff to escalate issues they need assistance with; and enables the MDT present to offer their expertise to help resolve or escalate problems. It ensures that across the system staff are aware of the daily capacity pressures and that patient flow is ‘everybody’s business’.
Delayed Transfers of Care (DTOC)
A delayed discharge can be defined as when a clinical decision has been made that the patient is ready for discharge but they continue to occupy a hospital bed .(The Care Act (2014) ) A delayed transfer of care from acute or non-acute care occurs when a patient is ready to depart from such care and is still occupying a bed. A patient is ready for transfer when:
A clinical decision has been made that patient is ready for transfer
AND
A multi-disciplinary team decision has been made that patient is
ready for transfer AND
The patient is safe to discharge/transfer.
All delays in discharge should be reported via the Trust’s TrakCare system to ensure appropriate reporting through the Unify report.
Delayed discharge within the Trust will be reviewed weekly by senior health and social care staff and reported to the Executive team by the Divisional Director The monthly submission obtained from Patient Transfer System is processed in line with the Delayed Transfers of Care Monthly SitReps Definitions & Guidance (NHS England, 2013) (v1.07) from NHS England.
For further advice and appropriate escalation within the Trust contact the appropriate Clinical Matron or Pathfinder Complex Discharge team. Where the patient is reluctant to leave hospital follow the following process.
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Reluctant Discharge Process
At the point at which a patient is ready for discharge or transfer of care, as decided by the MDT, they cannot continue to occupy a hospital bed. No one has a right to remain indefinitely in an NHS bed. If a patient refuses to be discharged from hospital all efforts should be made to secure resolution, by exploring all options. The MDT will identify potential ‘reluctant’ discharges and discuss these within the ward board round and tactical meeting. If the patient is clinically fit, has no on-going care needs, all options have been explored with no agreement and the patient is refusing to leave, the hospital may begin to implement discharge, in an appropriate and sensitive manner.
All discussions and decisions must be accurately and legibly documented. For further support please contact the Divisional Director and Divisional Nurse. The Trusts legal team will be able to offer further advice and support with any formal correspondence, which may be required.
The following framework is relevant to all inpatients that are required to choose a destination and/or care provider on discharge from hospital. The process applies equally to all patients irrespective of funding arrangements for on-going care. (The formal stages of 4 and 5 apply to those patients where appropriate choices have been refused).
This process ensures that Choice is managed fairly throughout the discharge planning process, and that the process is a continuum across organisations to reduce the length of super spells. This requires consistent and timely MDT intervention across all bed based settings. Where choice has become a barrier to discharge and appropriate options have been refused, the organisations will follow the formal stages 4 and 5. Support for the Ward MDT, in following this process will be from the Divisional Director and Divisional Nurse.
The Choice process ensures that:
Hospital beds will be used appropriately and efficiently for those requiring bed based care.
When patients no longer need bed based care they will not remain in hospital if the preferred options are unavailable.
Planning for effective transfer of care, in collaboration with the patient, their representatives and all members so the MDT will begin at or before admission but no later than 24 hours after admission.
The process for offering choice of care provider and/or discharge destination will be followed in a fair and consistent way throughout the acute and community provider. The will be an audit trail of choices offered to the patient.
Where a patient is unable to express a preference, an advocate will be consulted on their behalf.
Managing Choice: The consequences of a patient who is ready for discharge remaining in a hospital bed are that:
The patient is exposed to an unnecessary risk of hospital-acquired infection
Frustration and distress may be caused to patients and/or their relatives whilst waiting for a preferred discharge destination to become available.
The needs of the person can be more appropriately met in a lower-acuity setting, including a non-hospital environment
Decreased level of patient independence, as a bed based environment is not designed to meet the needs of people who are medically well.
Increased pressure within the Health care system due to the unnecessary use of hospital beds.
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The organisation will acknowledge and offer support with any concerns, whether financial or otherwise, whilst reinforcing the message that each member of the MDT will work towards discharge, at the end of the period of care, to a safe destination. This destination may not be the patient’s preferred destination of choice. At the point at which a patient is ready for discharge or transfer of care as decided by the MDT they cannot continue to occupy a hospital bed. No one has a right to remain indefinitely in a NHS bed. If a patient refuses to be discharged from hospital, all efforts should be made to secure resolution by exploring all options. The MDT will identify potential ‘reluctant’ discharges and discuss these within the MDT. If all options have been explored and there is still no agreement, the hospital may begin to implement discharge in an appropriate and sensitive manner. All discussions and decisions must be accurately and legibly documented.
If the patient preferred choice is not available they will be required to accept an alternative location or care provider whilst they await availability of their preferred choice.
People who are self-funding their care will be provided with the same advice, guidance and assistance on choice as those fully or partly funded by the Local Authority. If such patients decline to accept advice, guidance and assistance, a risk assessment will be completed and arrangements will be made for their onward care on discharge from hospital. Once a patient is clinically fit for transfer to their usual place of residence of a less acute setting they will be subject to the Choice process. Where people make an interim move into a care home, their case will be followed up by Pathfinder Social Care Team or allocated Community Care Manager and transferred to a Locality Team to review after 7 days, the interim placement and where possible support a move to the preferred choice care home. If a patient indicates he/she would prefer to stay in the interim care home, either when offered a place in one of the preferred care homes originally chosen or during the waiting process, this can be agreed at the point of review of the Interim placement.
The MDT must ensure that discussion between the patient and their representatives has been undertaken prior to initiating the Choice process. Emphasis should be placed on accessing available support, clarification of the process and the possible need to transfer to an interim placement if the preferred option is not available. The problem remains we are aware of support services that are available but barriers remain e.g. funding disagreements/process of accessing support. The Discharge and Choice Process (described in Appendix K)
Stages 1 to 3 apply to every patient in order to provide support and prevent the need for further escalation.
Stage 1 – Provision of information to patient As part of discharge planning, once the EDD and patient pathway is agreed, and the patient is medically well, the “leaving hospital” patient information letter is issued by the ward staff and documented in the patient record (Appendix L).
