Discharge Policy for Adult Patients Leaving Hospital · Supersedes: V2 (original approved February...

Discharge Policy

For Adult Patients Leaving Hospital

To be read in conjunction with University Hospitals of Leicester NHS Trust Good Practice in Discharge Planning

Approved By: Policy and Guideline Committee

Date Approved: 28th October 2011

Trust Reference: B2/2003

Version: V3

Supersedes: V2 (original approved February 2003 by the Clinical Governance Executive)

Most Recent Review: 28 October 2011 – Policy and Guideline Committee 21 December 2009 – Policy and Guideline Committee 13 August 2007 – Policy and Guideline Committee 12 September 2005 – Policy and Guideline Committee

Author / Originator(s): Mandy Gilhespie, Specialist Nurse for Discharge

Name of Responsible Committee/Individual: Mandy Gilhespie, Specialist Nurse for Discharge

Review Date: October 2014

CONTENTS

Section Page

1. Introduction 3

2. Policy Aims 3

3. Policy Scope 4

4. Equality Impact Assessment 4

5. Roles and Responsibilities 4

6. Definitions of all Adult Patient Groups 6

7. Policy Statements 7.1 Simple Discharge 7.2 Complex Discharge 7.3 People who are frail and / or elderly who want to return home and live

alone or with a carer who may have difficulty coping 7.4 Intermediate care or rehabilitation in a community facility 7.5 Patients’ who are homeless 7.6 Patient has long term condition or at risk of readmission 7.7 Patient with mental health / behavioral issues 7.8 Patients with a Learning Disability 7.9 Terminal patients requesting discharge home at end of life 7.10 24 hour care required in a care home facility 7.11 Discharge out of hours 7.12 Self Discharge

7

8. Information and discharge documentation to accompany patient on discharge

21

9. Discharge / delayed transfer of Care 22

10. Training and education 23

11. Dissemination and Implementation Process 23

12. Document Control, Archiving and Review 23

13. Legal Liability 23

14. Evidence Base and Related Policies 24

15. Glossary 24

16. Monitoring compliance with processes outlined within this policy 25

Review and changes made: October 2011 – V3 has undergone a complete review and update based on current literature.

Discharge Policy for Adult Patients leaving hospital of 25 Final Version Approved by Policy and Guideline Committee on 28th October 2011 Trust Ref: B2/2003 Next Review: October 2014

NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Document

1. INTRODUCTION

1.1 The University Hospitals of Leicester (UHL) NHS Trust is committed to ensuring best practice in the discharge/transfer of patients who have completed their episode of care within the Trust.

1.2 UHL recognises the importance of the multi-disciplinary team in effective discharge planning. The engagement of, and active participation of patients and their carer(s) as equal partners is central to the delivery of care and in the planning of a successful discharge.

1.3 Prompt and efficient discharge of patients from acute hospital beds to the next level of care plays a vital part in ensuring capacity is available for patients needing to access acute care beds.

1.4 Equally important is the need to ensure that the transition for patients from acute hospital to community care is safe, timely co-ordinated, and well communicated.

1.5 This policy has been developed to support good practice in discharge planning by providing direction for staff involved in the discharge planning process. It is specifically designed to be used in conjunction with other guidance and policy defined within this document.

2. POLICY AIMS

2.1 The aim of this policy is to ensure provision of robust, timely discharge/transfer arrangements to an appropriate safe environment for all patients on completion of their treatment in UHL. In order for this to happen the multi professional team must be aware of their role in discharge planning, have access to appropriate tools and guidance, and be supported by relevant education and training opportunities.

2.2 This policy has been developed to ensure:

a) Best practice in discharge planning for patients transferring from UHL to the next level of care

b) Safe transition for patients from secondary to the next level of care

c) Highest standards of communication within the multi-disciplinary team, between primary and secondary care, and with colleagues in social care and the independent sector.

d) Staff in clinical areas in UHL have access to and awareness of up-to-date relevant national and local policies and guidelines to enable highest standards of practice in discharge planning

e) That Discharge planning commences prior to, or immediately on admission to hospital and continues throughout the patient’s acute hospital admission

f) The multidisciplinary nature of discharge planning is maintained and involves all appropriate health and social care professionals throughout the pathway of care.

g) That patient/carers are involved and have the opportunity to influence and receive appropriate information throughout the discharge planning process.

h) That patient’s are provided with information/medication/equipment to enable and foster independence for the patient/carer.

Discharge Policy for Adult Patients leaving hospital of 25 Final Version Approved by Policy and Guideline Committee on 28th October 2011 Trust Ref: awaiting allocation B2/2003 Next Review: October 2014

NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents

i) That continuity of care is provided through effective communications between hospital and community multi-disciplinary/multi-agency teams.

j) That discharge requirements are addressed which are specific to each patient group.

k) The provision of appropriate documentation accompanies the patient upon discharge.

l) That the process for discharge out of hours is identified.

2.3 In light of the complex nature of discharge planning this policy has been written to be used in conjunction with the supporting guidelines and policies which are highlighted in Section 14 – Evidence Base and related Policies

3. POLICY SCOPE

3.1 This policy applies to all staff employed within the University Hospitals of Leicester NHS Trust, those staff working in a contracted capacity, and staff contracted with partner agencies or NHS Trusts and working within UHL.

3.2 This policy is supported by the document ‘Good Practice in Discharge Planning’ (Trust reference B20/2009) which provides greater detail on roles and responsibilities and information and procedures to support the discharge process

3.3 This policy relates specifically to the discharge needs of adults admitted to the University Hospitals of Leicester NHS. Many of the principles outlined in the document apply equally to good practice in discharge of children; therefore staff caring for children on an adult ward will comply with this policy unless there are issues which need specific advice from the children’s hospital, this advice is available via the Childrens hospital bleepholder contacted via switchboard.

4. EQUALITY IMPACT ASSESSMENT

As part of its development, this policy and its impact on equality have been reviewed and no detriment was identified.

5. ROLES AND RESPONSIBILITIES

(More detail is provided in part 2 of Good Practice in Discharge Planning; UHL Service contribution to discharge planning by the MDT)

5.1 The Medical Director and Director of Nursing have overall responsibility for the quality of medical and nursing intervention to support the policy.

5.2 The Chief Operating Officer/Chief Nurse has overall responsibility for ensuring that there are effective arrangements for discharge planning within the trust.

