Trust Policy and Procedure Discharge Planning Operational ... · Case Conference On occasion, the MDT may consider it beneficial to hold a case conference for a particular patient

Source: Discharge Planning Team Lead Status: Approved Page 1 of 63 Issue date: Sept 2019 Review date: Aug 2022 Document reference PP(19) 062

Trust Policy and Procedure

Discharge Planning Operational Policy Document Ref: PP(19)062

For use in: Trust Wide

For use by: All staff

For use for: All staff

Document owner: Discharge Steering Group

Status: Approved

INTRODUCTION .............................................................................................. 3

ACKNOWLEDGEMENTS ................................................................................. 3

FLOW CHART SIMPLE DISCHARGES ........................................................... 4

FLOW CHART COMPLEX DISCHARGES ...................................................... 5

THE DISCHARGE TEAM (ADULT SERVICES) ............................................... 6

SECTION 1 ADULT AND CHILD DISCHARGE POLICY .................................. 7 Principles ....................................................................................................... 7 The Multidisciplinary Team (MDT) ................................................................. 7 Case Conference .......................................................................................... 8

Section 1.1 - Routine Discharges ..................................................................... 9 Good practice for board rounds …………………….……………......… 10 SAFER …………………………………….…………..……..……………..11

Section 1.2 - Points for a Complex Discharge................................................. 14

Section 1.3 – Patients discharging against medical advice ............................. 14

Section 1.4 - Discharges out of hours ............................................................. 15

Section 1.5 Alternative Discharge Destinations .............................................. 17 Nursing & Residential Care Homes ............................................................. 17 Hospice ....................................................................................................... 17

Section 1.6 Discharge Planning in End of Life Care and Last Days of Life 18

Principles ........................................................................................................ 18 Rationale ..................................................................................................... 19 multidisciplinary team ................................................................................ ..20

Checklist ……………………………………………….………….……………..20

SECTION 2 RESPONSIBILITIES OF GROUPS/AGENCIES INVOLVED WITH THE DISCHARGE PROCESS ...................................................................................................... 21

Section 2.1 - Registered Nurses ..................................................................... 21 Discharge Responsibilities .......................................................................... 22

Section 2.2 - Consultant Teams ...................................................................... 24 Discharge Responsibilities .......................................................................... 24 In-patients on Discharge.............................................................................. 24 Attendance at ED ........................................................................................ 24 GP Discharge Notification ........................................................................... 24


Section 2.3 - Discharge Planning Team .......................................................... 26 Discharge Planning Team (DPT) ................................................................. 26 Discharge Responsibilities .......................................................................... 26

Section 2.4 - Care Co-ordinators .................................................................... 27

Section 2.5 - Adult Care Services ................................................................... 28 Referral Criteria ........................................................................................... 28

Section 2.6 - Physiotherapists ......................................................................... 30

Section 2.7 - Occupational Therapist (OT) ...................................................... 31 Section 2.8 - Speech and Language ………………………… ……….………..32

Section 2.9 Early Intervention Team (EIT) ………………………………………34

Section 2.10 - Nutrition & Dietetic Services..................................................... 35 Discharge Planning for Inpatients ................................................................ 35

Section 2.11 – Suffolk Community Services …… …………………….……….36Error! Bookmark not defined.

Section 2.12 – Support to Go Home Service .................................................. 38 Section 2.13 - Medically Optimised Team …………… ..…………………........39 Section 2.14 - General Practitioners ………… …………………………………41 Section 2.15 - Pharmaceutical Services. … ……………………………………42

SECTION 3 DEPARTMENTAL ISSUES ......................................................... 43

Section 3.1 - Accident and Emergency (ED) ................................................... 43

Section 3.2 - Day Surgery ............................................................................... 44

Section 3.3 - Maternity .................................................................................... 45

Section 3.4 - Mental Health ............................................................................. 47

Section 3.5 - Patients with Learning Disabilities …………………..……………48

Section 3.6 - Discharge Waiting Area ............................................................ 50

SECTION 4 ..................................................................................................... 53

ADDITIONAL INFORMATION ........................................................................ 53

Section 4.1 - Transport Facilities ..................................................................... 53

Section 4.2 - Patient Escorts ........................................................................... 53

Section 4.3 - Equipment .................................................................................. 54

Section 4.4 - Patients Property ....................................................................... 55

Section 4.5 - Suffolk Family Carers ................................................................. 56

Section 4.6 – British Red Cross Support at Home …………...………….……57

Section 4.7 Chaplaincy Friend Service ……………………………. ..….………58 Section 4.8 Outpatient Parental Antimicrobial Therapy (OPAT) .......……..….59 Section 4.9 West Suffolk Housing Options ………………………......……...….60 Section 4.10 The Warm Homes Fund …………………………..…..….………..61


INTRODUCTION

West Suffolk NHS Foundation Trust provides acute and community care services to a population of approximately 280,000 people. This policy identifies the roles of those involved in the discharge of patients and guides the reader through the processes of discharge. It has long been recognised that collaborative working and good communication between agencies are key in ensuring that people needing care have the supporting services they need at home or elsewhere. As an integrated organisation working to support patients across a number of care settings including clinics, hospitals and patients own homes, any ongoing care needs from one setting to another is regarded as a transfer of care, rather than a discharge; with the aim of ensuring that this takes place as smoothly as possible and is supported by the provision of robust clinical detail and an understanding of the needs of the person concerned. The aim of this policy is to ensure that all agencies involved in the provision of social, nursing or medical care work together to deliver an effective, smoothly co-ordinated service that meets the needs of it users, patients, carers and families. The document will be reviewed as new developments and processes are implemented.

ACKNOWLEDGEMENTS

The following departments and agencies have contributed to this Discharge Planning Policy. They have reviewed and commented on this document.

Adult Care Services – Suffolk County Council

Service Managers

Patient Forum Groups

Consultant Teams

Patient Flow Team

Occupational Therapists

Paediatrics

NHS Suffolk

Pharmaceutical Services

Physiotherapist

Speech & Language Therapists

Nutritional & Dietetic Services

All those practitioners who are detailed in this policy


SIMPLE

Key – key worker can be hospital or community based e.g. Social Worker, Registered Nurse, Nurse Specialist, Health Visitor, Occupational Therapist, Physiotherapist, Speech & language therapist, District Nurse Liaison

Key – key worker can be hospital or community based e.g. Social Worker, Registered Nurse, Nurse Specialist, Health Visitor, Occupational Therapist, Physiotherapist, Speech & language therapist, District Nurse Liaison

Usually discharged to usual place of residence

Have simple care needs that do not require complex planning and delivery

Yes No

Nursing staff to inform patient, relatives/carers of estimated discharge date

Refer to Therapies and Social Services if necessary.

Provide if required: - Outpatients appointment - Dressings - Equipment - Information leaflets/advice

sheets - To Take Out (TTO’s)

medications - Book transport (in

exceptional circumstances) - Ensure a copy of the

transfer of care summary is given to the patient and sent electronically to GP

- SPOA sent to community services

Identify discharge co-

ordinator

GO TO

COMPLEX

DISCHARGE PATIENT

HOME

If medically/surgically optimised indicate on whiteboard


COMPLEX

Discharge Co-ordinator/Specialist Discharge Planning Nurse Multi-disciplinary team to identify patient needs for discharge

Identify changing needs or service requirements of the patient Discharge planning nurse to complete D2A paperwork/refer to palliative care if potential fast track patient

COMPLEX

Yes

Nursing staff to inform patient, relatives/carers of estimated discharge date

Refer to Therapies and Social Services if necessary.