Stage 2 – Daily patient review If barriers are identified to effective discharge planning, a case conference will be arranged by the ward, led by the Senior Nurse to include the patient and their representative within 5 working days. The Choice Process will be clearly explained within this case conference. The case conference will clarify the expectations of the patient, family or carer with regards to discharge planning and a further 5 working days will be afforded to engage in the process and prepare for discharge.
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The decision should be documented in the medical notes and a reminder for the stage 2 letter to be issued after the next MDT. If appropriate care arrangements are unavailable due to a lack of vacancies in health or social care organisations, the MDT will discuss with the patient and give the stage 2 letter. If the offered care arrangements are declined, the MDT will arrange a meeting within 3 working days to explore the reasons. At this meeting the patient will be given another 3 working days to arrange an alternative (Appendix M and N).
Stage 3 – Preparing for discharge to include; identification of onward care options, identification of two or more appropriate and available discharge destinations, provision of any outstanding documentation. The destination(s) may not always be the patient or representative’s preference (Appendix O and P).
Stages 4 and 5- represent the Formal Choice process:
Stage 4 – Formal letters; A Transfer of Care letter is sent to the family, carer or patient within 48 hours of failure to comply with the agreed timescales as outlined within stage 2. A list of available onward care options are provided and a request to provide the ward with a decision of 2 options within 10 days. The letter will be prepared and signed by the Divisional Director or Divisional Nurse (Appendix Q and R).
Stage 5 – Formal planned discharge process; If after 10 days there has been no information regarding discharge provided by the patient/ family/carer, a second letter will be issued with either the name of an available care home or care provider that is able to meet the patient’s care needs and a confirmed date for discharge. The patient will be discharged in accordance with this letter. The letter will be signed by the Director of Operations (Appendix S)
Additional discharge considerations
Equipment
Timely referral to the Occupational Therapist is required for all patient equipment needs. If equipment is required to facilitate a safe discharge this should ideally be arranged 3-7 days in advance (before the discharge date), depending on the patient requirements.
Where equipment is required to support community services, such as Carers or Community Nurses, please note care cannot commence, until the equipment has been installed.
Oxygen Therapy
Oxygen for patients being discharged
Ideally all home oxygen should be prescribed by the specialist oxygen team, however GPs and other health professionals can order oxygen via the Part A portal.
www.airliquidehomehealth.co.uk/hcp/portal (link also on BOB under oxygen)
There is no requirement for a password for Part A and prescribers need to follow the steps on the screen.
Part B prescribers are the professionals able to prescribe ambulatory oxygen or to override a previous prescription.
A consent form needs to be downloaded, signed and filed in the
patient records
A risk assessment needs to be downloaded and completed by the
prescriber and filed in the patient notes.
(The consent form and risk assessment form are available on the
portal.)
Please remember oxygen therapy is for any patient that is Hypoxic, a
blood gas with a PO2 level lower than 7.3
All patients discharged home on oxygen must be referred to the
oxygen service for follow up.
Ward co coordinators are asked to contact the oxygen
assessment service as early as possible regarding patients being
discharged on oxygen.
Lead Oxygen Nurse Ext 5811 bleep 633
Respiratory Nurses (Part B prescribers) Ext 3600.
O2 Out of hours Oxygen can still be prescribed to prevent hospital discharge, in the form of a concentrator.
A current oxygen prescription cannot be overridden; this can only
be done by oxygen prescriber.
To order a concentrator to prevent a delayed hospital discharge
log onto Part A electronic HOOF, via the air liquid portal. (see
PDF ) www.airliquidehomehealth.co.uk/hcp/portal
Part B can only be used by oxygen prescribers Ex 5811 and 3600.
In the event of the HOOF being rejected, (usually because the
patient has already some form of oxygen in situ), contact one of
the oxygen prescribers.
For Out of hours contact air liquid by phone and discuss the discharge requirements. You will need to ensure the oxygen assessment service is informed when they are next in the office.
Air liquid professionals help line: 0808 202 2229 should home oxygen be required, a Home Oxygen Order Form (HOOF) must be completed electronically by the clinical specialist Patients should not be discharged until oxygen delivery is confirmed. When arranging transport, oxygen must be made available for patients requiring it during the journey to home or transfer to another hospital Should a patient not have a nebuliser and require one at home, they should be referred to the Specialist Respiratory Nurses via NDDH switchboard for further advice.
Transport Requirements
By giving the patient and relative the planned date of discharge they can make arrangements to collect their relative from hospital on the day of discharge. It is not always appropriate to use private transport. For those patients requiring hospital transport this must be booked as early as possible to facilitate a morning discharge.
The ward nurse should assess the appropriateness of the time of discharge, for each patient.
When booking transport ensure that it is made clear to the transport service whether the patient is able to walk, sit in a chair or require a stretcher. Also ensure that the transport department are aware of those patients who require oxygen or who have any other specific needs that may impact on their transfer for example, steps, lift or narrow doors.
Please remember that approval needs to be sought for any repatriations/out of area journeys as early as possible during the admission.
If a patient is not for resuscitation (DNAR), a copy of the ‘Treatment Escalation Plan’, signed in accordance with the Trust’s Resuscitation Policy must accompany the patient.
Patient property
Please see the Patients’ Property Policy and Procedure.
Healthcare records
If the patient is to be transferred to another site within NDHT, all their records must accompany them. If transfer to another provider, sufficient copies of records must accompany them, to affect a safe discharge and future care. (See the Healthcare Records policy).
Discharge Out Of Hours
Out of hours refers to the hours between 5:00pm & 8:00am, and includes weekends & bank holidays).
All medical teams should identify those who are likely to be ready for discharge over the weekend.
If a patient requires a medical review prior to discharge this should be handed over to the weekend on call team.
Discharge summaries and medication (TTAs) should be written up before the weekend, where possible.
Out of Hours discharges not only apply to the weekend, but transfers to Community hospitals. Consideration should be given to the age of patient, home circumstances and support required post discharge.