5.3 It is the responsibility of the Consultant to ensure that:

a) all patients in his/her care have an estimated discharge date (EDD) within 24 hours of admission to hospital and that this discussed with the patient and family/ carer and is reviewed daily.



b) ward rounds occur each working day, to identify patients who are ready for discharge. Patients potentially ready for discharge should be reviewed as early in the day as is consistent with clinical priorities (i.e. at the beginning of the ward rounds wherever possible).

c) The frequency of individual patient discharge reviews reflect the clinical condition of the patient and the nature of the discharge plans.

d) TTO prescriptions for discharge are written at least 24 hours before discharge or as soon as practicable when discharge is confirmed with less than 24 hours notice.

e) plans are put in place to identify patients who may be ready for discharge at weekends and bank holidays when ward rounds may not be routine.

5.4 The Consultant and MDT have responsibility for agreeing the patient is ready for transfer and that this is recorded in the medical notes as “Health Complete.” This is a statutory requirement under the Community Care (Delayed Discharges) Act 2003.

5.5 The Heads of Nursing and matrons are responsible for ensuring compliance with this policy, supporting audit, reviewing results and implementing change where appropriate. Delays in discharge should be monitored and escalated to the discharge team for support and if necessary improvements made to the process, if delays for failing to meet the EDD are due to non clinical reasons.

5.6 The Ward Sister/Charge nurse has responsibility for ensuring that systems are in place to facilitate a safe, timely discharge for all patients under their care. Discharge needs to be coordinated through a multidisciplinary approach by the ward sister or their deputy, to enable discharge by the EDD. The sister should ensure that standards of discharge planning are maintained (see part one of Discharge Practice & Guidance) and that staff report any examples of non adherence to the policy through the hospital adverse events reporting system.

5.7 It is the responsibility of all members of the multidisciplinary team to ensure patients their families and carers are consulted and regularly updated about discharge planning from admission (or preadmission when patients are attending pre-assessment clinics prior to admission); throughout inpatient stay and up until 30 days post discharge.

5.8 The Specialist Nurse for Discharge has responsibility for providing a focus to bring about sustained improvement in discharge planning by working with multidisciplinary teams within UHL and partner agencies by:

a) The development, implementation and evaluation of policies, standards and guidance on discharge planning.

b) The maintenance of an effective inter-agency and multidisciplinary communication strategy, internal and external to UHL.

c) Ensuring that clinical areas have access to information and support in the implementation of local and national policy and legislation relating to hospital discharge.

d) Ensuring a programme of audit to monitor effectiveness of discharge tools and practise and identify areas of improvement

e) Influencing strategic planning to achieve national and local performance targets

f) Monitoring the patients experience with discharge planning within the Trust



g) Monitoring and escalation of daily delayed discharge census (sitreps) and working in partnership with multidisciplinary teams within UHL and community services to resolve specific issues relating to delays.

h) Provide monthly report to Chief operating officer, identifying key themes of delays under the control and those delays outside the control of UHL and actions being taken to achieve the Trust target for delayed transfers of care

5.9 The Discharge Team has the operational responsibility for discharge planning in conjunction with the ward sister and multidisciplinary teams by:

a) Promoting good practice in discharge planning across UHL, Leicester, Leicestershire & Rutland, Health & Social care community.

b) Providing active support to the MDT for discharge of patients with complex needs.

c) Developing strong links with all divisions within UHL, community health services, including community hospitals and other partner agencies to identify and progress delayed discharges.

d) Ensuring that local and national policies and guidelines are used throughout the discharge planning process.

e) Participation in audit programmes to monitor performance and identify areas for improvement.

f) Collation of daily delayed discharge census for delayed transfers of care on each hospital site ensuring verification of all reimbursable social care delays.

g) Collation of national sitrep weekly delays (Thursday 12 midnight) including verification from specific services

5.10 The Allied Health Professionals (OT, Physio, and other allied groups) provide holistic functional patient assessment and consider equipment, adaptations and/or goals for rehabilitation, to enable the patient to return to their baseline. They will liaise with patients, their carers, families and multidisciplinary teams within UHL and externally to enable the needs of the patient to be met.

5.11 The chair of the Trust Discharge Planning Group has responsibility for aligning discharge process across all clinical business units, ensuring that issues are forwarded to Leicester, Leicestershire & Rutland Transitional Planning Steering Group for resolution.

6. DEFINITIONS OF ALL ADULT PATIENT GROUPS

6.1 The majority of patients who are discharged from hospital will be classified as a simple discharge. A simple discharge is one that

‘Involves minimal disturbance to the patients’ activity of daily living; does not hamper a return to their usual residence and where there is no significant change in the support offered to the patient or their carer in the community.’

6.2 This policy also acknowledges that some patient groups are more complex and may require particular attention when planning and delivering discharge care. A complex discharge is usually one that involves the input of 2 or more services and involves multidisciplinary planning and will frequently include the following patient groups:



a) People who are frail and/or elderly, who may live alone or with a carer who may have difficulty coping and want to return home

b) Patients with a long term condition with high risk of readmission.

c) Patients being discharged to a care home

d) Terminally ill patients at the end of life.

e) Patients with mental ill health/learning disabilities.

f) Patients who are homeless

g) Those who self discharge against medical advice

7. POLICY STATEMENTS The following policy statements detail the discharge requirements for specific patient groups. Most will fit wither a simple (section 7.1) or complex (section 7.2) discharge process, however there are some groups of patients who will have additional discharge requirements to thise set out in section 7.2 and these are set out in section 7.3 – 7.12.

No Policy Statement Link to further reference / resource document

7.1 Simple Discharge 1. Estimated discharge date within 24 hours from admission part one, Good Practice

in Discharge planning 2. Letter A -on admission (copy available in patient information

folder at patient bedside) or pre admission in elective cases. part one, Good Practice in Discharge planning

3. Completion of Discharge planning template confirming that the patient has no new ongoing care needs and has returned to baseline.

Template is in the Nursing assessment documentation

4. Telephone notification to social care/ care agencies for restart of package of care, if patient was receiving care package prior to admission. Contact the discharge team for assistance with contact numbers for patients who are ‘out of county.’