Provide if required: - Outpatients

appointment - Dressings - Equipment - Information

leaflets/advice sheets

- To Take Out (TTO’s) medications

- Book transport (in exceptional circumstances)

- Ensure a copy of the transfer of care summary is given to the patient and sent electronically to GP

- SPOA sent to community services

Does patient have complex transfer of care needs?

No

Patient is discharged

If medically/surgically optimised indicate on whiteboard


THE DISCHARGE TEAM (ADULT SERVICES)

Multi-disciplinary Team Members and agencies who can be involved in the Discharge Process

Care Co-ordinators Registered Nurses

Transport Physiotherapist

Consultant Teams Occupational Therapist

Pharmacist Social Worker

Discharge Specialist Nurses Planning Nurses

Sheltered Nursing & Residential Accommodation Care Homes

Voluntary Warden Controlled Groups & Charities Accommodation

Relative/Carer NHS Funded Continuing Health Care

NHS Suffolk Intermediate Care Resources

District Nurses General Practitioners

Macmillan Nurses

The Patient


SECTION 1 ADULT AND CHILD DISCHARGE POLICY

Principles

There are a number of principles, which underpin practice across all aspects of discharge planning; these are listed below.

Each patient's discharge will be planned by the multi-disciplinary team in conjunction with the patient, relatives, and/or carer, and will begin on or before the patient's admission to hospital. It will be an on going process that will involve the patient, relatives and carer, and will provide a seamless transfer from hospital to the most appropriate environment.

The estimated discharge date (EDD) should be set at the first consultant review.

The multi-disciplinary team will identify those patients who may be vulnerable and have special needs, which will need additional consideration. Guidance on patients who may be considered to be vulnerable is given in Appendix 1. Such patients must be identified as soon as possible and their needs addressed in order to facilitate their discharge.

All elements of discharge planning along with dates and contact details will be clearly recorded in the patient's documentation.

Respect and consideration will be shown for the needs of relatives and carers. Where necessary, needs assessment and referrals for relatives and carers can be completed.

A carer is defined as “any person, voluntary or professional, who is involved in providing care related services” (Carers Charter and Carers Recognition and Services Act (2)).

All patients will be provided with the relevant health education and support relating to their discharge, whilst encouraging self-care wherever possible.

The patient/relevant others will be kept informed and involved regarding their discharge arrangements. Access to patient’s information will be given in accordance with the Data Protection Policy PP(18) 110.

Written information should support and reinforce any verbal instructions given regarding discharge arrangements. This can include for example:

Leaflets

Booklets

Advice sheets following operations (operation specific)

Relevant contact numbers should the patient or carer experience a problem following discharge.

The Multidisciplinary Team (MDT)

This title refers to all staff involved in the patient’s care and management. These include but not limited to nurses, doctors, therapists (OT, PT, SALT) and social workers but many other hospital staff are involved where required, as are community services.

Individual members of the multi-disciplinary team involved in the care of the patient should identify when referrals or communication is needed to be made to other disciplines not currently involved in the patient's care.


The MDT should decide the appropriate date and method of the patient’s discharge. Some Consultants schedule formal MDT meetings where they can co-ordinate their patient’s plan of care with all team members present.

All members of the MDT should communicate and document all discharge plans.

Case Conference

On occasion, the MDT may consider it beneficial to hold a case conference for a particular patient. The MDT will meet (as described above), with the addition of the patient, relative, and /or carer. It may be necessary for a professional preparatory meeting prior to the case conference. In some instances the patient or relative may request a particular aspect of care or service not to be discussed at the conference; this must be acknowledged and taken into account with the best interest of the patients the prime consideration. A record of the case conference must be documented.


Section 1.1 - Routine Simple Discharges

A routine simple discharge is one that:

Will usually return to their own home

Have simple ongoing care needs which do not require complex planning and delivery

Do not confuse the needs of a patient who has complex clinical needs with those of a patient who has complex transfer of care needs.

Points for Routine Discharge

Start planning for discharge or transfer before or on admission.

An estimated discharge date should be identified after the first consultant review. When informing the patient of this date, remind them that it is estimated and subject to change.

The admission assessment should identify as much information about the patient as possible and include details of community and family support being delivered and inform any established community care services and care agency of the patient’s admission within 24 hours. Any discharge needs that are identified should be documented and the named or appropriate professional should be informed.

If the patient was in receipt of community services prior to admission, for example District Nursing Services (DNS). Please inform them that the patient has been admitted. If a patient requires community services on discharge, please inform relevant services by completing a single point of access (SPOA) referral as soon as care needs have been identified and discharge date known.

If a patient was in receipt of a social services package of care prior to admission and their care needs remain the same, follow the restart of care package flow chart. If the patient has a change in care need of requires further social services input follow the Assessment/Discharge Notice process.

Ensure the patient has all their discharge requirements e.g. transport arrangements, to take out (TTO) medications, equipment, follow up appointments etc. TTO medication must be checked against the prescription and explained to the patient or carer prior to discharge.

For the patient, relative and carer even the most simple discharge can be concerning. They may require additional information and advice about potential lifestyle changes following their discharge. Providing advice sheets or booklets are useful for the patient to take home. Always ensure that the patient and if appropriate, carer is given the opportunity to ask questions prior to leaving the ward.

General Practitioners (GP) must receive notification of the patients’ discharge from hospital within 24 hours for all patients and on the day of discharge when the patient will be receiving a package of health and/or social care support in the community. The electronic discharge summary is sent via e-Care to the GP and a copy given to the patient.

It is the responsibility of the registered nurse discharging the patient to follow the discharge plan and ensure ‘discharge planning’ is complete. The registered nurse should be satisfied that the patient will leave with the best and most appropriate support.

Patients discharged with equipment such as PEG feeds or an indwelling catheter will need to be educated in its use and management. Information must be provided prior to discharge with contact numbers and names given to the patient, relative or carer in case of difficulties


With the patient’s consent or in their best interests, the relatives and informal carers should be involved in the discharge arrangements. When the patient is a child, all the discharge planning will be undertaken in partnership with the child and parent or carer. Unless, with parental consent it is deemed in the best interest of the child or young person that their discharge is planned without their knowledge until the actual time discharge.

Good practice for board rounds

In attendance:

Senior Clinical Decision Maker (Consultant)

Nurse in Charge

Care co-coordinator

Therapists

Pharmacist

Social worker and or discharge planning

Where possible:

Start with all patients marked as red on the whiteboard

Start at 8.30am - 30 Minutes Maximum (20 minutes is the ideal)

To include:

Clinical Criteria for Discharge (CCD)

Planned Discharge Date (PDD)

What needs to be done today? – Then what?

Name to actions

Huddle in the afternoon to check actions complete

Conduct the Board Round at the white board completing the actions for the day by 10.30am. Mark patients

as Red or Green. Red patients that the ward cannot unblock escalate to divisional manager of the day

LEAVE THE BOARD ROUND KNOWING EXACTLY WHAT YOU ARE DOING FOR EACH PATIENT

TODAY

Red and Green bed days

‘Red and Green bed days’ is a visual management system to assist in the identification of wasted time in a

patient’s journey. This approach is used to reduce internal and external delays as part of the SAFER

patient flow bundle.

A red day is when a patient receives little or no value adding acute care. The following questions should be

considered.

Could the care or interventions the patient is receiving today be delivered in a non-acute setting?

If I saw this patient in out-patients, would their current ‘physiological status’ require emergency

admission?

If the answer is 1. Yes and 2. No, then this is a ‘Red bed day’

Examples of what constitutes a Red bed day:


A planned investigation , clinical assessment, procedure or therapy intervention does not occur

The patient is in receipt of care that does not require an acute hospital bed

The medical care plan lacks a consultant approved expected date of discharge

There is no consultant approved physiological and functional clinical criteria for discharge in the

medical care plan.