Please consider support which may be required from Out of Hours Services (Nursing /Medical) accessed via Devon Doctors on 01392 269467
Self-Discharge (against medical advice)
Patients who wish to self-discharge against medical advice could potentially be at risk. Staff should record that they have informed the patient of the risks in order for the patient to make an informed choice. It is essential that the patient has capacity (DOH 2005) to make this decision in assessing the risk of a ‘Self-Discharge’.
If after all appropriate personnel have been informed and have spoken to the patient, and the patient still wishes to leave, staff should seek advice from the Clinical Site Manager at NDDH.
Patients wishing to self-discharge should be advised to contact their G.P practice, as they may need services or treatment in the community. The doctor will, as with regular discharges, send a discharge letter to the G.P and should contact the G.P or Out of Hours GP, via Devon Doctors 0845 6710270, if they have any immediate concerns.
Nursing staff should inform any appropriate Community Staff (via patients surgery), / Urgent Care Community Nurses (via Devon Doctors), 01392 269467 relatives/carers, Care Direct Plus (if appropriate) and the Manager on Call (Bleep 500).
Following discussions, if the patient still insists on leaving, he/she should be asked to sign a “Discharge against advice form”. In addition the healthcare professional present should also document the patient’s decision and action, in the patient record.
If the patient is under sixteen or deemed to be a ‘vulnerable adult’ and wishes to leave against advice, the nurse should inform the:
Parent or carer
Senior nurse on duty
Doctor, and
The police. If a patient wishes to discharge him or herself because they have a Concern or complaint, all efforts need to be made to resolve the problem in order to allow their care to continue. Further information on dealing with complaints can be sought by contacting the Trust’s Patient Advisory Liaison Service.
Infection Prevention and Control
Criterion 4 of The Health and Social Care Act 2008 Code of Practice on the Prevention and Control of Infections details that “registered providers must provide suitable accurate information to service users, their visitors and any person concerned with providing further support or nursing / medical care in a timely fashion” Therefore relevant information relating to an individual’s infection status that may affect their personal care, or a carers safety must be included in discharge handover communications. Similarly consideration of a patient’s infection status is essential when planning transport arrangements for discharge to ensure the safety of other patient’s using transport and the transport staff. During times of hospital outbreaks of infectious diarrhoea and / or vomiting discharges may be delayed depending on the patient’s discharge destination – particularly if discharge is to another inpatient facility or a care home. In most situations a patient can be discharged to their own home during an outbreak provided they are well enough (even if symptomatic) as long as any household contacts are informed of the outbreak. Care workers must be informed if a care package is in place that the person has been discharged from an affected ward. In most circumstances patient’s should not be transferred or discharged from an affected ward to any other ward, hospital, nursing home residential / care home or other community based institution until they have been 48 hours free of symptoms or the outbreak has been declared over by the IP&C team.
The decision to accept a patient from an outbreak affected area is at the receiving institutions discretion – however in some situations residential care / nursing homes may take individuals during an outbreak after liaison between the discharge co-ordinators, the care home, Public health England and the IP&C team.
The IP&C team / on call microbiologist can assistance with risk assessment of infection issues in relation to discharging patient’s from hospital if needed. Please contact via NDDH 01271 322577.
Pathfinder Team are available to undertake training and up-date sessions on the discharge planning process for NDHT Staff. This includes contributing to the Staff Induction Process, Staff Nurse Development Courses, Ward Managers Forum, and Junior Doctor induction.
Training on specific topics such as up-dates to the Continuing Healthcare Process or new Documentation can be arranged at request.
Signed records must be kept of all training undertaken in the Trust. These records will be held centrally and reported Trust wide through Electronic Record (ESR). Individuals are encouraged to keep a copy of this in their portfolio.
The Development of the Policy
Document Development Process
As the authors, the Pathfinder Manager and Team Lead for Pathfinder Urgent Care are responsible for developing the policy and for ensuring stakeholders were consulted with. The advice of the Equality and Diversity lead must be sought. For NHS Litigation Authority (NHSLA) policies, the author must seek the advice of the Compliance Manager. Draft copies were circulated for comment before approval was sought from the relevant committees.
Equality Impact Assessment
The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. An Equality Impact Assessment Screening has been undertaken and there are no adverse or positive impacts (See Appendix S).
Consultation, Approval and Ratification Process
Consultation Process
The author consulted widely with stakeholders, including:
Clinical Leads/Head of Departments
Health and Social Care Leads
Compliance Manager (for NHSLA Policies)
Discharge Planning Group
Equality and Diversity lead
General Practitioners
Head of Learning and Development
Health and Safety Advisor
Maternity
North Devon Carers Hospital Discharge Group
Out of Hours Services
Paediatrics
Patient Documentation Group
Patient Safety Lead
Head of Clinical Site Services
RIC Manager
SCBU
Senior Nurse for Community
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Senior Nurses
Transport manager
Consultation took the form of a request for comments and feedback via email. Hard copies were available on request.
Policy Approval Process
Approval of the policy will be sought from the Quality Assurance Committee. The policy does not require ratification by the Trust Board in future.
Review and Revision Arrangements including Document Control
Process for Reviewing the Policy
The policy will be reviewed every three years. The author will be sent a reminder by the Corporate Governance Manager four months before the due review date. The author will be responsible for ensuring the policy is reviewed in a timely manner.
The reviewed policy will be approved by the Quality Assurance Committee. If this policy has been identified as required by the NHS Litigation Service (NHSLA), the author will ensure the Compliance Manager is sent an electronic copy. The author must update the Document Control Report each time the policy is reviewed. Details of what has changed between versions should be recorded in the Document Control Report.
Process for Revising the Policy
In order to ensure the policy is up-to-date, the author may be required to make a number of revisions, e.g. committee changes or amendments to individuals’ responsibilities. Where the revisions are minor and do not change the overall policy, the authors will make the amendments, record these in the document control report and send to the Corporate Governance Manager for publishing. Significant revisions will require approval by the Quality Assurance Committee. For NHS Litigation Authority (NHSLA) policies, the author will notify the Compliance Manager when a revision is being made or when the document is reviewed. The Compliance Manager will ensure that the revised document meets the NHSLA/CNST standards. The authors must update the Document Control Report each time the policy is revised.
