Swansea Nhs Trust

SWANSEA NHS TRUST

SWANSEA LOCAL HEALTH BOARD

CITY & COUNTY OF SWANSEA

ALL WALES AMBULANCE TRUST

DISCHARGE PLANNING POLICY/GUIDANCE

Originator / Swansea NHS Trust and Partners Discharge Planning Review Group
Original Date / November 2003
This Revision / 2007
Next Review Date / January 2008
Review Body / Swansea NHS Trust and Partners Discharge Planning Review Group
Approved by / Swansea NHS Trust Executive Board
Partnership Organisational Approval in March 2007
Date of Approval / December 2007
Policy Number
Classification / Corporate
CONTENTS

TITLE PAGE Section 1 - Framework– Introduction 4

Section 2 - Procedures forScheduled/Non – Scheduled 11

Admissions

Section 3 - Discharge where there is a Lack of Mental 19

Capacity

Section 4 - Information Sharing Protocols 21

Section 5 - Unified Assessment and Care 24

Management

Section 6 - Care Programme Approach 29

Section 7 - Information for Families and/or Carers 32

Section 8- Commissioning of Long Term Health and Social 33

Care

Section 9 - Choice of Accommodation 36 Section 10 - Discharge of Vulnerable People 38

Section 11- Discharge of Homeless People 40

Section 12 - Discharge of Children and Young People 41

Section 13 - Discharge from Accident and Emergency 50

Department

Section 14 - Discharge against Medical Advice 52

Section 15 - Multi-agency, Multi-disciplinary Training 53

Section 16 -Audit Arrangements 54

Appendices

Appendix - 1 Definition of Terms

2UAP Assessment Documentation

2b UAP Guidance

3Discharge Planning Integrated Care Pathway (DCICP)

3a DCICP Flowchart - Trust

3b DCICP Flowchart - Local Health Board

4 Role of the Care Coordinator

5 Communication Protocols – Interdisciplinary referral

for Discharge Planning(CPIR) – Welsh Ambulance

Service

5a CPIR - Intermediate Care

5b CPIR - Community Paediatric Physiotherapy

5c CPIR - District Nursing Service

5d CPIR - Swansea Palliative Care Team (SPICE)

5e CPIR - Health Visiting Services for Children

5f CPIR - Health Visiting Services for Older People

5g CPIR - Homeless Outreach Nursing Service

5h CPIR - Leg Ulcer Clinic – Community

5i CPIR - Orthopaedic Bridging Team

5j CPIR - Traumatic Brain Injury Service

5k CPIR - Burns Outreach service

5l CPIR - Speech and Language Therapy - Adult

Service

5mCPIR - Occupational Therapy – Inpatient Adult

Services

5n CPIR - Liaison District Nurse Accident and

Emergency Department

5o CPIR - COPD Early Discharge Team SATS

5p CPIR - Welfare Benefits Project Age Concern

Swansea

5q CPIR - Home Services Project Age Concern

Swansea

5r CPIR -AgeConcernSwanseaHospital Discharge

Service

5s CPIR - Housing Information Project Age Concern

Swansea

5t CPIR - Advice Information and Advocacy Service

Age Concern Swansea

5uCPIR - Supporting People Project Age Concern

Swansea

5v CPIR - Age Concern Luncheon Club Swansea

5wCPIR- SocialServiceDepartmentCity and County

of Swansea

5x CPIR - Ty-Olwen Specialist Palliative Care Service

5y CPIR - Asylum Seekers Team

5z CPIR - Chronic Disease Conditions Nurses

6Blaylock Assessment Tool

7Discharge Leaflet

8Contact List – Health Visitors/District Nurses –

Bromorgannwg Trust

8a Contact List – Social Services Neath and Port Talbot

Social Services Department

8b Contact List – Health Visiting/District Nursing

Swansea NHS Trust

8c Chronic Disease Conditions Nurses Contact List

9LHB Submission Pack

10 Transfer of Care Form, Checklist

10a Transfer of Care Form, Multidisciplinary Care Plan

10b All Wales Transfer of Care Form (Repatriation only)