A RED day is a day of no value for a patient

A Green day is when a patient receives value adding acute care that progresses their progress towards

discharge.

A Green day is a day when the patient receives care that can only be in an acute hospital bed

A Green day is a day of value for a patient

At the centre of the system is the person receiving the acute care whose experience should be one of

involvement and personal control, with an expectation of what will be happening. It can be useful to

consider whether that person is able to answer these simple questions as soon as possible after their

arrival at hospital:

Do I know what is wrong with me or what is being excluded?

What is going to happen now, later today and tomorrow to get me sorted out?

What do I need to achieve to get home

If my recover is ideal and there is no necessary waiting, when should I expect to go home?

Red to Green Days

What constitutes value to a patient’s journey to make it green today?

All patients will remain red irrespective of actions taken if:

There is no senior clinical decision maker at the Board Round – this should be the Consultant

There is no Predicted Date of Discharge (PDD)

There is no Clinical Criteria for Discharge (CCD)

All patients will start the day as red

Some will go straight to green as a plan is already in place and being actioned with no foreseeable further

actions being needed e.g. patients receiving IV therapy that can only be administered in an acute hospital.

Most patients will only go green once the agreed action for the day has been completed.

SAFER

The patient flow bundle is a combined set of simple rules for adult inpatient wards to support an improvement in patient flow and prevent unnecessary waiting for patients.

The SAFER bundle blends five elements of best practice. It’s important to implement all five elements

together to achieve cumulative benefits. It works particularly well when it is used in conjunction with the

RED and GREEN days approach. When followed consistently, length of stay reduces and patient flow and

safety improves.

The Safer patient flow bundle


S - Senior review. All patients will have a senior review before midday by a clinician able to make

management and discharge decisions.

A - All patients will have an Expected Discharge Date (EDD) and Clinical Criteria for Discharge (CCD), set

by assuming ideal recovery and assuming no unnecessary waiting

F-Flow of patients to commence at the earliest opportunity from assessment units to inpatient wards.

Wards routinely receiving patients from assessment units will ensure the first patient arrives on the ward by

10am

E – Early discharge 33% of patients will be discharged from base inpatient wards before midday

R – Review A systematic multi-disciplinary team (MDT) review of patients with extended lengths of stay (>7

days – also known as ‘stranded patients’) with a clear ‘home first’ mind set.

S – Senior review All patients should have a senior review before midday

Planned Date of Discharge and Clinical Criteria for Discharge

Planned Date of discharge (PDD) and Clinical Criteria for Discharge (CCD) are essential care coordination

tools.

CCD is a minimum physiological, therapeutic and functional status the patient needs to achieve before

discharge. It should be agreed with the patients and carers where necessary.

PDD should be set at the first consultant review and no later than the first consultant post-take ward round

the next morning. It is important that PDD’s

The use of Red Green Bed Days at Board Rounds and the implementation of SAFER patient flow bundle

help teams identify and manage constraints to delivering the PDD

Stranded patients

Stranded patients can be identified as those with a length of stay (LOS) of seven days or more. The aim of

any review of these patients is to understand what is the plan and what is the next thing that these patients

are waiting for on the day of review.

The review should capture both qualitative and quantitative information on the reasons for the wait with a

report compiled from all the material gathered and should aim to:

Understand why patients are in hospital for seven days or more

Identify themes, where possible

Identify patient characteristics so patient groups can be identified early

Identify areas of good practice

Identify areas requiring focus where there is an opportunity for improvement

Stranded patient review meetings are led by the executive chief operating officer or deputy. They are

attended by discharge planning team, medically optimised team, Adult and community services, (ACS)

ward coordinators and ward nurse coordinators.

Stranded patient meetings are held on a Tuesday and Thursday from 1pm – 3pm. The Tuesday meeting

focuses on all patients with a length of stay between 3 – 20 days. Ward co-ordinators and a nurse attend

and the points above are discussed and information captured.


The Thursday meeting focuses on patients with a LOS >21 days (super stranded patients) in the acute

setting. There is also a focus on patients from other counties (predominantly Norfolk and Cambridge) and

Delayed Transfers of Care (DTOCs).

Each patient in the Trust with a length of stay > 21days is coded (by the discharge planning team) using

guidance for Long length of stay Discharge Patient Tracking List (LLOS DPTL) from NHS England and

NHS Improvement.

Patients are also reviewed who occupy Community Assessment beds, (Newmarket and Glastonbury

Court). Teleconference in to the meeting and each patient with a LOS > 7 days are reviewed.

Today’s Action Red to Green Status

The patient needs a diagnostic / investigation arranged

Red until the diagnostic / investigation has been arranged

The patient is waiting for the diagnostic / investigation

Red until the diagnostic / investigation has been completed and reported on

The patient needs a referral to another team Red until referral has been made

The patient has been referred to another team and a date to be seen has been confirmed

Green as a clear plan is in place

The patient was referred to the other team yesterday but not yet seen or date/time confirmed

Red as no clear plan to be seen in in place

The patient can go home and is waiting for TTOs to be written up and transport to be arranged

Red until TTOs have been prescribed and requested and a transport time has been confirmed

The patient can go home tomorrow once reviewed

Green as plan today has been agreed

The patient is going home at 11.30. TTOs ordered and transport arranged

Green as all actions are complete

The patient is medically optimized and waiting for confirmation of a social care package or placement

Red until the package has been confirmed

The patient is medically optimized and is going home tomorrow with their care package

Green as all actions are complete


Section 1.2 - Points for a Complex Discharge

All the points relating to simple discharges also apply to complex discharges. Patients with more complex needs often require assessment, planning and delivery by the MDT to facilitate their discharge.

The daily morning board round held on the ward will highlight those patients who have complex discharge issues.

There are specialist teams that facilitate complex discharges. These include: the Discharge Planning team, medically optimised and social services. Referrals to particular services should occur as soon as the need is identified.

It is the responsibility of the medical staff to specify when a patient is medically optimised for discharge, and this date should be documented in the patient's medical notes. This should also be indicated on the ‘whiteboard’ on e-Care.

Discharge will generally only occur after a full assessment of an individual’s needs. Patients will be reviewed and discussed with relevant community, health and social care staff as part of their discharge. If the individuals are assessed against any of the continuing health care eligibility criteria they will be kept informed and given written evidence of the outcome by the relevant Clinical Commissioning Group.

If a patient is identified as homeless (no fixed abode) or have housing needs, health and social care staff have a duty to refer to Housing Services.

Child and Family

Over recent years paediatric nursing has changed and there is now a strong emphasis in nursing children at home. Paediatric nurses have an essential role to ensure a safe transition from hospital to community care. The role they play in partnership with paediatric community nurses is to ensure parents and caregivers have appropriate teaching and support to care for their child at home.

Therefore discharge planning should be started from the time of admission. The named nurse has an ideal opportunity to discuss problem issues the child and family may have at home and support systems should be initiated at this point.

Over recent years paediatric nursing has changed and there is now a strong emphasis in nursing children at home. Paediatric nurses have an essential role to ensure a safe transition from hospital to community care. The role they play is to ensure parents and caregivers have appropriate teaching and support to care for their child at home.

Therefore discharge planning should be started from the time of admission. The named nurse has an ideal opportunity to discuss problem issues the child and family may have at home and support systems should be initiated at this point.

Section 1.3 – Patients Discharging Against Medical Advice


If by discharging themselves the patient could potentially be at risk, then all staff should endeavour to persuade the patient to stay. They should not, however risk their own personal safety. Any treatment or medication should be given wherever possible to remedy any inappropriate behaviour due to a medical complaint and TTO’s supplied.