Document Control
The authors will comply with the Trust’s agreed version control process, as described in the organisation-wide Guidance for Document Control.
Dissemination and Implementation
Dissemination of the Policy
After approval, the author will provide a copy of the policy to the Corporate Governance Manager to have it placed on the Trust’s intranet. The policy will be referenced on the home
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page as a latest news release and staff will be informed that this policy replaces any previous versions. Information will also be included in the weekly Chief Executive’s Bulletin which is circulated electronically to all staff.
Implementation of the Policy
Line managers are responsible for ensuring this policy is implemented across their area of work. Support for the implementation of this policy will be provided by Pathfinder, Senior Nurses/Matrons, Therapy Leads, Lead Clinicians and Health and Social Care Managers.
Document Control including Archiving Arrangements
Library of Procedural Documents
The author is responsible for recording, storing and controlling this policy. Once approved, the author will provide a copy of the current policy to the Corporate Governance Manager so that it can be placed on the Trust’s Intranet site. Any future revised copies will be provided to ensure the most up-to-date version is available on the Trust’s Intranet site.
Archiving Arrangements
All versions of this policy will be archived in electronic format within the Discharge Team policy archive. Archiving will take place by the author once the final version of the policy has been issued. Revisions to the final document will be recorded on the Document Control Report. Revised versions will be added to the policy archive held by Discharge Team.
Process for Retrieving Archived Policy
To obtain a copy of the archived policy, contact should be made with the Discharge Team.
Monitoring Compliance with and the Effectiveness of the Policy
Process for Monitoring Compliance and Effectiveness
The following monitors the discharge process:
Patient Survey
Patient Experience Group
Reviewing data e.g. Delayed Transfers of Care, Readmissions
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Complaints – from patients and other receiving agencies e.g. Primary Care, Nursing home
Incident reports
Adherence to targets and data compiled from monitoring is reviewed at:
Directorate performance meetings.
Activity planning and delivery meetings.
Operational team meetings.
Multi-disciplinary and multi-agency groups at both strategic and operational levels meet to review the discharge process and transfers of care to community and intermediate care services. There is carer representation on the operational group. There is regular monitoring of delayed transfers of care, and appropriate action plans are produced to improve on system issues that delay the discharge process. Readmission data is analysed to ensure this is not due to poor discharge processes. Complaints that raise discharge issues are regularly reviewed and action plans agreed. Information from Patients’ Surveys is reported back through performance meetings and action plans agreed where necessary.
Monitoring Arrangements
Compliance of this policy against all minimum requirements in the NHSLA Risk Management Standards will be monitored on a continuous basis with a continuous rolling audit and assessment of:
Complaints and incidents.
Length of stay.
Delayed discharge.
Re-admissions within 28 days.
Breaches within A&E waiting for a hospital bed.
Responsibility
The Divisional General Managers for Medicine and Paediatrics and Community hospitals will be responsible for monitoring and reporting to the Service Delivery Unit Performance meetings:
Length of stay.
Delayed discharge.
Re-admissions within 28 days.
Breaches within A&E waiting for a hospital bed.
Proportion of morning discharges.
Methodology
Using audit tool attached (see Appendix T).
Reporting Arrangements
The result of audits or other performance data will be reviewed at:
Service Delivery Unit Performance meetings.
Activity Planning and Delivery Group.
Operational Team meetings.
Action plans will be developed to improve compliance and ensure improvements in performance occur. Action plans will be implemented by the heads of department responsible for teams.
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They will monitor progress of the action plan on a monthly basis and exceptions will be reported via this group to the (primary oversight committee or group). Identified risks related to the non-compliance with this policy through audit will be registered on the Trust Risk Register system by the Risk Co-ordinator.
Where non-compliance is identified, support and advice will be provided to improve practice.
References
National Framework for Continuing Health Care Funding (Health and Social Care Act 2012)
The Care Act (Dept. of Health 2014)
The Community Care Act (Delayed Discharge 2003) End of Life Care Strategy (Dept. of Health keep in
(keep in )
NHS Choices (2013). Leaving Hospital - Being Discharged from Hospital (NHS England).
Delayed Transfers of Care Monthly SitReps Definitions & Guidance (NHS England, 2013) (v1.07) from NHS England.
Valuing People Now (Dept. of Health 2009)
Mental Capacity Act (Dept. of Health 2005)
Homeless Act (Dept. of Health 2002)
NHSLA Risk Management Standards
Department of Health (2010) Ready to go? Planning the discharge and transfer of patients from hospital and intermediate care
Royal Pharmaceutical Society (2011) Keeping patients safe when they transfer between care providers – getting the medicines right Pharmaceutical Services Negotiating Committee (2008) Moving patients, Moving medicines, Moving safely: Guidance on Discharge and Transfer Planning
Medicines Management in Care Homes (March 2015) NICE Quality Standard 85 National Institute for Health and Clinical Excellence.
National Service Framework for Children and Young People (DOH 2004)
Laming. William – Report of an Enquiry (Dept. of Ed 2003)
Associated Documentation
Carers Policy
Bed management policy
Choice of accommodation and Reluctant Discharge Policy
Appendix A: Clinical Criteria for Discharge (CDD) & Expected Date of Discharge (EDD)
Expected Date of Discharge (EDD) and Clinical Criteria for Discharge (CCD) are essential care coordination tools mandated by: •The Royal College of Physicians •The Royal College of Surgeons •The Enhanced Recovery Programme •The Keogh Review •The Seven Day Programme
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EDD and CCDs must be clearly defined and used consistently if they are to work effectively. They should be set using simple rules as part of clearly constructed clinical case management plans. The aim is to get the whole multi-disciplinary team aligned to specific ‘objectives’ for every in-patient stay. EDDs and CCDs ‘flush out’ the constraints or waits (both internal and external). It is the rigour with which the ‘constraints’ or waits are identified and proactively managed that reduces length of stay. The guidance in this short paper is based on experience across a large number of organisations and the principles of the ‘Theory of Constraints’. The Process Clinical Criteria for Discharge 1. This is the minimum physiological, therapeutic and functional status the patient
needs to achieve before discharge. It should be agreed with the patient and carers where necessary.