10c Paediatric Transfer of care Form

10d Discharge Summary

10e Medication Counselling for Patients on Discharge

10f Procedure for Nurses Operating Medicines

Management Ward

10g Procedure for Processing a TTO on a “Patients Own

Drug” Ward

11 Discharge Lounge Operational Plan

12 DToC Arrangements

13 Bed Management Policy

14 Escalation Policy /Flowchart

15 Repatriation pf Patients Escalation Pathway

16 Mental Capacity Act, Summary

17 UAP Continuum

18 Discharge Poster

18a Information Sharing Protocols

19 Choice of Accommodation Policy

19aChoice Flowchart

20 Hospital Discharge Protocols – Joint Agreements

20aSocial Services Timescales for assessment – Neath and

Port Talbot

20bSocial Services Timescales for Assessment – City

and County of Swansea

21 Choice Policy Patient Letter 1

21aChoice Policy Patient Letter 2

21bChoice Policy Patient Letter 3

22Discharge Against Medical Advice Form

23DPICP Variance Tracking Record

24Concerns Relating to Transfer/Discharge, Form

25Resource Document File

SWANSEA NHS TRUST

DISCHARGE PLANNING POLICY

SECTION 1 – FRAMEWORK

1. INTRODUCTION

This policy has been developed in response to WHC (2005)035 “Hospital Discharge Planning Guidance” and the need to ensure Swansea NHS Trust has an up-to-date, robust and clear process in place for planning patient discharges. The document has been developed with partner agencies to ensure joint working, communication and collaboration are fundamental to planning patient’s discharges.

This policy also reflects the changes in commissioning arrangements and the statutory requirements for partnership working between the NHS and local authorities operating from April 2003 as well as changes following the full implementation of NHS funded nursing care (2004), updated Continuing NHS Health Care guidance and Framework for Implementation (August 2004), updated Guidance on Choice (September 2004), and the ongoing introduction of Unified Assessment.

1. CONTEXT

WHC(2005)035 requires Trusts, working closely with all relevant local authorities, commissioners and the Welsh Ambulance Services Trust, and in liaison with voluntary and non-statutory partners to ensure that:

Local policies related to discharge planning comply with the requirements of the guidance and reflect multi-agency and multi-professional planning, development and implementation with explicit implementation and monitoring strategies to support this;

Multi-agency policies and supporting protocols utilise and reinforce the Unified Assessment process as the main instrument to deliver effective discharge arrangements and subsequent arrangements to meet ongoing care needs;

All relevant staff are fully conversant with both the requirements of this guidance and the operation of local multi-agency discharge policies and supporting protocols;

Front-line staff are regularly updated and receive training appropriate to their needs related to assessment and the discharge planning process in order to deliver effective discharge planning arrangements;

Information in an appropriate format is developed and provided specifically aimed at patients, carers, relatives and those staff who will be providing ongoing care on discharge from hospital, to explain the operation of local discharge planning arrangements.

1. DEFINITIONS

Definitions of all key terms used in this document are contained in Appendix 1

1. SCOPE OF THE DISCHARGE PLANNING FRAMEWORK

This framework covers all adults and children in the care of Swansea NHS Trust. However due to the different requirements and additional considerations of discharging children, details of these processes are included in a separate section of this document.

This policy should be read and implemented with reference to all other Welsh Assembly Government guidance relevant to assessment and discharge planning, and guidance specific to service groups such as mental health and learning disabilities. Particular reference should be made to:

WHC(2004)024 / NAFWC 25/2004: NHS Funded Nursing Care in Care Homes Guidance

WHC(2004)54 / NAFWC 41/2004: Continuing NHS Health Care – Guidance and Framework for Implementation in Wales

WHC(2002)32 / NAFWC 09/2002: Creating a Unified and Fair System for Assessing and Managing Care

WHC(2004)066 / NAFWC 46/2004: Guidance on National Assistance Act 1948 (Choice of Accommodation Directions 1993)

Mental Health Policy Guidance: The Care Programme Approach for Mental Health Service Users, A Unified and Fair System for Managing Care, February 2003

Learning Disability Strategy – Welsh Office Guidance 1994; Section 7 Guidance on Service Principles and Responses, August 2004.