If after all appropriate personnel have been informed, have spoken to the patient and the patient is deemed to have capacity but still wishes to leave, they should sign a ‘Discharge Against Medical Advice’ form. The patient should be advised to contact their GP practice, as they may need services or treatment in the community.

The doctor will, as with regular discharges send a discharge letter to the GP and should contact the GP by telephone if they have any immediate concerns. Nursing staff should inform any appropriate community staff or relatives/carers and their senior nurse on duty.

If the patient is under sixteen and wishes to leave against advice or leaves without permission the nurse should inform: the parent or carer, the senior nurse on duty, their Medical/Surgical team, the police (security and the child psychiatrist if involved in the child’s care).

All appropriate paperwork should also be completed. If a parent attempts to discharge a child who is under a child protection order, the police and social services must be informed immediately.

If a patient wishes to discharge him or herself because they have concern or complaint, all efforts need to be made to resolve the problem in order to allow their care to continue.

NB if patient lacks capacity, refer to the Trust Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). Policy ref: PP(19) 223.

Further information on dealing with complaints can be sought by contacting the PALS Team on ext 2555 who will give appropriate advice. Please also refer to the formal complaints leaflets in ward and clinical areas and the Formal Complaints and Management Policy PP(19) 002

Section 1.4 - Discharges out of hours


Discharges made outside hours of 09.00 – 17.00 and during holiday periods for patients with complex needs requiring community support (as defined in Appendix 1) requiring community support are only appropriate if planned well in advance and agreed by all parties involved. Unplanned discharges at such times can fail and can consequently result in re-admission. To ensure patients are discharged appropriately:

The patient, relative and any carer must be informed of the date and time of discharge.

Patients, relatives and carers should be given the contact details of the relevant care/service provider in the event of care not starting as planned after discharge.

If transport is required out of hours then this can be arranged via normal non-emergency patient transport booking system.

If the patient requires TTO medication it must be available on the ward for the patient. In urgent circumstances the on-call Pharmacist can be called to dispense the medication and contact via patient flow team.

The duty Social Worker can be contacted if there is an important issue relating to a patient being discharged out of hours.

Duty Social Worker contact details (out of hours only)

Suffolk County Council

Telephone 01473 219669


Section 1.5 Alternative Discharge Destinations

Illnesses that require hospitalisation can sometimes mean that patients are unable to return to their original place of residence and require an alternative discharge destination. It is important to ensure that communication regarding the patient’s discharge destination is explained clearly to the patient, relatives and carers.

Nursing & Residential Care Homes

Do the patient and relatives know where the home is, how to get there and the contact number?

It is the named nurses’/team nurses’ responsibility to contact the home and confirm the time of transfer

Transfer information should be provided and a copy kept in the patients’ notes.

If the patient needs to attend any follow up outpatient appointments or clinics the care co-ordinator will inform appointments to send the appointment letter to the patient.

It is the responsibility of the nurse discharging the patient to ensure they are suitably dressed when being transferred from hospital.

If a patient is to be transferred to a residential home and has a nursing need, a referral needs to be made to the District Nursing Service via SPOA on Evolve.

Hospices (see section 1.6)

If the patient is known to the hospital Palliative care team staff should liaise with the clinical nurse specialist to access hospice care services.

If they are not known referrals to the hospice can be done by ward staff, but a referral for inpatient care is likely to need assessment by the hospital palliative care team prior to being accepted.


Section 1.6 - Discharge Planning in End of Life Care and Last Days of Life

(Please read in conjunction with End of Life Policy number PP(17)310 and Last Days Clinical Guideline number CG10057-5)

Principles

The NICE (2004) Guidance for Improving Support and Palliative Care for Adults with Cancer, in the future will apply to the care of all patients with a life threatening disease, states that:

Patients wish to be enabled to die in the place of their choice, often in their own home

Therefore people’s preferences on the location of care are followed whenever possible

All patients should have a dignified death with family and other carers adequately supported during this process

Discharge Planning in End of Life Care and Last Days of Life Patients reaching the end of their lives will often require special attention to their discharge planning and clear communication is essential for good co-ordination of care. Patients (and carers) will need to be involved in discharge planning which should consider medications (required now and ‘Just in Case’). These will be sent with the patient, along with community administration sheets to allow the District Nurses to administer the medications. These sheets are completed by the Palliative care team prior to discharge. Ongoing care will also help to avoid crisis by anticipating future care needs. For some patients who have a short prognosis, or are rapidly deteriorating there may not be time to go through the normal continuing care health needs assessment. These patients may be suitable for Fast Track Continuing Care funding and this can be facilitated through the Palliative Care Team and Discharge Planning Team. The table below is a guide

Prognosis Routine discharge Complex discharge

Months Ward Discharge Planning Team

Weeks Discharge Planning Team/Palliative Care Team

Discharge Planning team and Palliative Care Team

Days Discharge Planning Team and Palliative Care Team

Discharge Planning Team and Palliative Care Team

Yellow ‘My Care Wishes’ Folders It is important that patient information is always available to the patient, staff and carers on transfer/discharge from hospital. Therefore, establishing patient held records as a solution is an initiative that is used in Suffolk. The ‘Yellow ‘My Care Wishes’ folder is a patient held record which may contain current information on discussions that the patient has had about their condition and what is important to them in terms of care; this could include a community Do not attempt resuscitation document On admission, if the patient brings in their Yellow ‘My Care Wishes’ folder, information contained in the folder should be acknowledged and discussed with the patient and family as appropriate. The yellow ‘My


Care Wishes’ folder and contents should remain with the patient and any new information from the admission added on discharge.

On discharge, if a new advanced care planning discussion has taken place during admission, it may be appropriate to issue a yellow ‘My Care Wishes’ folder. Please contact the hospital Palliative Care Team for advice, or ask the GP to consider issuing a yellow ‘My Care Wishes’ folder after discharge. For all end of life care discharges, always refer to district nurses using “single point of access” to request a ‘palliative care assessment’ and complete a comprehensive hospital discharge

letter (including patients diagnosis, prognosis, understanding of condition and care arranged) suggest that the GP enters the patient on their GP GSF/palliative care register and inform their out of hours provider as appropriate. Discharge Home in Last Days of Life Occasionally when patients and families become aware that death is imminent they express the wish for discharge home to die. The principles for care and assessment still apply but in addition consideration must be given to who will provide care once the patient is discharged, whether equipment is required, transport and communication with community health care professionals. The family will require information on the process of dying, understand the task they are taking on and who is available to call on should help be required. Families need to be informed there is a risk the patient may die on the journey in the ambulance and that if this should occur the body is likely to be returned to the hospital Emergency Department for verification rather than be taken to the patient’s home. The discharge planning team and palliative care team should be informed asap as discharge is likely to be required the same day. The Fast Track discharge checklist, GP medication guidance and further information can be found on the Pink Book ‘End of Life Care Discharge’ section.

Addressograph


CHECKLIST FOR FASTRACK DISCHARGE

This is a checklist. All decisions, care plans and arrangements should be documented in the patient’s notes. Due to the complex nature of rapidly deteriorating patients, the Palliative Care Team, specialist discharge planning nurse and ward nurse should be involved and kept informed.

Information for ward use

Discharge checklist - details should be recorded in the patient’s notes

Yes N/A Initials

COMMUNICATION WITH PATIENT/FAMILY

Are the patient/family aware and in agreement with the discharge plan/destination.

Is the family aware the patient is being discharged for end of life care?

Has a yellow ‘My Care Wishes’ folder been issued by the palliative care team?

Patient is identified by multidisciplinary team as appropriate for fast track discharge (FTD)

Conversation on future care planning with patient and/or family agreed

Refer to Palliative Care and send e-Care referral, stating fast track discharge.