Page 20-21, Good Practice in Discharge planning Team numbers: LRI – ext 6882 LGH – ext 8311 GH – ext 2331

5. On the day of discharge the discharging nurse must confirm all arrangements are in place and the patient is fit to leave hospital

discharge checklist in nursing assessment documentation

6. The nurse discharging the patient should ensure that a referral to the practice nurse is made, if dressings are required and the patient is well enough to attend the GP surgery. If the patient is not well enough to attend the surgery, then a referral should be made for the district nurse to visit the patient within their home environment

district nurse-telephone numbers available page 40- Good Practice in Discharge planning

7. The patient should be supplied with a transfer letter recording any wounds, pressure ulcers, bruises or skin blemishes and a minimum of 3 days supply of dressings

part one, and page 65 Good Practice in Discharge planning

8. The nurse discharging the patient should confirm that the patient or carer understands the information provided regarding the expected signs to look for and when and who to contact for help and advice



Link to further reference / No Policy Statement resource document

7.1 Simple Discharge 9. The patient/ carer should be given information relating to

medicines, including regime and side effects

10. The nurse discharging the patient will be given details of outpatient appointments or other follow up appointments. If the information is not available by the day of discharge, the patient/ carer will be sent an appointment by post; in these circumstances staff need to confirm with the patient/carer, the address the appointment is sent to and the patient and carer should be given a contact number in case the appointment is not received.

11. A discharge checklist (Available in the standard nursing documentation) will be completed by the nurse responsible for discharging the patient on the day of discharge.

12. The doctor responsible for discharging the patient will provide a medical sick note if patient is to refrain from work

No Policy Statement Link to further reference /

resource document 7.2 Complex Discharge Pre admission / on admission 1. Discharge planning commences at the pre admission stage for

elective cases and on admission for non-elective admissions part one, Good Practice in Discharge planning

2. All patients must be given an Estimated Date of Discharge (EDD) within 24 hours of admission which will be recorded in the case notes, HISS, Nursing assessment documentation and patient information boards (where these are in use). This date will be discussed and agreed with patients their relatives or carers and any changes to this date will be discussed with the relevant stakeholders

part one, Good Practice in Discharge planning

3. All patients will receive choice letter A, at pre admission or on admission, which can be formatted and translated into various languages upon request

page 47, Good Practice in Discharge planning

4. All patients will have a UHL Discharge Planning template commenced on admission. The Discharge template is the single document recording all multi disciplinary referrals relating to the patient journey from admission to discharge/transfer of care and is part of the Nursing assessment documentation

page 88, Good Practice in Discharge planning.

Identifying and addressing discharge / care needs 5. Patients with ongoing care needs following discharge will be

provided with an information leaflet ‘leaving hospital,’ to empower them with the questions they need to ask the multidisciplinary team regarding discharge


6. Where English is not the patient’s first language, staff should request assistance from an interpreter by completing an Interpreting request form. These are available on INsite. Please make sure you fill out all sections to allow Pearl to arrange the best possible interpreter for your session. Once filled, please email the form to [email protected] alternatively it can be fax it to 020 7253 0700

UHL Interpreter and translation guidelines, Trust Ref: B11/2011.



mailto:[email protected]


7.2 Complex Discharge Capacity and Safeguarding 7. Where suspicions or disclosures are made concerning any

vulnerable patients, prompt adherence to existing safeguarding procedures should be made.

page 58, Good Practice in Discharge planning Safeguarding Adults Policy, Trust Ref: B26/2011

8. Where patients have capacity then patients must provide consent to referrals made during the discharge planning process and to information being shared with carers/relatives


9. Where patients lack capacity regarding decisions relating to discharge the views of family members should be sought and considered. However, the consultant will usually take responsibility for determining the future management of the patients healthcare needs on the ‘best interest’ of the patient, unless there is someone who has authority under Lasting power of attorney or have been authorised to make decisions as a deputy appointed by the court of protection. (Mental Capacity Act 2005)

MCA Policy, Trust Ref: B23/2007

10. Where patients lack capacity regarding decisions relating to discharge and there are no family or friends the multidisciplinary team must consider making a referral to an independent mental capacity advocate (IMCA) by completing an IMCA POhWER referral form available on INsite. (Mental Capacity Act 2005)

MCA Policy, Trust Ref: B23/2007

Assessment of ongoing care needs / care packages 11. Carers will be offered a carer’s assessment from social services,

where disclosures are made regarding their ability or willingness to continue caring or where staff suspect/observe difficulties in meeting the caring role.

12. Patients will be referred to physiotherapist and occupational therapist, if they have not returned to their baseline to assess suitability for rehabilitation or intermediate care

page 22-23, Good Practice in Discharge planning

13. The multidisciplinary team are advised to seek early help and advice from the discharge team with patients who have complex care needs or any issues that could potentially result in a delayed discharge


14. A fast track continuing healthcare form should be completed for patients who are being discharged and are suffering with a terminal or rapidly deteriorating condition


15. Patients with ongoing healthcare needs should be considered for 100% NHS funding for continuing health care funding prior to referral to social services by the completion of a continuing healthcare checklist


16. Section 2 notification (iCM) will be issued to the appropriate social work department to inform them that an assessment is required for services required after discharge. The patient will need to consent to referral. Out of county referrals county referrals can be made by contacting the discharge team


17. A decision support tool (DST) should be completed on all patients page 56, Good Practice




7.2 Complex Discharge when the continuing healthcare checklist indicates further consideration is required. (1 tick in column A marked with an asterisk; 2 or more ticks in column A without asterisk; 5 or more ticks in column B; or 1 in A and 4 in B) or if a request is received from the patient and or carer

in Discharge planning

18. Patients requiring discharge to a care home with nursing, who have a negative checklist will require an assessment for funding nursing care (RNCC)


19. If an existing care package needs to be restarted, the registered health professional undertaking the assessment will need to confirm this will continue to meet the patient’s needs and contact the relevant health or social work department

Page 20-21, Good Practice in Discharge planning

20. Arrangements will be made to provide patients with any necessary equipment/aids to daily living prior to discharge from the physiotherapist (mobility aids e.g. walking frame, walking stick) or occupational therapist (aids to assist transfers e.g. hoist, bed lever, commode ). Pressure relieving equipment is organised by contacting the community nursing services Where appropriate, patients/carers will receive instruction on the use of aids and equipment prior to discharge as a means of encouraging self management Referrals for assisted technology can be made via the relevant social service department, patients may be charged for this service.