2. The CCD should not be stated as ‘back to baseline’. For example, the BTS/SIGN (British Thoracic Society) guidance 2014 states that there is no one physiological parameter that defines absolutely the timing of discharge. A patient admitted with acute severe asthma who normally runs a PEFR (peak expiratory flow rate) of 90-95% may not need to achieve this level at the point of discharge, but does need to achieve a PEFR >75% with less than 25% variability due to the higher risk of relapse.
3. For patients with frailty or impairments in activities of daily living, the clinical criteria should include functional factors. For example, a patient with dementia and reduced mobility who has a normal exercise tolerance of 25 yards but whose toilet is only 5 yards from their bedroom, may well be fit for discharge if mobile with a frame and supervision of one person for 5 yards. It is important to anticipate that patients will continue to recover at home with or without support.
4. For a proportion of patients, the clinical criteria for discharge can be used to trigger discharge if agreed with the patient and well communicated across the team. For other patients, the CCD is a guide, and ‘sign off’ for discharge by a senior clinician may still be required.
5. The CCD can be a short list of ‘objectives’ and the aim is to keep them simple to act as a ‘aid’ to maintain team focus on the objectives.
Appendix A continued …
Expected Date of Discharge 1. EDDs should be set at the first consultant review and no later than the first consultant
post-take ward round the next morning. If a patient is to be transferred to a ward based specialty team, then the EDD and CCD should be set by the team who will be responsible for their discharge. Crucially, the sooner the patient is identified as in need of sub-specialty care and that sub-specialty team reviews and sets the EDD and CCD, the sooner that patient’s care will be progressed.
2. For patients with an expected length of stay of 2 days or less, it is also appropriate to set an expected time of discharge.
3. It is important that EDDs are set assuming an ‘ideal’ recovery pathway
unencumbered by either internal or external ‘waits’. If the EDD is set embedding anticipated waits and delays in the system (for example waits for clinical decisions, diagnostics, inter-specialty referrals, social care decisions etc.), then these waits become hidden and thus not amenable to resolution.
4. The EDD and CCD are clinical, not managerial, tools. Together with a comprehensive clinical care and discharge management plan, they describe the ‘objective for the admission’. They can be used to co-ordinate care and minimise unnecessary waits in the patient’s journey. The system’s managerial capacity should
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focus on tackling unnecessary waits in support of the clinical team. In most circumstances, it will be the internal waits within the acute hospital that predominate.
5. If a patient’s stay goes beyond the EDD, best practice is to highlight this as ‘EDD +1,
+2’ etc., and identify the constraints that caused the ‘overshoot’ (for example, delays in critical inter-specialty referral responses)
6. The use of Red / Green Bed days at Board Rounds and the implementation of the
SAFER patient flow bundle help teams identify and manage constraints to delivering the EDD.
Appendix B: Home to Hospital Framework
Pathway 1- Home
Discharge Policy Appendix C
Pathway 2 – Community Rehab bed
Discharge Policy App D&F
Pathway 3- Complex assessment
Discharge Policy Appendix H
Patient no longer has care needs that can only be met in Acute Hospital
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Appendix C: Pathway 1 Discharge Home
Patient’s needs can be met safely at home
Unable to return home and patient requires further rehabilitation / reablement
Unable to return home – patient has complex care needs and may need continuing care.
Reablement service up to 4
weeks
Supported discharge by Acute or Community Rehab Teams.
Community Step Down Bed.
Discharge Policy App F
Community Hospital specialist
services/rehab.
Discharge Policy
Appendix D
Care Home short term offer.
Discharge Policy
Appendix H
NHS Community, Social Care or CHC assessments
Self-Care
Self-Funded Home Care
Funded Home Care
Self-care at home
Pathway 1
Discharge policy
Appendix C
LA funded care at home
Self-funded care at home
Long Term Care
Assessment of needs by MDT completed and agreed by patient/carers. Consider equipment needs and refer via DILIS
MDT agrees patient is ready for discharge. Consider rehab needs.
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See appendix D+F
Appendix D: Community Hospital Transfer
Need is the same as before
Yes
No
No need for formal care
Need for formal care. Medically fit for discharge planning/further
rehabilitation
Agree medically fit for discharge and EDD
with the patient/carer.
No change to existing
Ring Care Direct Plus on 01392 381208 to restart 72 hours notice
Discharge checklist (TTA’s,
discharge summary, transport, referrals)
Discharge
Increase or new (simple)
Consider Acute/Community rehab support required.
Social Care re-ablement as appropriate.
Refer to Care Direct Plus on 01392 381208 giving 72 hours notice for care.
Complex discharge planning refer to Pathway 3. Unable to return home due to rehab needs Refer to Pathway 2
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Appendix E: Community Hospital Transfer Form
This is to be completed prior to any transfer by the profession responsible for the transfer of the patient.
Current location of patient:
NDDH staff:
MDT identifies patient requiring specialist services of a Community Hospital (as early as possible).
Note Check patient meets criteria for community hospital.
Has patient been identified and agreed with Pathfinder Complex Discharge Nurse (bleep 121) and on waiting list.
Waiting list updated daily on shared drive.
When appropriate fax pre-admission transfer form (appendix H) to appropriate CH
.EDD TrackCare.
NDDH staff – to discuss with patient and obtain consent.
Ward SHO/Consultant referral to care of the elderly staff grade for appropriate handover
Consultant bed.
G.P. bed
Ward SHO/Consultant to give verbal handover to GP and arrange transfer
Patient transferred with healthcare records, new completed drug chart, at
least 4 4 days TTA’s and any
equipment.