If not suitable for FTD please refer to Specialist Discharge Planning

team

Medical team complete: FTD paperwork, discharge letter and TTOs

CCG - Identify discharge destination and date of discharge. Ward: Order Transport for AM discharge

Information to confirm with patient transport when booking

Name and discharge address Patient is being discharged for end of life care Type of ambulance needed ie stretcher/chair Is the patient on O2 Does patient have community DNACPR Are there any access issues (check with patient

/family)

The ward doctors must ring the GP the day before a fast track discharge: To inform the GP that the patient is a fast track discharge, the likely rate of deterioration and any preferences or priorities the patient may have. To ensure the GP visits the patient. To inform them that ‘Just in case’ medications are prescribed in a way that the district nurses can give them ie GP has completed instructions to give. Special patient notes have been completed by GP to inform

the Out of Hours GPs of the patient’s situation.

Palliative care to refer to Discharge Planning Team on bleep 540 to: issue paperwork order equipment identify discharge destination


Has a community DNA CPR been discussed with patient/family and completed?

Has the family been provided with information leaflet `End of Life, The Facts’ booklet?

Do the patient/family need to have discussion regarding risks associated with travelling? If yes please document conversation in notes.

If appropriate, have any outstanding out patient appointments been cancelled?

Has the family been provided with emergency contact numbers?

FUNDING

Has the Fast Track document been scanned to the relevant CCG and discussed and care package/placement agreed?

MEDICATIONS

Has the hospital doctor prescribed medications for one week, including end of life medications “Just In Case”?

Is the patient receiving medications via syringe pump? If yes please see syringe pump policy. In addition:

Have extra giving sets and supplies been provided?

Has the medical equipment library been informed and are documents completed for syringe pump to accompany patient into community?

Has the syringe pump been reloaded and new battery inserted?

Has the District Nurse been notified of the syringe pump?

HOME OXYGEN (if applicable)

Is the level (L/min) of home oxygen decided and documented?

If receiving oxygen at home already is this sufficient for their needs - set to correct flow rate?

Has the oxygen been ordered? (Specialist Discharge Planning Team)

EQUIPMENT

Has the patient’s equipment needs been assessed?

Has all equipment been delivered?

Are supplies from ward being sent with patient (pads, pants, needles, syringes, gloves, aprons, catheter bags etc)?

TRANSPORT

Is there any problem with accessing the property?

Has transport been booked and the time documented? Advise transport ‘End of Life Care’ patient.

DISCHARGE COMMUNICATION - Home

Has a Single Point of Access Referral been sent to the appropriate District Nursing Team for palliative assessment?

Has the discharge summary been completed and sent to the General Practitioner (GP)

Has the hospital doctor phoned and spoken to the patient’s GP to advise of discharge, discuss medication and to request a home visit?

If appropriate, has a referral been made to the Community Palliative Care Team?

DISCHARGE COMMUNICATION – Nursing Home

Nursing home staff in agreement with date/time of discharge?

Discharge Health Assessment completed and sent with patient?

Has the hospital doctor phoned and spoken to the patients GP to advise of discharge and to request a visit and review?

IMMEDIATELY PRIOR TO DISCHARGE – check

Syringe pump reloaded?

Are stat doses of medication required for the journey?

Medications all complete?

All property with patient?

Is patient fit to travel?

Yellow My Care Wishes’ folder and e-Care discharge letter sent with patient

Have Palliative Care Team notified: Out of Hours GP of the discharge?

SECTION 2 RESPONSIBILITIES OF GROUPS/AGENCIES INVOLVED WITH THE

DISCHARGE PROCESS

Section 2.1 - Registered Nurses


The role of the nurse is central to safe and effective discharge. The patient’s most common source of information when planning discharge is the nurse on the ward. It is therefore essential that the nurse prepare the patient using all the appropriate resources available.

Discharge Responsibilities

The registered nurse is accountable for the patient’s discharge and works closely with the MDT to co-ordinate discharge. They must ensure that all relevant information is gathered, recorded and communicated in order to plan effective discharges.

The nurse who admits the patient should collect as much information about the patient as soon as possible. Names and contact details of any district nurses, community matron or family support must be documented clearly. It is helpful to explain to the patient, relative or carer that this information is essential to assist in their care and to facilitate a safe discharge.

The patient’s name, consultant, date of admission and estimated discharge date must be written clearly in the patient documentation. If the estimated date of discharge cannot be documented at this point, then it should be identified within 48 hours of admission. The estimated discharge date can be discussed and established via ward rounds, multi-disciplinary team meetings, whiteboard meetings and established pathways of care. It is the responsibility of the multi-disciplinary team to communicate regarding the discharge details date and the electronic patient record whiteboard should be updated accordingly. Once established the doctor should document the date in the medical notes and inform the named or accountable nurse.

The registered nurse should discuss with the patient any relevant information regarding their care and discharge. A discharge plan should commence on admission (if no pre-admission planning has taken place) and the nurses can then co-ordinate the discharge.

The RN should pay particular attention to how the patient manages their medication and if any appropriate medication aids are required to assist administration and concordance.

It is the nurse’s responsibility to liaise with existing community support services to inform them of the admission as soon as possible. This should be within the first 24 hours and will predominately apply to emergency admissions. If a patient is admitted over the weekend the community care services must be informed as soon as possible on the next working day. When an admission is planned the patient’s community support should have been informed in advance but this should be checked.

Community nurses and matrons are responsible for informing discharge planning if a patient on their caseload is admitted to WSFT. A secure answerphone is available: 01284 713030 for community staff to inform discharge planning of this.

The nurse caring for the patient on any shift should know the stage the patient has reached in their discharge preparation and should ensure that discharge planning is continued.

The nurse who has been assigned to patient care by the nurse in charge is responsible for the patient’s care. If they admit a patient they must familiarise themselves with any documentation required. As registered nurses, they are accountable for their practice and the basic principles of discharge planning. They should be informed as to what stage the patient has reached in their discharge preparation.

If a patient wishes to self-discharge it is the nurse’s responsibility to inform the appropriate personnel and ensure that all appropriate documentation is complete. Refer to section 1.3 for more information on patients discharging against medical advice

Outpatient appointments will be arranged on discharge. Details of the date and time of the appointment will be sent to the patient’s address

If there is an identified nursing need, the patient should be advised to make an appointment with their practice nurse.


If the patient is house bound and unable to attend their General Practice, referral to the District Nursing Service may be required. For further details see Section 2 – Community Nursing Services.

The specialist discharge planning team can assist in the management of patients with complex discharge planning needs: see Section 2.3.

On discharge the patient may have various requirements, these could include:

To take out medication (TTO), checked by the nurse against the prescription

Any dressings (minimum 3 days supply) or supplies required.

Refer to community services i.e. Community Nurses, via SPOA

Any aids the patient may need i.e. a frame.

Discharge letter and any relevant patient information.

Any outpatient appointment if required.

It is the nurse’s responsibility when the TTO medications are given to the patient, relative or carer that these should be discussed in detail. It is essential that adequate time is taken to ensure that the patient and carer understand how and when to take the medication. It may be appropriate to ensure that patients demonstrate how they will administer their medications with the nurse present. The pharmacist will supply a compliance sheet for the patient to take home if required. For further details on ordering of TTOs and Pharmacy Services see Section 3.0.

The nurse discharging the patient should ascertain how the patient would gain access to the property and ensure any keys are sent with the patient.

If the patient is employed they may require a sickness certificate. The nurse who is discharging the patient must ensure that the patient receives a certificate if required.