WHC (2005)013: Standard Procedure for the handover of Elderly Mentally Infirm Patients between NHS Trusts and the Welsh Ambulance Service.

1. COLLABORATIVE WORKING

Effective multi-agency and multi-professional working is essential to ensure the successful management of discharges from hospital. Decisions on further care requirements following hospital discharge are based upon professional assessments of health, social care and other related needs, taking into account the patient’s views and consideration of the views of relatives, advocates or others who know the patient well, within the context of Unified Assessment. It is essential therefore that the input from professionals and others to these assessments is coordinated effectively and in a timely and responsive manner. The development of the agreed joint local protocol outlined in a later part of this document will help to ensure these outcomes. Similarly, it is important to deliver services in a coordinated way to ensure there are no gaps in services or duplication of efforts.

Effective partnership working will support the implementation of Unified Assessment and enable effective assessments to be undertaken to inform safe discharge and future care planning.

Effective communication at all levels and across all organisations, including relevant non-statutory agencies is necessary for the patient to experience a coordinated patient journey from pre-admission through to hospital discharge.

1. KEY PRINCIPLES

The following are the key principles of discharge planning in Swansea NHS Trust which are reflected in the local multi-agency policies and supporting protocols outlined later in this policy:

Planning for hospital discharge must begin at, or in the case of elective admissions before, admission to hospital. It should be considered as a process not an event. The process of planning discharge from hospital needs to operate concurrently with clinical care. This helps to ensure that patients clinically fit for discharge – determined by the clinician responsible for the inpatient care, in consultation with all necessary colleagues in the multidisciplinary and multi-agency team – are able to be transferred to the next stage of care in an appropriate and timely manner.

The discharge policy must be implemented within the framework, context and principles of Unified Assessment and the Care Management Approach. In the event of patient transfer, either to another ward within Swansea NHS Trust or to another ward in a different Trust, The assessment information collated to inform care planning must be shared with the receiving area to avoid duplications of assessment and potential extended lengths of stay.

Planning for hospital discharge requires the input and engagement of all appropriate members of the multi-disciplinary and multi-agency team. In addition to Trust and local authority staff, it is important that this includes the Welsh Ambulance Services Trust and voluntary / non-statutory partners.

Hospital discharge planning is a continuous process that takes place seven days a week. Whilst not all members of the multi-agency team may be available on this basis, communication, coordination and planning can and should continue. This will be particularly significant in planning simple / non-complex discharges which comprise the majority of hospital discharge arrangements.

The individual’s interests and wishes are central to the hospital discharge planning process and are taken into account when considering future care options. The assessment and discharge process must be person centred and involve regular consultation with the patient and his / her family / carer / advocate, and where appropriate paid care staff or providers of services.

The hospital discharge process should be coordinated by a named person who has responsibility for coordinating all stages of the patient’s journey. The further development of integrated care p[pathways will facilitate and support the management of discharge arrangements as an ongoing process.

All patients should be provided with an Estimated Date of Discharge on admission, or for elective patients, at pre-admission, reviewed and amended as necessary. Predicting the length of stay is fundamental to timely discharge. The provision of a documented discharge date allows families and carers the opportunity to plan for discharge and can reduce the demand for hospital transport, including reducing demand for ambulance transport.

A whole systems approach to assessment, commissioning and delivering services will facilitate effective hospital discharge arrangements. Implicit within this is an ethos of multidisciplinary and multi-agency working, to include housing, support and other needs which relate directly to the individual’s health and well-being.

The ability to discharge effectively is dependent upon the availability of a range of services to meet ongoing or longer-term care needs.

A review should be carried out to ensure all arrangements are in place on the day of discharge. This should include ensuring all equipment, transport, medication and ongoing needs for services have been identified, planned for and met in a timely manner. The ability of the patient to manage their mediation at home should be assessed and arrangements made as appropriate to ensure ongoing compliance.

This document clarifies roles and responsibilities for each professional group including responsibilities for coordinating all staff involved in the discharge process, both directly within the hospital and within community settings.

Patients and their families and / or carers will be provided with written and verbal information in a range of formats appropriate to them, taking into account any sensory or spoken language needs. The information should include details of arrangements and any relevant information regarding their future treatment and care.