New Drug chart sent to pharmacy so that non-stocked items can be
supplied as TTAs
Transport booked by NDDH staff
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For transfer to:
Reason for transfer Rehab (state potential)
Palliative Care
Complex geriatric Assessment
Awaiting care/ package/ vacancy
Name
Address
Patient informed Next of kin informed
Yes No Yes No
RELEVANT MEDICAL/CLINICAL INFORMATION (Acute) Consultant G.P Diagnosis Past medical history Anticipated progress/future plans (including rehab potential) Medications (please list if e-discharge summary not completed) Further investigations ordered Any equipment needed? E.g. pressure relieving mattress Follow up arrangements (i.e. OPD, SSD) SHO Bleep number
Freedom Trust 01271 321171 free hot meals, clothing (Monday to Friday pm)
Devon Drug and Alcohol Services 01271 344454
Harbour Project Bideford 01237 423891
Care Direct Plus 01392 381208
Cornwall Social Services 0300 1234131
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Information, helpful telephone numbers if you are homeless continued...
North Devon Housing Options 01271 388870 (appointment only)
Torridge Housing Options 01237 428858 (drop in sessions Town Hall Bideford and Appointment) Mid Devon Housing Options 01884 255255 (appointment only)
East Devon Housing Options 01395 516551 (appointment only)
North Devon and Torridge Area
Encompass Southwest 01271 371499
(May be able to support emergency accommodation such as, sleeping bags, clothes, food and support)
Freedom Trust 01271 321171
Monday to Friday 1200 hrs To 1600hrs offer free hot meals, clothing and support.
Care Direct Plus 01392 381208 for advice and information regarding care services.
Cornwall Social Services 0300 1234131 as above for Cornwall Residents.
Devon Drug and Alcohol Services 01271 344454
Harbour Project Bideford 01237 423891
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Stage 1: Provision of information
You should have been given your Estimated Date of Discharge within 24 hours of admission and confirmed at the MDT meeting.
A multi-disciplinary team meeting on the ward agrees the date at which you no longer need to stay in a hospital bed.
We will then discuss this with you and offer an appropriate future care plan to meet your assessed onward care needs as quickly as possible.
Stage 2: Daily review
If your appropriate care arrangements are unavailable due to a lack of vacancies in health or social care organisations, we will discuss and give you a letter explaining this.
If you decline the offered care arrangements, we will arrange to meet with you within 3 working days to explore your reasons.
At this meeting you will be given another 3 working days to arrange an alternative.
Stage 3: Prepare for dischargeAlternative discharge arrangements are agreed with you (this may not be
your preferred choice)Your discharge is arrangedWhere an agreement cannot be reached, the formal Stage 4 and 5 process
will commence.
Stage 4: Formal LettersIf you cannot arrange an alternative within the timescales identified in
Stage 3, you will be given a Stage 4 choice letter with a list of vacancies You will be asked to choose 2 options from this list and inform us of your
decision within 5 days so we can arrange your discharge
Stage 5: Formal planned dischargeIf after 3 days you have not provided us with any information regarding
discharge, we will give you a final letter ‘Formal stage 5’ providing the name of an available care home or provider that is able to meet your needs with a confirmed date for discharge.-We will plan to discharge you as described in this letter.
Appendix K: Discharge and Choice Process/Reluctant Discharge
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Appendix L: Stage 1 - Choice Letter
North Devon District Hospital Raleigh Park
Barnstaple Devon
EX31 4JB
Dear ……………………….. Your Ward Sister / Charge Nurse is: ……………………………….
“You Are Ready to Leave Hospital – What Happens Now?” During your time in hospital your Care Team has made regular assessments of your abilities and needs. We have assessed the help and support you need now with you and have decided you are medically fit to leave the acute hospital. Now you are at this stage, there are good reasons why you shouldn’t stay in hospital:
A hospital ward is not the best place to continue your recovery once your acute illness/ treatment is over
Staying in hospital too long can make you lose confidence
Staying in hospital may increase your risk of acquiring an infection
Other people are in need of this acute bed, we have a responsibility to make sure beds are vacated promptly to free them up for other sick patients.
What happens next? Your team will work with you and/or your family to find an appropriate on going care depending on your needs [Care Package at Home Agency, Residential Home / Nursing Home, Community Hospital] that has a vacancy. We will make every effort to meet your preferences, according to your needs, in your next steps along the discharge pathway. Options are:
If you are waiting for a package of care to support you at home and we cannot
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identify an agency to support you within 3 days, we will ask you to move to a care home to wait for the package of care to become available. Eligibility for possible funding will be assessed.
If you are waiting for a Residential or Nursing Care Home, and the chosen Care Home has no vacancy within 3 days, or the choice becomes a longer process as planned, you will be asked to move to a suitable alternative until your first choice becomes available or you can decide on your final choice.
If you need rehabilitation, we will transfer you to the first available bed, in order to maximise your therapy and rehabilitation opportunities. If this is not a Community Hospital, it is possible for you to receive rehabilitation, funded for an agreed period, in a local care home assessed as suitable to your care needs.
Support will be available throughout the discharge process and you should speak to me if you have any questions or concerns. Most people are able to move once the team have agreed you are medically fit. There may be disagreements about the timing of transfer or the care required and we will work with you to resolve these. We are all here to help and recognise that discharge from hospital can be a difficult and stressful time for patients, families and carers. Yours sincerely, Add in Authorised Signatory and Consultant
Appendix M: Stage 2 - Package of Care Choice Letter
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North Devon District Hospital Raleigh Park
Barnstaple Devon
EX31 4JB Date: ……………
Dear ………………………..
Your Ward Sister / Charge Nurse is: ………………………………. Your Discharge Key Worker is: ………………………………………
You have been a patient hospital since …../…../………. and we are pleased that you are now ready to leave the hospital. We have completed all the assessments and have agreed with you (and your family) that your care needs can be best met with a supportive Package of Care back at home, which may be funded dependant on assessment of your eligibility.
We have not forgotten about you but unfortunately we have not yet been able to find an agency to provide a Package of Care that can meet your needs. We are continuing to check for availability every day and will tell you as soon as an agency is available.
We appreciate that this is a difficult time for you and we recognise your needs no longer require a hospital bed. Therefore, the medical team and discharge key worker have agreed with you (and your family) that it is in your best interests to move to a temporary Care Home placement where you can be in a more settled environment, awaiting the Package of Care to come available. This will be a temporary arrangement only and there will be an assessment for eligibility for funding.