The nurse who undertakes the patient’s discharge is responsible for following the discharge plan. Before the patient leaves the RN’s care, they must be satisfied that the patient will leave with the best and most appropriate support. The nurse should not allow a patient to be discharged if there is any evidence or concerns that they could potentially be at risk once they leave the hospital

If the discharge date is cancelled the nurse caring for the patient on that shift must ensure that the patient, relatives, carers and appropriate services are informed as soon as possible.


Section 2.2 - Consultant Teams

It is the responsibility of the medical team to identify when a patient is medically or surgically optimised for discharge and this should be documented in the medical notes and on the electronic whiteboard on e-Care.


Only a consultant can accept responsibility for the patient while in hospital. Patients cannot be discharged from hospital without the authority of a consultant or a deputy acting on their behalf.

Where possible an estimated date of discharge (EDD) should be discussed and documented within 24 hours of admission. This is fundamental to ensure effective discharge planning between all internal and external health care agencies. The potential discharge date must be clearly communicated to the appropriate MDT and documented in the medical notes and on the whiteboard

Medical staff should initiate appropriate multi-disciplinary assessments and if a referral to other disciplines is required, medical staff must complete this as soon as possible. Any such referrals should be clearly recorded in the patient’s notes and communicated to the appropriate nurse.

Consultants and their teams should discuss with patients, relatives and carers the likely outcomes of treatment, the estimated length of stay in hospital and any arrangements for transfer to specialist/other hospitals where appropriate. They should ensure that these discussions and any input from the patient, relatives or carers are documented. Wherever possible, patients and their relatives should be asked to expect and help expedite a morning discharge.

As soon as a patient is considered medically/surgically optimised for discharge this should be communicated to the nurse in charge of the ward at that time and indicate on the whiteboard to inform MDT members.

Any changes made to the discharge plan by the consultant team or any MDT must be communicated immediately to the nurse in charge of the patient.

A doctor who is familiar with the patient’s case history should prepare the electronic discharge summary including TTO medication, ideally at least 48 hours before discharge.

Hospital doctors are to provide sickness certificates for as long as they feel the condition is likely to warrant it to minimise the need for the patients to go back to their GP.

The following procedure should be adhered to:

Inpatients on Discharge

Hospital In-patient certificate should be completed advising the patient to refrain from work for whatever it is felt to be an appropriate time.

Attendance at Emergency Department

If patients come to ED and are discharged with a condition which is likely to mean that they would be unable to work, they should be given an appropriate sick certificate for a period consistent with the anticipated incapacity.

GP Discharge Notification

The GP letter must provide the following information:

Dates of admission and discharge


Consultant and ward

Diagnosis

Significant investigations and results

Treatment given and any procedures/operation carried out

Rationale for any changes in drug treatment

Any complications of treatment and required monitoring

Medication on discharge

Follow up appointment requirements.

Referrals made to other agencies e.g. District Nurses, Allied Health Professionals, Social Services

Information and advice given to patient.

Medical staff will write a ‘Discharge Letter/Summary’. The GP should receive this within 24 hours. Some departments, where appropriate, will follow this up with a formal typed summary within a short time and emailed.


Section 2.3 – Specialist Discharge Planning Team

Specialist Discharge Planning Team (SDPT)

The Specialist Discharge Planning Team provides support and management for all patients with complex discharge planning needs and provides additional support and information around discharge planning. The Team also coordinates and manages the NHS Continuing Healthcare (discharge to assess) process for adult patients under the care of West Suffolk Hospital NHS Trusts including the community bed settings.

The Specialist Discharge Planning Team works with all members of the multidisciplinary team, relatives and external agencies to provide an integrated approach to discharge planning.

The team consists of Specialist Discharge Planning Nurses and Discharge Planning Practitioners who cover adult wards and attend daily whiteboard multidisciplinary meetings. The team also provide support to community beds located at Glastonbury Court, Newmarket Hospital and Hazell Court. Hospital staff can make a referral to the SDPT or contact them for advice regarding both simple and complex discharges and nursing equipment needs.

Care Home Liaison Practitioner The Care Home Liaison Practitioner’s role is to be the point of contact between the hospital and care homes with the aim to increase engagement, reduce delays and improve patient experience by an well communicated, safe discharge. The Care Home Liaison Practitioner also undertakes the role of Trusted Assessor, completing assessments for patients on behalf of care home managers to ensure a timely and effective discharge


Liaise with patients and their families, helping them to identify needs, keeping them informed of discharge arrangements.

Work closely with all members of the multi-disciplinary team in the planning of a patient’s discharge. They will attend MDT meetings as appropriate.

Inform and liaise with community liaison teams, GP, area social workers, MDT professionals and voluntary services as appropriate.

Co-ordinate the assessment process for NHS Continuing Health (D2A) care and liaise with the Clinical Commissioning Group as appropriate.

Co-ordinate the Delayed Transfer of Care (DTOC) process

Provide education and training to students and staff as required.

Participate in discharge planning meetings, and case conferences

Contact Details

Specialist Discharge Planning Team

Telephone No: 01284 713369/713629


Section 2.4 - Care Co-ordinators

The principal role of the Care Co-ordinators is to act as a conduit for multidisciplinary communications. Under the guidance of the ward clinical and medical teams, and the ward manager. They facilitate referral processes ensuring requests are timely and accurate.

Responsibilities include:

Attending ward rounds and takes action to expedite investigations and treatments as appropriate.

Referrals of patients to Social Care Services.

Ensure that appropriate referrals are made to other specialist services.

Liaise with patients, families and carers relating to any issues they may have.

Act as a point of contact during the patient’s stay and after discharge where appropriate.

Assist in the timely transfer of patients to community and other hospitals as required.

Arrange transport for patients.

Maintain an active record of patients, monitoring their progress through the hospital from admission to discharge.

Participate in case conferences as required.

Obtain and follow up information/results for investigations for patient and report to the appropriate clinical teams.

Liaise with general practice’s surgeries when requested by the medical teams.

Liaise with pharmacy department to ensure appropriate information is given to assist in the expedition of medication for patients to take home and that where wards have “near patients” pharmacy services that the technicians are aware of planned discharges.

Contact via individual wards


Section 2.5 - Adult Care Services

Social Care Services can advise, support and assist in planning a patient’s discharge from

hospital. Social Care Practitioners work as part of a multi-disciplinary team and are often present

at the daily board round meetings held on the ward. Social Care practitioners will support a

patient to achieve their identified outcomes and help them to do as much as they can for

themselves so that they can return to live at home or if necessary, find other suitable

accommodation.

The ward can make a referral to the Local Authority in which the patient resides (if appropriate).

This is completed through the Assessment/Discharge notice process. Suffolk Adult and

Community Services (ACS) have a team based within the West Suffolk Hospital. Other Local

Authorities have Social Care practitioners who will liaise with the patient and the ward staff

regarding discharge.

Services arranged may include domiciliary (home) care, residential or nursing care, respite care,

direct payments, signposting and advice to other services. We also work closely with the

discharge planning team who can assess and organise provision of community nursing

equipment.

A package of care provided by Home First service may be offered short-term to enable the patient

to regain independence and assess what longer-term support is needed. The service will usually

be provided to the patient by practitioners employed by Home First (which is part of Suffolk County

Council) and is normally only provided for a short term period of reablement.

For Suffolk Local Authority patients, who require a restart of an existing care package, (once this is

established that this is appropriate to meet their needs), follow the flow chart for restarting a care

package for discharge. Please see flow chart on page 29.

Referral Criteria

Patients or relatives who request to see a social worker

Patients who require advice and/or information regarding on going social support at home.

Patients who require services on discharge

When a member of the MDT feels social worker input would assist in the patients discharge

planning process

Safeguarding concerns

Before referring a patient to the relevant Local Authority the following should be considered

The patient (or relative where appropriate) should be consulted regarding the referral to

social services

Ascertain which county the patient lives in, as the referral system may differ

When making a referral clearly identify the needs of the patient.