Local audit arrangements, as outlined later in this document, will be operated to ensure this discharge policy and supporting procedures are consistently and effectively implemented and applied. This includes user feedback and will be considered within the context of continuous improvement and the wider clinical governance responsibilities of Swansea NHS Trust and its relevant Local Health Boards.

Multi-agency training will be implemented, as outlined later in this document, for all staff involved in discharge planning.

Specific protocols are outlined in this document relating to:

• standards for response times for all agencies;
• agreed information sharing protocols;
• agreed referral procedures for assessment and intervention;
• NHS funded nursing care eligibility;
• Continuing NHS Health Care assessments and procedures;
• Carers’ assessment;
• People who are homeless to ensure they are assessed in a timely manner to determine whether they have access to accommodation on discharge;
• Explicit procedures for cases where patients do not have the mental capacity to represent themselves.
• People with learning disabilities.
• Additional considerations to be taken into account when arranging discharge for vulnerable groups.
• Use of interpreters, translators and advocacy services;
• Access to intermediate care and rehabilitation services;
• Access to any additional early discharge schemes operating, either in care homes or for enhanced short-term packages of care in community settings;
• Policy relating to management of choice of accommodation;
• Management of discharge from hospital against medical advice and refusal of discharge;
• Management of discharge directly from Accident and Emergency Departments.

1. ACCOUNTABILITY

Each professional group will be required to work within their professional framework and be accountable for their actions. The implications of this in ensuring hospital discharge are safe, effective, and to a suitable setting need to be considered by multi-professional and multi-agency teams. Explicit and shared agreements related to each individual’s role and responsibilities as part of the multi-agency team will support effective organisational accountability arrangements.

1. PERFORMANCE MANAGEMENT

All agencies will work together to ensure the collection and collating of data which will be used by agencies to jointly evaluate the effectiveness of hospital discharge arrangements. The process involved is outlined later in this document and will be used to inform review of this policy and identify additional training needs that arise.

Delays in timely discharge and transfer arrangements are reported to the Welsh Assembly Government through a monthly snapshot census. This provides point in time management and commissioning information and will inform Swansea and related areas about gaps in service provision and analyse reasons for delays in order to inform service planning and redesign. Local Health Boards, Swansea NHS Trust and local authorities all have an important role to play in ensuring this information is used and acted upon.

The Regional Offices of the Welsh Assembly Government monitor delayed transfers of care performance as part of their wider performance management responsibilities related to the delivery of the Service and Financial Framework (SaFF) operating in Wales.

1. ROLE OF COMMISSIONING

Commissioners need to ensure that services provided meet identified needs and collect and utilise management information on discharge planning to ensure the timely availability of services.

Effective and timely discharge requires the availability of appropriate and alternative care options to ensure identified needs are met. The need for service development or redesign is reflected in Swansea’s Health and Social Care and Well Being Strategy 2005-2008 the provision of effective assessment and discharge is also reflected in the Local Health Board’s Commissioning Plan with Swansea NHS Trust, Health, Social Care and Wellbeing Strategies, commissioning plansand contracts for service provision.

Each patient following a health needs assessment, where appropriate will have a health care plan. These plans are used by Swansea Local Health Board to inform commissioning of individual care packages which are monitored on a regular basis.

10. ROLES AND RESPONSIBILITIES

Executive board Members

Executive board Members will be responsible for ensuring that their staff are made aware of and are implementing this policy.

Line Managers

Line Managers will support the Executive Board members in disseminating and implementing this policy at operational level. They must ensure that as part of local induction procedures that new staff is shown how to access Trust Policies.

The Line manager will also monitor working practices and ensure they are consistent with this policy.

All Staff

All staff have a responsibility to ensure they are aware and conversant with this policy and the procedures there-in and that they are in accordance with these at all times

SECTION 2 – SCHEDULED AND UN-SCHEDULED ADMISSIONS

1. INTRODUCTION

This section of the policy identifies the procedure, pathway, processand protocolsfor non-scheduled and scheduled discharges and is to be followed by all professionals working in health and social care organisations in Swansea.