We will now give you a choice of two available Care Homes and would like you tell us your preference as soon as possible, to arrange your move within the next 3 days.
We would now like to proceed with the move as soon as possible and ask you for you cooperation. We are happy to discuss any concerns you have. Yours Sincerely
Care Home Name Care Home Address and Contact Number
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Insert Authorised Signatory and Consultant Signatures
Appendix N: Stage 2 – Care Home Choice Letter
North Devon District Hospital Raleigh Park Barnstaple Devon EX31 4JB
Date: ……………
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Dear: ………………………………………… Your Ward Sister / Charge Nurse is: …………………………………………… Your Discharge Key Worker is: ……………………………………… You have been a patient hospital since …../…../………. and we are pleased that you are now ready to leave the hospital. We have completed all the assessments and have agreed with you (and your family) that your care needs can be best met in a [Residential Care / Nursing Care] Home. We have not forgotten about you but unfortunately we have not yet been able to find a Care Home of your choice, with a vacancy that can meet your needs. We are continuing to check for availability every day and will tell you as soon as the Care Home is available. We appreciate that this is a difficult time for you and we recognise your needs no longer require a hospital bed. Therefore, the medical team and discharge key worker have agreed with you (and your family) that it is in your best interests to move to a temporary Care Home placement where you can be in a more settled environment, awaiting your chosen permanent Care Home to come available. This will be a temporary arrangement only and there will be an assessment for eligibility for funding in which you will be fully involved. We would like to proceed with the move as soon as possible and ask you for you cooperation. We are happy to discuss any concerns you have. Yours Sincerely Insert Authorised Signatory and Consultant Signatures
Appendix O: Stage 3 - Choice letter – Care Home
North Devon District Hospital Raleigh Park
Barnstaple Devon
EX31 4JB Date: ……………
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Dear: ………………………………………………..
Your Ward Sister/ Charge Nurse is: ……………………………………………
Your Discharge Key Worker is: ………………………………………
You have now been a patient in Hospital since …../…../………. and we are pleased that you are ready to leave. We have completed all the assessments and have agreed with you (and your family) that your care needs can be best met in a Care Home. On …../…../………. We discussed eligibility for funding and we asked you to identify a suitable Care Home and gave you information regarding the homes which were assessed as suitable to meet your needs. Unfortunately as yet, you have not told us your decision, so we attach a list of homes with current vacancies. Please be aware that these vacancies may change due to demand for beds. We ask you to identify at least 2 homes from this list as soon as possible, so that the home can make an assessment of you in order for you to move from hospital quickly.
On the (date of stage 2 letter) …../…../………. we wrote to you stating that while you are still waiting for your chosen Care Home to become available, we wanted you to move to a temporary Care Home, however, you have as yet not agreed to this move. We believe this option is in your best interest, as by remaining in the hospital is not good for your longer-term health and well-being. We would ask now that you identify the Care Home, from the attached list, which will be available for you to move to within the next 3 days.
We are happy to discuss any concerns you have but please be aware if you decline the move during the time frame stated above, we will have to take further action. Please address any questions or concerns you may have with your Ward Sister/Charge Nurse in the first instance. Yours Sincerely Insert Authorised Signatory and Consultant Signatures
Appendix P: Stage 3 Letter– Package of Care
North Devon District Hospital Raleigh Park
Barnstaple Devon
EX31 4JB Date: ……………
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Dear: ……………………………………………….. Your ward Sister/ Charge Nurse is: …………………………………………… Your discharge key worker is: ……………………………………… You have now been a patient in Hospital since (date)………. and we are pleased that you are now ready to leave the acute hospital. We have completed all the assessments and agreed that your care needs can be best met with care support at home, with a package of care. On the (date of stage 2 letter) …../…../………. we wrote to you stating that while you are still waiting for your Package of Care to become available, we wanted you to move to a temporary Care Home. However, you have as yet not agreed to this move and we will need to discharge you to the identified Care Home within the next 3 days. We believe this option is in your best interest, as by remaining in the hospital is not good for your longer-term health and well-being. We are happy to discuss any concerns you have but please be aware if you decline the move during the time frame stated above, we will have to take further action. Please address any questions or concerns you may have with your Ward Sister/Charge Nurse in the first instance. Yours Sincerely Insert Authorised Signatory and Consultant Signatures
Appendix Q: Stage 4 Letter – Package of Care
North Devon District Hospital Raleigh Park
Barnstaple Devon
EX31 4JB
Dear …………
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Your ward sister is: ……………………………………………
Your discharge key worker is: ………………………………………
You have been a patient in hospital since …../…../………. and you have been medically fit to leave the hospital since …../…../……….
We asked you in the Choice Letter Stage 2 and Choice Letter Stage 3 to wait for the availability for a Package of Care at home, in a Care Home. We have asked you to choose from the list of Care Homes we provided on …../…..../……..
It has been agreed by the medical team, your discharge key worker and discussed with you that this option is in your best interest, as by remaining in the hospital is not good for your longer-term health and well-being.
However, to date you still have not agreed to the move therefore we would ask that you agree to one of the two care homes listed below.
If, within the next 5 days we have still not confirmed an agency for your Package of Care at home, we will give you a final letter providing you with the name and address of an available Care Home that can meet your needs and your date for discharge from the hospital.
If you wish to discuss this further please contact your ward Sister/ Charge Nurse in the first instance.