The patient is entitled to an assessment but this does not mean that they will be eligible for

a service.


There may be a fee to pay. This will depend on the type of care the patient needs and

personal circumstances. The patient will be assessed financially where upon contributions

towards any services will be established.

The patient can be referred to Social Care Services by sending an Assessment Notice, to inform

that a needs assessment is required.

A Discharge Notice is sent to ensure the local authority receives fair advance warning of the

discharge. A Planned discharge date is required when sending both the Assessment notice and

Discharge notice.

Section 2.6 - Physiotherapists


One of the physiotherapist’s key roles in the discharge process is to ensure the patient is safe to mobilise, by whatever means is most appropriate to that individual and their discharge destination.

Referral procedure

The inpatient physiotherapy service is available Monday to Friday, 08.30 – 16.30. On the stroke unit (G8) and the orthopaedic wards there is a weekend service from 08.30 – 16.30.

All wards have a named physiotherapist who assesses and manages relevant patients. The physiotherapist’s name and contact details are displayed on the ward.

Physiotherapists work autonomously on the wards, seeking out relevant patients on a daily basis, rather than relying on referrals being made. This is supported through board rounds and MDT discussion. The physiotherapist will assess and treat patients who are clinically appropriate, avoiding un-necessary interventions for patients who will not benefit from input.

It is important that when a need is identified, patients are discussed with the physiotherapist as soon as possible. If appropriate the physiotherapist will assess and treat the patient in preparation for discharge. Relevant information will be documented and discussed with the MDT, including reasons why physiotherapy is not appropriate.


The physiotherapist will assess appropriate patients, agreeing goals with the patient. These will then be discussed with the relevant MDT members; community based staff and relatives or carers where necessary.

The physiotherapist will attend MDT meetings as appropriate, providing information on treatment and suggesting referrals to other disciplines as necessary.

The physiotherapist will provide appropriate equipment to promote patient function and safety e.g. walking aids to promote mobility. Patients who require equipment will be given full instructions and practice in its use before discharge.

The physiotherapist will make a timely record of the assessment, treatment, plans/goals and discharge status of the patient, in relation to physiotherapy.

It is essential that all equipment issued to the patient for use after discharge, be sent home with them. It will be labelled with the patient’s name.

To enable discharge, physiotherapists can liaise with community services to provide or recommend relevant pieces of equipment.

Physiotherapists will make referrals for continuing treatment at the discharge destination if appropriate. This will be recorded in the patient’s records.

Contact Details: Contact named ward physiotherapist or Physiotherapy Reception Extension: 3300


Section 2.7 - Occupational Therapist (OT)

Role of the Occupational Therapist

Occupational therapists assess and treat patients to enable optimum independence and safety with their personal and domestic activities of daily living. The occupational therapist considers the individual’s physical, cognitive, personal, social and cultural needs when planning their intervention. They will also consider the environmental factors that may impact upon their ability to safely function at home.

A leaflet explaining the role of the occupational therapist and our contact details can be provided to the patient/carer/family.

The acute occupational therapists are responsible for screening all new patients admitted to the wards and they will determine if intervention is required. Staff can call ext.3560 if they would like to refer patients if they do not have a regular ward occupational therapist.

Please leave a message on ext. 3560 (medical team) or 3570 (orthopaedic/surgery team) for out of hours queries.

Hours of working are normally 0815-1630hrs Monday-Friday. Currently the orthopaedic and stroke teams work the weekends and bank holidays.

Role responsibilities

Occupational therapy is initiated upon admission as appropriate. Information is obtained about the patient’s pre-morbid physical and cognitive function, home environment, equipment and support networks. Functional and cognitive assessments are undertaken when the patient is clinically stable. Functional assessments may be completed out of the hospital and in the patient’s own home in line with the Pathway 1 process for discharge to optimise and assess (D2OA). Home visits with patients are not regularly undertaken due to D2OA. Occupational therapists assess all domains of personal care and domestic tasks that is typical for the individual patient. If the patient is assessed to be unsafe for discharge home then strategies are used such as adapting the task, providing equipment, or support is provided. Close communication with the MDT, family, carer and external agencies is imperative to ensure the patient’s needs are met.

Occupational therapists may identify patients needing moving and handling equipment to enable a safe discharge home. The occupational therapist will determine the type of equipment required and if the equipment is essential for discharge. It is important to note that not all equipment ordered is needed to be delivered prior to discharge from the hospital. Essential equipment is also available within the hospital to support timely discharges. Occupational therapists often refer to a wide range of internal and external agencies as part of the discharge process. This could be for wheelchair referrals, home technology support, community therapy team (SPOA) or relevant social services team involvement.

The occupational therapist attends the ward board meetings and MDTs to ensure information is obtained

and shared to facilitate timely discharges. They also attend family case conferences as appropriate. Close liaison is essential throughout admission with the patient, carer, family, MDT and external agencies to ensure the discharge is timely and effective.

Contact the occupational therapist involved with the patient or the lead occupational therapist on

extension 3570


Section 2.8 - Speech and Language Therapy

If the need for Speech and Language Therapy becomes apparent during multi-disciplinary assessments then referrals can be made at any point electronically via e-Care.

Referrals for communication difficulties can be signed by any health care professional but a Doctor (or formally designated nominee) signed referral is required for patients with swallowing difficulties to ensure this is in keeping with the patients overall management plan. Referrals to therapists must be documented in Medical notes, and should be requested via e-Care. If the referral is considered urgent, please also telephone our department to ensure that the patient is seen within 24hrs. If there are any queries regarding the referral then contact the department for advice.


The therapists will ensure that patients with swallowing difficulties are provided with appropriate and adequate information regarding suitable food and fluid textures and consistencies, postures and strategies and ensure other agencies involved are made aware of patient’s needs as well as carers if appropriate.

Relevant information will be documented in medical notes. Speech and Language Therapy involvement will be indicated within the patients discharge summary, or a separate letter may be provided on e-Care. The Speech Therapists will then send a written referral and report to other agencies or Speech and Language Therapy Departments, containing information on communication and swallowing problems if indicated.

Written advice will be left on the ward for staff to give to the patient/family. If the patient is on thickened fluids the ward will need to collect a supply for the patient from the kitchen.

Patients, and where possible carers, will be taught how to use any recommended communication aids prior to discharge, as well as use of techniques to aid communication and how to continue with any relevant exercises.

The Speech and Language Therapy Department will make arrangements for on-going out-patient, day hospital or domiciliary therapy, or transfer to a Speech Therapy Department in another district if necessary.

Contact Details

Extension: 3303 / 3846

Bleep: 208 / 209


Discharge Planning for Inpatients

Nutrition and Dietetics is a comprehensive professional service seeking to maximise the health and well being of patients and clients through appropriate nutrition.

Referral

Patients referred to the service for dietetic intervention will be given written dietary information as appropriate, with a telephone number to contact if they have any queries regarding the diet once they have been discharged.

If ongoing follow up Dietetic treatment is appropriate, the Department will refer on to our Community Dietetic Service.

If a patient is discharged when a dietician is not available, a written referral, signed by a doctor, must be sent to the Nutrition and Dietetic Service and arrangements to attend, as an out-patient, will be made.

Documentation

Full and accurate documentation of dietetic care are kept in the departmental electronic patient records and will include information of the dietetic discharge plan.

Provisions on Discharge – Supplied by the dietetic department – As required

14 days supply of home enteral feeding and/or nutritional supplements.

Information regarding prescriptions is forwarded to family practitioners.

Feeding Pumps, sets and plastics.