pages 38/71 Good Practice in Discharge planning


21. Where patients are identified as being at high risk of readmission, staff responsible for discharge planning should check that the patient and carer/family are fully informed about and understand their care plan, including contact numbers for them to contact if they are concerned or worried

part 1, Good Practice in Discharge planning

Preparation for discharge 22. Telephone notification to social care / care agencies to restart

package of care (if no change and being received prior to admission) Contact the Discharge team for assistance with contact numbers for patients who are out of county

Page 20-21, Good Practice in Discharge planning Team numbers: LRI – ext 6882 LGH – ext 8311 GH – ext 2331

23. If dressings are required: The nurse discharging the patient should ensure that a referral to the practice nurse is made, and the patient is well enough to attend the GP surgery. If the patient is not well enough to attend the surgery, then a referral should be made for the district nurse to visit the patient within their home environment

District nurse-telephone numbers available page 40- Good Practice in Discharge planning

24. The patient should be supplied with a transfer letter recording any wounds, pressure ulcers, bruises or skin blemishes and a minimum of 3 days supply of dressings

part one, and page 65, Good Practice in Discharge planning

25. Adults, including older people, who do not require community support can be discharged without the need of referring to social services but may be given a contact number for the relevant





7.2 Complex Discharge Social Services Department should they require help in the future

26. Patients should be informed to plan their own transport arrangements for discharge. Patients with a clinical need can be referred for ambulance transport


27. The date of discharge should be confirmed with patients and their families, and care homes giving at least 24 hours notice


28. A copy of the discharge letter should be ready 24 hours before admission wherever possible. The letter should be given to the patient at the time of discharge with opportunity to discuss the content and ask questions. The discharge letter should be used to confirm the patients/ carers understanding of their condition, treatment and care needs at the time of discharge

see page 10, Good Practice in Discharge planning

Day of Discharge 29. On the day of discharge the discharging nurse must confirm that

the patient is fit for discharge and that all arrangements are in place The discharge checklist will be completed by the nurse responsible for discharging the patient on the day of discharge (found in the Nursing assessment documentation)


30. Those patients planned for patient discharge will be ready to leave the ward area by 13.00hrs (this includes all patients where ongoing care is expected to be completed on the discharge lounge).

31. Where applicable, medical staff should issue a form Med 3 sickness certificate on discharge when they advise the patient to refrain from work


32. An inter healthcare patient infection prevention transfer form will be completed for all patients to identify any infection risks for the receiving care provider


Patient Information (Also see section 8) 33. The discharging nurse is responsible for ensuring the patient and

/ or carer understands their medication regime on discharge by discussing the following: • The name of medication • The purpose of the medication • The times the medication is to be administered • Make note of any special instructions including side effects, If appropriate medications counselling by a pharmacist should be considered

34. The nurse discharging the patient from the ward will provide and explain any written information specific to the patient condition (including, GP letter) and must ensure that the patient and / or carer receives instructions on any care required after discharge; understands the information provided regarding the expected signs to look for and when and who to contact for help and advice

part one, Good Practice in Discharge Planning

35. The nurse discharging the patient will provide details of outpatient appointments or other follow up appointments. If the information is not available by the day of discharge, the




7.2 Complex Discharge patient/ carer will be sent an appointment by post; in these circumstances staff need to confirm with the patient/carer, the address the appointment is sent to and the patient and carer should be given a contact number in case the appointment is not received.

36. A discharge letter will reach the general practitioner (GP) within one working day of discharge.

37. For patients who self discharge or die whilst in hospital the named nurse will l ensure that the relevant relatives, carers, agencies and GP are informed

No Policy Statement Link to further reference

/ resource document 7.3 People who are frail and/or elderly, who want to return home and may live alone or

with a carer who may have difficulty coping 1. Medical and/or nursing assessment on admission to include

patient, family or carers to determine patients’ baseline before admission. Multi disciplinary team also to consider contacting support services responsible for the patients care prior to admission, for background information e.g. GP, care agency, district nurse, community psychiatric nurse, ambulance service.

2. If it is likely the patient requires ongoing support on discharge – this should be recorded in the discharge planning template (available in the nursing assessment documentation), and the nursing staff need to use the various prompts on the template to make the appropriate referrals for discharge planning.

page 88, Good Practise in Discharge planning

3. Where suspicions or disclosures are made concerning any vulnerable patients, prompt adherence to existing safeguarding procedures should be made

page 58, Good Practice in Discharge planning Safeguarding Adults Policy, Trust Ref: B26/2011

4. The multidisciplinary team need to contact the discharge team as early as possible for support, advice or assistance with discharge planning

page 14, Good Practice in Discharge planning.

5. The multidisciplinary team needs to establish whether the patient is able to make decisions regarding discharge destination & ongoing care. A Mental capacity assessment should be completed, if there is any doubt regarding decisions for discharge destination and ongoing care and treatment following discharge The discharge team and social worker can assist with this process.

MCA Policy, Trust Ref: B23/2007 Mental Capacity assessment form available on INsite

6. If the patient is identified to be at risk of malnutrition, the multidisciplinary team should make a referral to the dietician. If the patient remains at risk due to poor dietary intake an action plan to manage this issue needs to be considered and discussed with the patient, family or carer before discharge e.g. enteral feeding.



Link to further reference No Policy Statement / resource document

7.3 People who are frail and/or elderly, who want to return home and may live alone or with a carer who may have difficulty coping

7. If the patient requires enteral feeding following discharge the HENS team will need to be contacted to provide support and training to the patient, family, carer or care providers


8. If there any concerns regarding mobility, nursing staff should refer the patient to the physiotherapist


9. If there are any concerns raised regarding coping at home e.g. cognitive impairment; falls, difficulties with managing activities of daily living, access to property, transfers from bed to chair, environment, -nursing staff to refer to the occupational therapist for assessment and consideration of any necessary adaptations or equipment required to maintain the patient safely within their home environment. Occupational therapist to document outcome of assessment and any equipment ordered, including date of delivery, in medical record


10. The Multidisciplinary team (MDT) needs to determine whether the patient will benefit from rehabilitation. If the patient is stable and fits the criteria for admission a referral form is completed by the MDT identifying specific goals for improvement and faxed to bed bureau The referral should be recorded in the discharge planning template.

page 81-82 Good Practice in Discharge planning), page 29, Good Practice in Discharge Planning

11. If patient has continence problems- a continence assessment should be undertaken. Advice is available from the continence nurse specialist.