Yours Sincerely
Insert Authorised Signatory and Consultant Signatures
Appendix R: Stage 4 – Placement
North Devon District Hospital Raleigh Park
Barnstaple Devon
EX31 4JB Date: …………… Dear: ……………………………………………….. Your ward sister is: ……………………………………………
Care Home Name Care Home Address and Contact Number
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Your discharge key worker is: ……………………………………… You have been a patient in Hospital since …../…../………. and you have been medically fit to leave the acute setting since …../…../………. Unfortunately, we / you have still not been able to identify a suitable Care Home of your choice that can meet your needs. We continue to check for availability every day and we will tell you as soon as one is available. We have asked you earlier in Choice Letters Stage 2 and Choice Letter Stage 3 to reside in a Care Home we have chosen until the Care Home of your choice becomes available. This temporary arrangement will be assessed for eligibility for possible funding. It has been agreed by the medical team, your discharge key worker and discussed with you that this option is in your best interest, as by remaining in the hospital is not good for your longer-term health and well-being. However, to date you still have not agreed to the move and we are asking you again, to please understand the situation and let us move you to one of these two Care Homes as soon as possible, we need to arrange your discharge:
Care Home Name Care Home Address and Contact Number
If, within the next 5 working days we have still not confirmed a Care Home for you or you have not provide us with any information regarding your discharge, we will give you a final letter providing you with the name and address of an available Care Home that can meet your needs and your date for discharge from the hospital.
Continued..
If you wish to discuss this further please contact your Ward Sister/Charge Nurse, in the first instance.
Yours Sincerely
Insert Authorised Signatory and Consultant Signatures
Discharge Policy
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Appendix S: Stage 5 Formal Letter
North Devon District Hospital Raleigh Park
Barnstaple Devon
EX31 4JB Date: …………… Dear: ……………………………………………….. Your ward Sister/ Charge Nurse is: …………………………………………………..
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Your Discharge Key Worker is: ……………………………………… You have been a patient in hospital since …../…../………. your treatment has been completed and you have been medically fit to leave the acute setting since …../…../………. We have asked you in the Choice Letter Stage 2, Choice Letter Stage 3 and Choice Letter Stage 4 to wait in a Care Home we have chosen, until the Care Home of your choice becomes available. However, to date you still have not agreed to move. The Organisation will now arrange for you to transfer to:
Your date of discharge will be …../…../…. unless you have made private arrangements within this time. All members of the ward team are available to answer any questions you may have. Alternatively, if you would like to discuss this decision with a Senior Manager, please do not hesitate to get your Ward Sister/Charge Nurse to contact me I will arrange for a Senior Manager to meet with you. Yours sincerely Director of Operations
Appendix T: Equality Impact Assessment Screening Form
Equality Impact Assessment Screening Form
Title Discharge Policy
Author Hannah Hopkins & Sandra Walsh
Directorate Nursing
Team/ Dept.
Pathfinder Team
Document Class
Policy
Document Status
Review
Issue Date
July 2017
Review Date
July 2020
1 What are the aims of the document?
This document sets out Northern Devon Healthcare NHS Trust’s system for discharge of patients from hospital, and supports our statutory duties as set out in the NHS Constitution. This policy describes a standard process for all inpatient units so that all staff and patients moving through more than one unit can be confident there is a common process for discharge.
Care Home Name Care Home Address and Contact Number
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2 What are the objectives of the document?
The purpose of this document is to ensure adherence to good practice and legislation. This policy is written in accordance with; Productive ward /Community hospital (NHS Institute for Innovation and improvement); the NHS and Community Care Act 1990; the Department of Health Ready to Go? Planning and transfer of patients from hospital and intermediate care 2010; The Community Care Act (Delayed Discharges) 2004; Health and Social Care Act 2012; Achieving Simple, Timely Discharge from Hospital DOH 2004 and Valuing People Now DOH 2009. This policy describes the process and pathways for timely discharge of all patients from any hospital setting in NDHT.
3 How will the document be implemented?
Please describe how this policy will be implemented within our Trust (Published on the Trust Intranet, included in Chief Executives Bulletin, included in Policy Update News, during induction, during/with training, at team meetings, awareness sessions, emailed, new staff will be directed to this policy by their line managers).
4 How will the effectiveness of the document be monitored?
Compliance of this policy against all minimum requirements in the NHSLA Risk Management Standards will be monitored on a continuous basis with a continuous rolling audit and assessment of:
Complaints and incidents.
Length of stay.
Delayed discharge.
Re-admissions within 28 days.
Breaches within A&E waiting for a hospital bed.
5 Who is the target audience of the document?
The policy applies to staff caring for inpatients and day surgery, whilst including Community Health and Social Care Teams with responsibility to track and expedite discharge for their patients.
6 Is consultation required with stakeholders, e.g. Trust committees and equality groups?
Please complete the following table using a cross, i.e. X. Please refer to the document “A Practical Guide to Equality Impact Assessment”, Appendix 3, on the Trust’s Intranet site (Bob) for areas of possible impact.
Where you think that the policy could have a positive impact on any of the equality group(s) like promoting equality and equal opportunities or improving relations within equality groups, cross the ‘Positive impact’ box.
Where you think that the policy could have a negative impact on any of the equality group(s) i.e. it could disadvantage them, cross the ‘Negative impact’ box.
Where you think that the policy has no impact on any of the equality group(s) listed below i.e. it has no effect currently on equality groups, cross the ‘No impact’ box.
Equality Group Positive Impact
Negative Impact
No Impact
Comments
Age X
Disability X
Gender X
Gender reassignment
X
Human Rights (rights to
privacy, dignity, liberty and non
degrading treatment)
X
Marriage and civil
partnership X
Pregnancy, maternity and breastfeeding
X
Race /
Ethnic Origins X
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Religion
or Belief X
Sexual Orientation
X
If you have identified a negative discriminatory impact of this procedural document, ensure you detail the action taken to avoid/reduce this impact in the Comments column. If you have identified a high negative impact, you will need to do a Full Equality Impact Assessment, please refer to the document “A Practical Guide to Equality Impact Assessments”, Appendix 3, on the Trust’s Intranet site (Bob).
For advice in respect of answering the above questions, please contact the Equality and Diversity Lead.
9 If there is no evidence that the document promotes equality, equal opportunities or improved relations, could it be adapted so that it does? If so, how?
Completed by:
Name Hannah Hopkins and Sandra Walsh
Designation Pathfinder Team
Trust Northern Devon Healthcare NHS Trust
Date 1st July 2017
Discharge Policy
Discharge Team Page 72 of 73 Discharge Policy v5.0 Final July 17
Appendix U: Process for compliance monitoring (required for NHSLA)