Contact Details

Dietetic Department, West Suffolk Hospital Tel. (01284) 713609

Community Dietetic Services, Disability Resource Centre, 4 Bunting Road, Moreton Hall, Bury St Edmunds Tel 01284 748850


Section 2.9 - Early Intervention Team (EIT)

The Early Intervention Team (EIT) is an integrated service working across the community and

front of the hospital to reduce admissions and support someone in crisis.

The team has: Physiotherapists, Occupational Therapists, Assistant Practitioners, Social Workers,

Reablement support workers (carers), British Red Cross, Suffolk Family Carers and Nurses.

We accept referrals from the Emergency Department (ED), Clinical Decision Unit (CDU), Acute

Medical Unit via Bleep 478/648 or on ext. 3712, during the hours of 830 – 9pm Monday to Friday

and 10 – 5pm Saturday, Sunday and bank holidays (From 20th January 2019, this will be extended

to 9:00- 18:30). Outside of these hours referrals can be made via ext. 3712 leaving a message

including the patients MRN and referral reason for patients deemed appropriate for discharge by

the medical team. EIT operate a telephone triage service and are able to support the discharge

with a follow up call, home visit if required and any onward referrals needed.

Due to the level of risk involved EIT work closely within the MDT. This includes attending daily

board meetings, verbal and written communication with both the acute MDT and the community

MDT.

In EIT we share a joint responsibility to consider and facilitate the need for –

Lying and standing BP ( In line with NICE falls Guidance and CEQUIN targets)

Urinalysis (Falls Assessment, Confusion screen, decreased function)

TTO’s (dosette box, meds required for community assessment beds, Medical management

on discharge)

Transport (Family, level of assistance needed, access to property)

District nurse and community matron referrals

Referrals to the bladder and bowel team.

Care of Older People Nurse/ Geriatrician review.

In EIT it is our responsibility to review the need for –

Appropriate equipment

Follow up phone calls or assessments within patients home on discharge

Social care and support on discharge

Reablement/ rehabilitation goals

Community Follow up – for example- Therapy, Falls Assessment, Social services, DIST,

Red Cross, community Dietetics, community SALT, GP, Memory clinic, Podiatry, Specialist

nurses.

Liaison with family or nominated point of contact.

To encourage self-management of long term conditions.

Cognitive assessment/ referral to DIST.

Sign posting to appropriate services


Section 2.10 - Nutrition & Dietetic Services

Discharge Planning for Inpatients

Nutrition and Dietetics is a comprehensive professional service seeking to maximise the health and well being of patients and clients through appropriate nutrition.

Referral

Patients referred to the service for dietetic intervention will be given written dietary information as appropriate, with a telephone number to contact if they have any queries regarding the diet once they have been discharged.

If ongoing follow up Dietetic treatment is appropriate, the Department will refer on to our Community Dietetic Service.

If a patient is discharged when a dietician is not available, a written referral, signed by a doctor, must be sent to the Nutrition and Dietetic Service and arrangements to attend, as an out-patient, will be made.

Documentation

Full and accurate documentation of dietetic care are kept in the departmental electronic patient records and will include information of the dietetic discharge plan.

Provisions on Discharge – Supplied by the dietetic department – As required

14 days supply of home enteral feeding and/or nutritional supplements.

Information regarding prescriptions is forwarded to family practitioners.

Feeding Pumps, sets and plastics.

Contact Details

Dietetic Department, West Suffolk Hospital Tel. (01284) 713609

Community Dietetic Services, Maple House, 24 Hillside Business Park, Bury St Edmunds,

IP32 7EA Tel. (01284) 713760


Section 2.11 – Suffolk Community Services

Suffolk Community Services provide nursing and allied healthcare professional services within the community in partnership with patients, carers, families, other agencies and practitioners.

Referral process

A referral to the District Nursing Service may be made (consent or verbal permission must be obtained from the patient for the District Nursing visit) when:

The patient is house bound and unable to get to the General Practice, and there is an identified nursing need for the District Nursing Service to address.

An individual/family requires assessment, management, support and co-ordination of their complex nursing needs. This may include patients with newly diagnosed potentially life threatening disease or those with pain and/or other distressing symptoms.

An individual family/group requires education or support of both physical and psychological needs to enable them to continue to care for their relative/friend/partner and maintain confidence and expertise in their own right.

An individual requires assessment and management of any wound. This may include surgical, minor traumatic, chronic wounds relating to pressure damage or ulceration of any aetiology.

An individual requires assessment, advice and management of their continence, faecal or urinary. This may include those with stomas and appliances associated with continence management.

An individual requires advice, education and/or management of some types of complex medication. This may include IV therapy management of Hickman Lines and injections.

An individual patient, who, following discharge from hospital, will require nursing support in order to re-habilitate to their optimum state of health/independence.

All the above may require a nursing assessment for the provision of appropriate equipment, medical, surgical and community equipment associated with moving and handling.

When unsure whether to refer to the District Nursing Service discuss the matter with the Specialist Discharge Planning Team who can clarify individual patients’ needs, prioritise and advise on or redirect to the most appropriate service.

The referrer must not give the patient any indication of when or how often the District Nurse will visit. The district Nurse will decide this during their initial assessment of the patient. An SPA referral form should be faxed to SPA during daytime working hours prior to the patients discharge so that any queries can be dealt with prior to the patient arriving home.

Intermediate Care

Those involved in an integrated team are occupational therapist and physiotherapists, carers and qualified nurses. They provide rehabilitation in a person’s own home, a designated intermediate care setting such as a community hospital or a residential care home for up to a maximum of six weeks in order to achieve:

An integrated and focused health and social care service for people who need rehabilitation, which would otherwise be difficult to meet.

Support and to complement existing nursing, therapy and care staff in meeting high levels of need.

A co-ordinated multi-disciplinary approach to care.


A higher level of functional independence for people, who are motivated, can be rehabilitated and able to transfer independently on referral to the service.

A reduction in the demands upon health and social services.

A Single Point of Access (SPA) referral form should be faxed to the Care Co-ordination Centre during daytime working hours prior to the patients discharge so that any queries can be dealt with prior to the patient arriving home.

Community Specialist Palliative Care Teams

A team of Community Specialist Palliative Care Nurses are based at St Nicholas Hospice. Referrals are usually made via this team for people who require ongoing specialist psychological and emotional support as well as physical symptom control.

There is a separate referral form on Evolve for community Palliative Care. The community team office can be contacted on 01284 702525.

Contact details

Care Coordination Centre Telephone 0300 123 2425

Section 2.12 Support To Go Home Service

The Service


The Support To Go Home Service provides a timely bridging care service for patients that are medically optimised and waiting in a hospital or Community Assessment Bed for reablement, long term or end of life care at home. Support To Go Home comprises a Team Lead/Senior Occupational Therapist, a Care Co-ordinator and 9 Reablement Support Workers. The service aims to enhance patient flow and prevent delayed patient discharges, reducing the risk of infections and physical deterioration associated with prolonged hospital stays. This flexible, responsive service provides continued person-centred assessments within the patients’ home to ensure they have the appropriate equipment and level of support from appropriate services to manage at home as safely and independently as possible, thus reducing the risk of readmission to hospital. The reablement element of the service strives to increase patients’ independence and confidence with essential daily tasks such as mobility, personal care and meal provision and adjust the package of care as appropriate before the patient is handed over to their next care agency. Referral process The service is able to assist patients that are aged 18 years and over and registered with a West Suffolk GP. Referrals are received from the Social Services team within the West Suffolk Foundation Trust and must have a confirmed start date for their care. Capacity within the Support To Go Home Service is reviewed and a response to the referral will be sent back to Social Services. Referrals are received and processed Monday to Friday between 08:00 and 16:00. