(4) Discharge to Long Term Care Settings

(4) Discharge to Long Term Care Settings

Choice Protocol

For Inpatients

Requiring Placement in a

Residential or Nursing Home




Page No.











APPENDIX 1 STAGE 2 NOTES - The Care Co-ordinator Role

APPENDIX 2A Choice Protocol Record Sheet

APPENDIX 2BDischarge Delay Record Sheet

APPENDIX 3ALetter Template -Failed contact at Stage 3 (Follow up call/visit) – 1st letter where patient supported by Carer/Family member

APPENDIX 3BLetter Template -Failed contact at Stage 3 (Follow up call/visit) – 1st letter for patient unsupported by Carer/Family member and with capacity

APPENDIX 4ALetter Template -Failed contact at Stage 3 – second letter for Carers/Family

APPENDIX 4BLetter Template -Failed contact at Stage 3 – second letter for patients unsupported by Carer/Family member and with capacity

APPENDIX 5Letter Template - Delays after 4 weeks where patient/carer/family has been in contact previously, has identified placements but has not identified placement with vacancy and declines interim placement

APPENDIX 6 Choice Protocol Leaflet

APPENDIX 7 Local Unified Assessment Guidance/Policy (not yet available)

APPENDIX 8Guidance Circular NAFWC 46/2004, NHC (2004) 118 - Updated Guidance on National Assistance Act 1948 (Choice of Accommodation) Directions 1993

APPENDIX 9Guidance Circular NAFWC 25/2004, WHC (2004) 024

NHS Funded Care in Care Homes: Guidance 2004

APPENDIX 10A Guidance Circular NAFWC 41/2004, WHC (2004) 54

NHS Responsibilities for Meeting Continuing NHS Health Care Needs: Guidance 2004

APPENDIX 10B Continuing NHS Healthcare: Framework for implementation in Wales 2004

Choice Protocol for Patients Requiring Placement

in Residential or Nursing Home


The choice protocol is for people who are receiving in-patient care in a hospital and have been assessed as requiring long term care in a residential or nursing home.

The purpose of the choice protocol is to achieve a clear, consistent approach for staff, patients and their families to arranging timely discharge to residential and nursing carehomes for in-patients. This will in turn improve patient experience by reducing unnecessary prolonged hospital stays and freeing up beds for other patients.

This choice protocol reflects guidance on choice which indicates that patients do not have the right to occupy an NHS bed indefinitely if they are ready for discharge (see Appendix 8, page 5, Section 1).

The Protocol applies to all patients who have been assessed as requiring long term care in a residential or nursing home excluding those patients eligible for continuing NHS healthcare who do not have a statutory right to choose their accommodation.

The objective of the protocol is to ensure that appropriate care home placements are achieved within a 6 week period of the decision being made that this is the most appropriate place of discharge. Appropriate discharges need to take into account the language and cultural needs of the patient as well as their health and social care needs. This Protocol is only triggered once a full Multi-Disciplinary Team (“MDT”) Assessment has been carried out confirming that the patient is fit for discharge.MDT working provides the following benefits to patients and carers:

  • Better quality decisions – diagnostic and treatment issues can be highly complex and serious. By using all the information from all the team there is less danger of decisions being taken in ignorance of vital data.
  • Clear roles and responsibilities – the allocation of roles and responsibilities is transparent and understood where all team members are together in a team meeting.
  • Greater commitment to the care plan -= ownership of decisions is better when people have participated in the choice of treatment.
  • One team, one voice - the whole team is working to a single treatment plan and is speaking with one voice to the patient and their family. There are few things more disturbing to a patient and families than team members disagreeing over treatment.
  • Mutual support and encouragement – team members can be a source of support and encouragement to each other in environments which re often stressful and pressurised.

The Protocol is therefore laid out in clearly defined steps that identify the roles, responsibilities and actions of organisations and staff at each point in the process. Furthermore, the protocol serves to anticipate needs, identify likely problems and the solutions to those problems at each stage of the process.

Every adult has the right to make his or her own decisions and must be presumed to have capacity to do so unless it is proved otherwise. Every patient has the right to be supported to make his or her own decisions and will be given all appropriate help before it is decided he or she does not have the capacity to make a decision in respect of his or her accommodation. The consent of a patient with capacity must be obtained before consulting with any other person regarding that patient.

Where a patient is assessed as not having capacity to make a decision in respect of accommodation in accordance with sections 2 and 3 of the Mental Capacity Act 2005, decisions will be made in the best interests of the patient in accordance with section 4 of the Act. As far as reasonably practical the patient will be permitted and encouraged to participate as fully as possible in the decision making process.

In deciding what is in the best interests of the patient, the views of others will be obtained and considered, namely:

  • Anyone named by the patient as someone to be consulted
  • Any carer or person interested in the patient’s welfare
  • An attorney appointed under a registered Lasting Power of Attorney
  • A deputy appointed by the Court

The reasons for the decision, how the decision was reached and who was consulted will be recorded in the patient’s records.