page 19, Good practice in Discharge planning

12. Staff may need to liaise with the Manual Handling team for advice regarding the needs of Bariatric patients

.page 87 Good Practice in Discharge planning

13. Patients requiring home oxygen will require a Home oxygen form and consent form completing


14. If the patient requires a pressure relieving equipment the nurse will need to make a referral to the district nurse to order the equipment Patients requiring bed rails require a bed rail risk assessment form which should be faxed to the district nurse.

page 71 Good Practice in Discharge planning

page 35 Good Practice in discharge planning

15. If the patient is returning home, lives alone and is unable to answer the door to carers - a key safe will need to be commissioned by the service commissioning the care ( e.g. social care or continuing health care)

16. If the patient does not require rehabilitation and is medically stable, the nursing staff should send a section 2 notification to social services for an assessment. The date of the referral should be documented in the discharge planning template. Staff should also consider eligibility for continuing health care. The outcome of the checklist should be documented in discharge planning template.

pages20-21, Good Practice in Discharge Planning page 57- Good Practice in Discharge planning



Link to further reference No Policy Statement / resource document

7.3 People who are frail and/or elderly, who want to return home and may live alone or with a carer who may have difficulty coping

17. If the checklist is Positive (1 A*; 2 A; 5 B or 1A+4B) – the discharge team will organise an MDT meeting with the social worker; district nurse if health needs are identified and pt/family/carer, to discuss the patients care needs and to complete a Decision support tool (DST). The MDT will make a recommendation for eligibility for NHS/ social care funding on the DST, which is faxed to the PCT CHC team to make a decision regarding eligibility for continuing health care funding.

18. If the checklist is negative and the patient requires a package of care from social services-the nursing staff need to check that the patient is ready for discharge (medically stable, equipment in place and the carer and family agree with discharge plan)- before sending a section 5 notification to social services for discharge- the notice should be sent before one pm in order to guarantee discharge on the following working day (Mon-Sat, except BH).

19. If the section 5 is sent after 1pm then staff need to give social care a further working day ( e.g. section 5 sent 2pm Thurs- discharge date Sat; section 5 sent 2pm Thurs prior to BH Mon-discharge date will need to be Tues). The date of notification should be recorded in the discharge planning template.

20. If social services are unable to complete their assessment or arrange a package of care within the section 5 timescale; an interim placement within a care home should be offered. The social worker should make their offer accompanied by a health representative, to ensure, the patient is suitable for an interim placement (behavioural issues may not be suitable) and also to ensure the patient, family or carer is given an explanation of the benefits of an interim placement and the risks associated with a prolonged hospital stay)

21. If the patient is eligible for 100% NHS funding for continuing health care, the district nurse should make the necessary orders for equipment required and should liaise with the discharge team to agree the level of care required to effectively care for the patient at home. The discharge team will notify the CHC team regarding the package of care required. The patient/family and carer will be involved with all decisions regarding care delivery and regularly updated regarding timescales for delivery of equipment and dates/ times for care packages to start.

22. The nurse coordinating discharge needs to ascertain if the patient will require respite care following admission, which needs to be organised by the responsible commissioner for discharge (e.g. social care/ continuing health care). If the patient is self funding the social worker will assist the patient / family with this process or the patient can be provided with a list of appropriate care homes or can be referred to care home selection

page 52, Good Practise in Discharge Planning.




7.4 Intermediate care or rehabilitation in a community facility. E.g.- Brookside Court, Clarendon Mews-(city); community hospitals (county)

1. The multidisciplinary team need to consider referral to intermediate care services if the patient is ready for discharge and could benefit by; improving their confidence with therapeutic input within their home environment; an assessment of the home environment to reduce the risk of trips and falls. Intermediate care can be accessed via (city 0116 2958788; county 08458400062).

page 30, Good Practice in Discharge Planning

2. The social work department will consider Reablement with patients discharged with a home care package, with the aim of improving their confidence and reducing the level of care required in the long term.

3. The multidisciplinary team should determine the patient’s pre admission baseline before admission. Patients who have not returned to their baseline following injury or illness should be considered for rehabilitation. If the patient is stable and fits the criteria for admission a referral form is completed by the multidisciplinary team identifying specific goals for improvement and faxed to bed bureau The date of referral to rehabilitation should be documented in the discharge planning template.

page 81 Good Practice in Discharge planning), page 28, Good Practice in Discharge Planning).


7.5 Patients who are homeless 1. Homeless patients frequently have complex health, social and

mental health issues. The multidisciplinary team should seek early advice form the discharge team


2. Patients visiting from abroad should be referred to the persons from abroad team (ext 5734) to determine eligibility to health care services.

3. Homeless patients with ongoing care needs following discharge should be referred to the relevant social services (section 2) for a community care assessment. The patients’ previous address will help to identify which local authority is responsible for the patients care. If the patient wants to reside in Leicester, then a referral should be made to city social services. The patients consent will be required for the referral.

4. The multidisciplinary team should liaise with the patient and request family, or friend contacts and seek support from them with discharge planning

5. The multidisciplinary team needs to refer the patient to housing options for a housing assessment or referral for a hostel. If patient is fit for discharge the patient can be directed to: Housing Options, City Council, New walk, Leics Mon-Fri 9am- 3pm. Tel: 0116 2528707. Out of hours referrals to the Dawn Centre 0116 2212770.





7.5 Patients who are homeless 6. Patients from abroad who may have no recourse fro public

funding and want reconnecting to their country of origin should be referred to the outreach team Tel: 0116 2995514 Patients requiring ongoing GP or district nurse can be referred to inclusion health care A referral letter should be given to the patient, with an explanation of the follow up treatment and care required. The multidisciplinary team could also fax a letter to the centre 0116 2212783 as there is high risk the letter provided to the patient may get lost. If the patient requires redressing of a wound then the patient should be provided with a 3 day supply of dressings.

page 33 Good Practice in Discharge planning see page 65, Good Practice in Discharge Planning

7. The Discharge team may seek assistance with repatriation of overseas patients by contacting the appropriate family members or by seeking advice from the appropriate Embassy or various charitable organisations e.g. red cross -0116 271359; refuge action 0116 2616223.