Where the patient does not have capacity to make a decision in respect of the accommodation he or she is to be discharged to an Independent Mental Capacity Advocate (“IMCA”) will be appointed unless:

  • The person has previously expressed a wish that a named person should be consulted in such matters, and that person is available and willing to be consulted
  • There is an Attorney appointed under a welfare Lasting Power of Attorney which has been registered
  • A welfare Deputy has been appointed by the Court.

The IMCA will represent and support the person and advise on what is in the patient’s best interests. This advice will be taken into account when making the decision in respect of choice of accommodation in the best interests of the patient.


The Choice Protocol will be adopted for use by the following partners:

North East Wales NHS Trust

Wrexham Local Health Board

Flintshire Local Health Board

Wrexham County Borough Council

Flintshire County Council


The Protocol will be used for all patients who meet all the following criteria:

  • are currently in hospital within North East Wales NHS Trust premises and;
  • are residents in Wrexham, Flintshire Denbighshire, Gwynedd, Shropshire or Cheshire and;
  • are in receipt of a multidisciplinary comprehensive assessment, the outcome of which indicates a care home placement is required either permanently or as an interim measure where major adaptations to a patient’s home have been agreed and will take some time to complete.


STAGE 1 Unified Assessment determining a patient’s needs can most appropriately be met in a care home. The Care Programme Approach (CPA) will also be used in respect of relevant patients with Mental Health needs.

The patient will receive an ongoing multi-disciplinary comprehensive assessment during their stay in hospital, co-ordinated by the Discharge Support Nurse or Ward Nurse. The outcome of this assessment process will indicate the need for a level of intervention and support required by the patient on discharge. It is essential that the multi-disciplinary team have considered and documented that:
all other possible options have been explored, including on going social care at home and all treatment options have been explored
the patient/carer/family/advocate or IMCA have been fully involved throughout the process;
maximum opportunities have been taken to pursue rehabilitation objectives;
it is not possible to support the continued independence of the person in their community, if that is the preference of the patient;
consideration has been given to whether or not an assessment for eligibility for continuing NHS healthcare is required and, if so, a full assessment has been carried out.
The outcome of the multidisciplinary assessment will determine whether the individuals need can be most appropriately met in:
  • Residential care home
  • Nursing care home
Effective assessment is determined upon multidisciplinary working and the various agencies and professionals involved acknowledging their complementary responsibilities and involving patients/carers/family and advocates, including those appointed under the Mental Capacity Act throughout the process. Where appropriate and within the relevant legislation and local policies this will include exchange of written assessments.
STAGE 2 Choice Protocol Triggered
  1. Meet with Patient/Carer/family/Advocate
The Care Co-ordinator (Discharge Support Nurse or Ward Nurse) will explain and discuss with the patient/carer/family the outcome of the multidisciplinary comprehensive assessment, the identification of needs and the options that are now available to meet the patient’s ongoing care needs.
The care co-ordinator will explain the funding implications of the outcome of the assessments.
If the patient does not have the mental capacity to make a decision in respect of the accommodation he or she is to be discharged to, an IMCA will be appointed unless -
  • the person has previously expressed a wish that a named person should be consulted in such matters, and that person is available and willing to be consulted or,
  • there is an Attorney appointed under a welfare Lasting Power of
Attorney which has been registered, or
  • A welfare Deputy has been appointed by the Court.
The term “advocate” is used in this Protocol in respect of all four of the above possible advocates necessary to be appointed for patients who do not have the mental capacity to made a decision in respect of their accommodation.
If the patient/carer/family/advocate agree with the outcome of the multi-disciplinary comprehensive assessment the Choice Protocol is triggered.
If the patient/carer/family/advocate do not agree with the multi disciplinary comprehensive assessment then the choice protocol is not triggered. If the disagreement is in respect of eligibility for NHS Continuing Health Care (CHC) an appeal will need to be dealt with before the choice protocol is applied. If the disagreement is in respect of a decision that the person’s needs would be best met in a care home, if the patient has capacity to make his or her own decision in respect of this issue then the choice protocol is not triggered and arrangements should be made to discharge the patient home with appropriate support, depending on the circumstances. If the family/carer/advocate disagrees with the decision for the patient to be discharged to a care home, and the patient does not have capacity, then although the family/carer/advocate may require additional time in order to consider the outcome of the MDT assessment and the recommendation that the patient be discharged to a care home, the policy would be triggered.
The Discharge Support Nurse or Ward Nursewill explain the choice protocol as laid out in Appendix 1 and then provide the patient/family with the Choice Protocol Leaflet.
Patients/families/carers/advocates must within 4 weeks choose at least three care homes that are able to meet the patient’s assessed needs. One of the chosen preferred care homes must have a vacancy. If the patient/family/carer/advocate refuses to choose a care home with a vacancy as one of the patient’s three choices, arrangements must be made for the patient to move into a care home which does have a vacancy as an interim arrangement. The patient/family/carer/advocate must identify the interim care home at the same time as the three preferred choices. Refusal to choose a care home with a vacancy will not be allowed to prevent the discharge process proceeding.
The partners of the Choice Protocol recognise that a hospital setting is not the best place to make a long term decision about moving into a care home. The patients name will also be placed on the list of the preferred choice even though an interim placement is made. Therefore, while the individual is in an interim care home their care needs will be reviewed and they will have more time to consider their future. The care co-ordinator (member of the Discharge Support Nurse or Social Worker) will be available to help them to move to their first choice of home as soon as a vacancy becomes available, if this is still what the patient/ carer/family still want. If the patient/family/carer/advocate refuse to co-operate with the process, legal advice will be sought and action taken to arrange the safe discharge of the patient to his/her home or alternative accommodation if the patient has capacity or, if the patient does not have capacity, and it is deemed in the patients best interests to an appropriate care home.
  1. Issue Care Plan
The Discharge Support Nurse or Ward Nursewill inform partner agencies that the Choice Protocol has been triggered. The Social Worker or Community Mental Health Nurse or Community Learning Disability Nurse, depending on the status of the patient, will draw up and send a copy of the Care Plan to the patient/family/carer within three working days of the initial meeting.
The Care Plan summarises the findings of the assessment process, laying out the assessed needs of the patient and forms part of the Local Authority Contract of Service Provision. This will allow the patient/carer/family to identify assessed care needs and discuss these with the care homes they visit to ensure the care homes are fully aware of the patient’s care needs and therefore in a position to confirm whether or not they would be able to meet them.

3. Two week phone call/visit

Two weeks into the choice protocol the Discharge Support Nurse or Ward Nurse will contact the patient/carer/family and enquire about progress and any problems that have been identified. This can be achieved through a visit or a phone call. At this time the Care Co-ordinator (Discharge Support Nurse or Ward Nurse) will:
  • assess if there have been any changes in the patient’s health status requiring the patient to be re-assessed. If there are changes that result in an alternative choice of care home being required (e.g. previously residential and reassessed as nursing) then the patient/family/carer will be given the same timescales to identify an alternative placement as a result of the changes.
  • support and advise the patient/carer/family to enable them to resolve any difficulties they have encountered
  • where problems are identified the patient/carer/family should always be asked how long a delay this will cause and ensure that this information is shared with the Multidisciplinary Team;
  • discuss current vacancies in suitable accommodation with the patient/carer/family.
/ Appendix 7: Local UA Guidance (to be attached)
Appendix 10A: NHS CHC Guidance 2004: Para 13
Appendix 1
Appendix 1
Appendix 6
Appendix 8
P7, para 3.12
Appendix 2a
Appendix 8 p7, Section 3.13 & 3.19
  • Notify other members of the multi-disciplinary team of any progress made and document in notes.
  • Patients/carers/families who do not respond to efforts to contact them will be dealt with in accordance with the procedure set out under “Dealing with Delays”
**The outcome of this telephone call/contact must be documented on the Choice Protocol Record Sheet. Further, the Care Co-ordinator must document details, dates and times of all attempts made to contact the patient/carer/family.
4. Completing the Discharge Plan/Funding arrangements
During this four week period the Discharge Support Nurse or Ward Nurse will liaise with appropriate members of the multidisciplinary team and the patient/carer/family to ensure that any additional assessments are completed in response to changing needs in order to develop a ‘Discharge Plan’ for the patient. This will includeensuring that the required financial assessments are completed by the social Worker to ensure that funding arrangements can be put in place.

5.Care Home confirmation

At the end of four weeks the Care Co-ordinator will contact patient/carer/family in order to ascertain which choices have been made and, if none of the three choices have a vacancy, which choice of interim placement has been made.
The Discharge Support Nurse or Ward Nurse will contact the Social Worker, Community Mental Health Nurse or Community Learning Disability Nurse in order to send out a final Care Planto the chosen home with a vacancy and to request the care home undertakes a formal assessment of the patient to ensure that the care home can meet the needs of the patient under Standard 3 of the National Care Home Standards “Prospective service users know that the placement they choose will meet their needs.”
This will entail the registered manager/representative of the care home visiting the patient, and/or the patient or family visiting the care home if he/she has not already done so. The assessment should be completed within one week of patient/carer/family confirmation of chosen vacancy.
  1. To facilitate the arrangement of a meeting between the Social Worker, Community Mental Health Nurse or Community Learning Disability Nurse and the patient/carer/family in 1 week to allow the patient/carer/family to fill in necessary paper work and sign agreements where appropriate with the Local Authority confirming arrangements.
  1. Finalising arrangements
Following final care home confirmation, final paper work should be filled in and agreements signed as required.
7. Discharge/transfer
It is only at this point that the patient is ready for discharge from hospital, it is expected that this will occur within 2 working days of all paperwork and agreements being finalised.
The whole process should be completed within 2 weeks of the Care Co-ordinator’s meeting with the family at Week 4.
**Any delay past this point will be recorded as a Delayed Transfer of Care** / Appendix 2a