7.6 Patient has long term condition or at risk of readmission, process is similar to frail elderly (section 7.3 above) with the addition of:

1. The multidisciplinary team need to contact the discharge team as early as possible for support.

2. A Multidisciplinary meeting needs to be arranged to discuss discharge planning, this will vary depending on the problem e.g. ward medical and nursing staff, social worker; OT, physiotherapist; community long term condition team e.g. community matron/specialist nurse (city 0116 2958788, county 08458400062); care home staff if the patient is resident in a care home; CPN or psychiatrist if patient has mental health needs, GP.

3. The aim of the meeting will be to determine the patients baseline prior to admission, including the community social and health care support the patient was receiving and to discuss the patients current ongoing health and social care needs following discharge to enable a medical management plan and appropriate package of care can be commissioned that meets the patients needs.

4. Occupational therapist may need to consider any equipment, adaptations or assisted technology the patient may require that can help to support the patient in the community The patient, family/carer will be provided with a full explanation of their illness, prognosis, likely set backs to expect and contact numbers of who to contact if concerned or requiring further assistance.


5. Staff may need to consider a contingency plan if the package of care/ care plan, is likely to breakdown, to prevent the patient from being unnecessarily admitted to acute care e.g. care home placement/ respite care; medical step down in community hospital.




7.7 Patients with mental health / behavioural issues, is similar to frail elderly (section 7.3 above) with the addition of:

1. The multidisciplinary team need to contact the discharge team as early as possible for support, advice or assistance with discharge planning


2. If the patient has no previous history of mental health problems, the medical staff need to rule out organic cause e.g. infections, side effects from medication, urinary tract infection. A referral to mental health services can be made as an emergency by switchboard; non urgent referrals by can be arranged by contacting 0116 2255911

3. If the patient is already known to mental health services the multidisciplinary team should contact the community psychiatric nurse or relevant psychiatrist to ascertain background information/ patient baseline (0116 2255911)

4. The CPN should be informed of the patient’s date of discharge and discharge destination for future follow up.


7.8 Patients with a learning disability the process for discharge is similar to frail elderly (section 7.3 above) with the addition of:

1. Establish if patient has known health or social key worker by contacting the GP or social work department (city 0116 2531191, county 0116 3050013)

2. Refer to learning disability nurse, for support with discharge planning, if the patient has ongoing care needs or issues relating to discharge (ext 4382)

3. Determine whether patient has mental capacity to make decisions regarding discharge, if this is unclear and an assessment is required, ensure the patient receives appropriate support with communication e.g. learning disability nurse, friend, family, speech & language therapist

No Policy Statement (in addition to requirements in 7.2) Link to further reference /

resource document 7.9 Terminal patients requesting discharge home at end of life- prognosis approximately

48 hours 1. Establish that the patient is not for further active treatment and

that this is documented in the case notes

2. Ensure the patient and the family are aware that death is imminent

3. Commence integrated care pathway available from print room

4. Establish if patient prefers to die at home 5. Make urgent referral to Discharge team for rapid discharge with

Hospice at home. If patients or families are requesting discharge out of hours, bank holidays or weekends, the ward nurse coordinating the discharge should contact the relevant district

page 37-Good Practice in Discharge planning



Policy Statement (in addition to requirements in 7.2) Link to further reference / No resource document

7.9 Terminal patients requesting discharge home at end of life- prognosis approximately 48 hours nursing service direct .

6. Discharge team to contact family to discuss discharge planning- ensure downstairs existence and there are no access issues into property.

7. Discharge team to contact Hospice at Home to ensure that there is capacity to accept patient. Referrals Mon- Fri before midday, discharge can be arranged on the same day; referrals after midday can be arranged for the next working day New referrals made on Saturday and Sunday can be organised by contacting the local district nursing service. (city 0116 2958788; county 08450450411)

8. Discharge Team to determine whether equipment is required for discharge e.g. hospital bed, slide sheets, pressure relieving mattress, and notify Hospice at home who will organise urgent delivery on the same day of discharge.

9. 3 days supply of End of life drugs to be prescribed by medical staff, and community nurse drug authorisation form to be completed. (available in end of life packs or from discharge team)

10. Discharge team to complete fast track assessment for continuing health care and fax to PCT for verification of funding. The discharge team will inform Continuing health care team of the support package required to meet the patients, families and carers needs e.g. four calls daily and night sitters

11. Complete DNAR form and fax to GP and EMAS (0115 9675099) 12. Complete and fax Hoof form if palliative oxygen is required and

mark as urgent page 60, Good practice in Discharge planning

13. Ensure the patient is pain free and comfortable before discharge 14. Arrange ambulance via ambulance desk- ensure end of life is

entered onto booking to ensure maximum 2 hour wait.

15. Notify GP and Hospice at home (01509 410395) of actual time of discharge

16. Ensure patient has copy of GP letter; DNAR form; integrated care pathway; nursing documentation; drug authorisation form and relevant medicines/ syringe driver.


7.10 24 hour care required in a care home facility 1. The multidisciplinary team need to contact the discharge team as

early as possible for support with discharge planning.

2. All patients will be actively supported to return home to their family environment before a care home placement is considered

page 52, Good practice in discharge planning




7.10 24 hour care required in a care home facility 3. The patient and family are involved with the decision for regarding

a care home placement following discharge. If the patient does not have mental capacity to make decisions regarding discharge destination or ongoing care and treatment - a full mental capacity assessment should be undertaken and a best interest decision is made by the decision maker who is coordinating the discharge (social worker or nurse)

MCA assessment form available on INsite

4. The multidisciplinary team will make a section 2 notification via ICM for assessment -to the social work department. Patient and family consent will be required.

5. The multidisciplinary team should decide if the patient requires residential or nursing care home placement- the discharge team or social worker can advise on the appropriate care home and registration required to meet the patients need.

6. The discharge team can advice on availability of beds in care home settings and distract families from viewing care homes that may be temporarily closed for safeguarding investigations.

7. If the patient has a rapidly deteriorating or terminal condition then a fast track assessment should be completed by the discharge team

8. If patient has negative continuing health care checklist and requires residential placement the patient should be referred to social services for further assessment and assistance with the process. Consent will be required before referral. A district nurse can be arranged if the patient has nursing needs that require up to a daily visit form the district nurse e.g. Leg ulcer dressings

9. If the patient has a negative checklist and requires a nursing home placement ( needs access to a trained nurse over a 24 hour period) – the discharge team will need to complete an RNCC application for funding nursing care towards nursing costs in the care home.

10. Patients who do not want to consider a social care assessment and are self funders should still be considered for RNCC assessment for a nursing home placement.

11. Families are advised to consider and view 3 care homes with vacancies to determine whether the patient will like the environment. Wherever possible the patient should be encouraged to the view the home. If the patient is not able to visit the home, the patient should be given leaflets or access to the website to assist with this process.

12. Families requiring further support to locate a nursing home can be referred to care home selection (0116 2542564) - consent will be required before referral.

13. If the Multidisciplinary team consider the family may delay discharge for a care placement ( standard time is 5 days) the discharge team should be notified to commence choice protocol


14. Once the family have identified a care home- the care home will attend the ward to assess whether they can meet the patients needs and confirm whether when the patient can be transferred.




7.10 24 hour care required in a care home facility 15. If patient is funded by continuing health care the care home will

need to submit costing’s to the PCT CHC team before discharge can be arranged. If standard costing’s are agreed the ward can negotiate a discharge date with the care home. If high costing’s have been submitted these will need to be agreed by the CHC team before the discharge can be arranged. The discharge team will liaise with care homes and PCT regarding costing’s.

16. If the patient is funded by social services the ward should notify the social work department of the date of discharge via section 5

17. Patient must be discharged with a GP letter which will include: diagnosis, investigations and treatment, medication regime and changes, infection status and any follow up arrangements. Patients should also be discharged with a transfer letter for the attention of care home staff and district nurse for residential placement and should include: the patients baseline, any care needs e.g. assistance with activities of daily living such as washing, feeding; infection status, all wounds, bruises or skin blemishes should be recorded on a wound chart, follow up arrangements and who to contact if concerned.


7.11 Discharge out of hours 1. Staff should not routinely discharge patients after 9pm, unless

patient or family request and are happy for discharge after this time


2. In the event of patients leaving the hospital after 9pm every effort should be made by the ward nurse discharging the patient to contact the family, carers, unless the patient requests otherwise.

3. Referrals for social care (city & county) e.g. emergency placement for ED, out of hours including weekend and BH -ring 0116 2551606


7.12 Self discharge 1. Patients wishing to take their own discharge will be advised by

nursing staff initially to stay. The medical staff should also be involved in encouraging the patient to stay, informing them of the risks associated with self discharge. If they believe leaving hospital is not in the patient’s best interest medically.

2. The doctor and nurse should make an assessment of capacity in relation to the patients’ ability to make a decision to self discharge and this should be recorded in the medical notes.

3. If the patient has capacity and is adamant that they wish to leave the nurse should ask the patient to sign the self discharge form which should be countersigned by a member of staff. This should then be placed in the patient’s health records.





7.12 Self discharge 4. Patients will be offered a prescription for relevant medication. If

the patient is unwilling to wait for the medication to be dispensed this should be recorded in the notes and the GP informed.

5. If the patient requires a district nurse this should be discussed with the patient to be established if the Trust should contact the DN service or if the patient wishes to make their own arrangements. If this is the case, the relevant contact number should be given to the patient. The decision and action should be documented in the patient’s health records.

8. INFORMATION AND DISCHARGE DOCUMENTATION TO ACCOMPANY PATIENT ON DISCHARGE

Patients may require some or all of the following information and documentation.

8.1 Patient Information Booklet ‘leaving hospital’ will be provided to all patients identified as requiring ‘ongoing care needs on discharge.’ This document enables the patient and/or carer to keep their own personal documentation relating to discharge, throughout their inpatient stay; including information about their condition, medicines and contact numbers for specific services.

8.2 Patients transferred to the discharge lounge will require case notes to accompany patients to enable further care or treatment delivered is documented in the care plan.

8.3 Transfer Letter for patients discharged back to a care home, confirming reason for admission, treatment and monitoring required

8.4 District Nurse Referral letter for community nurse confirming reason for admission, treatment and monitoring required. Any wounds, bruises or skin blemishes will be recorded on a body map.

8.5 GP Letter (page 10, Good Practice in Discharge Planning) - the contents of this letter should be discussed with the patient/carer to ensure they fully understand about their diagnosis, treatment and recovery time and possible set backs.

8.6 Medicines information card for patients who require additional support for the appropriate dose of medication and any potential side effects.

8.7 Relevant literature/ advice cards in relation to the patient’s condition as deemed appropriate by the Medical staff or Named Nurse or if requested by the patient

8.8 Contact details of who to contact for advice if worried following discharge.

8.9 Outpatient appointments

8.10 A medical certificate for patients who have been advised to refrain from work

8.11 Inter healthcare infection prevention transfer form- if the patient has had any infections during hospital admission

8.12 Copy of decision support tool –can be provided for families and carers/ care homes, if this is requested and the patient consents.

8.13 A discharge planning checklist is completed by the nurse discharging the patient on the day of discharge



9. DISCHARGE / DELAYED TRANSFER OF CARE

9.1 The statement below is taken from the Community Care (Delayed Discharges) Act 2003 and is used to define a delayed transfer/discharge for patients in UHL. It should be recognised that only patients fulfilling this criteria should be reported as delayed in transfer/discharge. Where any of the criteria below is not fulfilled and/or there is no documented evidence the patient cannot be defined as delayed in discharge/transfer of care.

“A delayed transfer occurs when a patient is ready for transfer from a general and acute hospital bed, but is still occupying such a bed”.

9.2 A patient is ready for transfer from acute hospital care when:

a) The consultant and clinical team agrees that the patient is ready for transfer and this is recorded in the medical notes –‘Health Complete’

b) The multidisciplinary team agrees that the patient is ready for transfer

c) The patient is safe for discharge/transfer

9.3 Reporting:

a) Monitoring of delayed transfers of care will take place by weekly census at midnight on Thursday for submission to DoH UNIFY 2.0 performance reporting. The information must be accurate and it is the responsibility of each ward to report all delayed transfers of care on the SITREP.

b) The Ward Sister/Charge Nurse is responsible for ensuring that the data is collected on his/her ward and submitted to the Discharge Specialist Team each week for the SITREP

c) The Discharge team will ensure that delays are signed as accurate by relevant team managers and partners.

9.4 Escalation

a) In the event that discharge is not progressing according to agreed timescales due to social services issues the flow chart showing escalation to be used (see Section 3 UHL Good Practice in Discharge Planning)

b) In the event of a planned discharge not going ahead, the Discharge team will be informed. The delay in transfer of care will be documented in the notes and a discussion with the multidisciplinary team to formulate an action plan will take place.

10. TRAINING AND EDUCATION

10.1 UHL is committed to raising awareness of effective discharge planning by the provision of discharge training for all staff within the Trust and partner agencies:

10.2 The Trust Discharge Team is responsible for the development, implementation and evaluation of Trust Discharge Training events.

10.3 The Trust Discharge Team will ensure up to date information relating to discharge is available on the Trust Document Management Service (DMS)



10.4 Ward Sisters, Senior Nurses, Heads of Nursing, Divisional Managers, Consultants and Clinical Directors will ensure that all staff has access to training and education to maintain up to date knowledge of local and national policies relating to discharge planning.

10.5 All staff have responsibility to attend an update of the Trust Discharge Training organised by the Discharge Team if a training need or gaps in knowledge are identified at appraisal’

11 DISSEMINATION AND IMPLEMENTATION PROCESS

This Policy will be disseminated through existing Divisional communication channels with a covering letter highlighting the changes in practice

12 DOCUMENT CONTROL, ARCHIVING AND REVIEW

12.1 The document will be reviewed and updated every three years, or sooner in response to any identified patient care issues or risks.

12.2 This document will be stored for access via SharePoint and archived through this system

13 LEGAL LIABILITY The Trust will generally assume vicarious liability for the acts of its staff, including those on honorary contract. However, it is incumbent on staff to ensure that they:

• Have undergone any suitable training identified as necessary under the terms of this policy or otherwise.

• Have been fully authorised by their line manager and their Directorate to undertake the activity.

• Fully comply with the terms of any relevant Trust policies and/or procedures at all times.

• Only depart from any relevant Trust guidelines providing always that such departure is confined to the specific needs of individual circumstances. In healthcare delivery such departure shall only be undertaken where, in the judgement of the responsible clinician it is fully appropriate and justifiable - such decision to be fully recorded in the patient’s notes.

It is recommended that staff have Professional Indemnity Insurance cover in place for their own protection in respect of those circumstances where the Trust does not automatically assume vicarious liability and where Trust support is not generally available. Such circumstances will include Samaritan acts and criminal investigations against the staff member concerned.

Suitable Professional Indemnity Insurance Cover is generally available from the various Royal Colleges and Professional Institutions and Bodies.

For further advice please contact Assistant Director (Head of Legal Services) on 0116 258 8960.



15. GLOSSARY

14. EVIDENCE BASE AND RELATED POLICIES

National framework for NHS funded Continuing Health Care and NHS funded Nursing Care (DoH revised 2009)

Achieving Timely ‘simple’ discharge from hospital. A toolkit for the multidisciplinary team (DoH 2004)

Safety First - Confidential Enquiry into Homicide and Suicide by People with Mental Illness DoH 2001

Report of the Confidential Enquiry into Homicide and Suicide by People with a Mental Illness 1999 page 98 recommendation 21

National Service Framework Mental Health DoH 1999 Standard 5 page 41

National Service Framework Coronary Heart Disease DoH 2000 Standard 12 page 52

National Service Framework for Older People

Community Care (Delayed Discharges) Act 2003

Discharge from hospital: pathway, process and practice (DoH 2003) http://www.doh.gov.uk

UHL Good Practice in Discharge Planning Trust reference B20/2009

CPN - community psychiatric nurse

DN - District nurse

ED - emergency department

RNCC - registered nursing care contribution

IMCA - independent mental capacity advocate

MCA - Mental capacity assessment

EMAS - East Midlands ambulance service

DNAR - Do not resuscitate order

PCT - Primary Care Trust

MDT - multidisciplinary team

CHC - continuing health care

Section 5 referral - notification to social services for discharge

Section 2 referral - notification to social services for assessment

EDD - Estimated discharge date

DFiT

ischarge Policy for Adult Patients leaving hospital of 25nal Version Approved by Policy and Guideline Committee on 28th October 2011 rust Ref: awaiting allocation B2/200 Next Review: October 2014


Legal affairs briefing note 33- Interim guidance on the role and appointment of Independent mental capacity advocates. http://www.pohwer.net

Deprivation of Liberty Safeguards. Trust reference B15/2009.

Advance Decisions and Lasting Powers of Attorney. Trust reference B21/2004.

UHL Mental Capacity Act Policy. Trust reference B23/2007.

Safeguarding Adults Policy and Procedures. Trust reference

3

http://www.doh.gov.uk/



Discharge Policy for Adult Patients leaving hospital of 25 Final Version Approved by Policy and Guideline Committee on 28th October 2011 Trust Ref: B2/2003 Next Review: October 2014

NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Document

16. MONITORING COMPLIANCE WITH THE PROCESSES OUTLINED WITHIN THE POLICY What will be monitored How, method, Frequency Lead Reporting to

Discharge planning metrics-EDD; Letter A; Patients with ongoing care needs following discharge are identified to encourage early discharge planning; identification of NOK/Carer involved with discharge planning; TTO completed prior to day of discharge

Senior nurse audits discharge planning template of 6 patients per ward each month

Divisional Head of Nursing, CBU lead nurse

Director of Nursing

1pm discharge standard- patients discharged by ward to discharge lounge by 1pm & patients discharged from Trust by 1pm

Weekly report by ward/ division across the Trust produced by acute division business analyst

Divisional manager Head of Nursing

Trust discharge planning group Transitional Planning Steering Group

Discharge planning process for patients with ongoing care needs-looking at discharge requirements for specific patient groups and documentation to accompany patient.

Annual-Retrospective audit of case notes by Discharge Team

Specialist Nurse for discharge

Nursing Exec Trust Discharge planning Group

Completion of discharge planning letter (GP) Quarterly performance audit/ report audit of discharge letter by CASE

Clinical Director CBU Leads

Medical Director

Readmission rates- patients who are readmitted within the first 7 days following discharge and patients who are readmitted within 30 days following discharge

Monthly report provided by business analyst

Clinical Director Divisional head of nursing CBU Lead

Trust readmission board

Delayed transfer of care (DTOC) DTOC -Recorded by Discharge team daily (monthly report by IT.) Monthly quality performance report for weekly national reporting for DTOC

Specialist Nurse for discharge

Chief operating officer Trust Discharge planning group Transitional Planning Steering group

Discharge Policy for Adult Patients Leaving Hospital · Supersedes: V2 (original approved February...

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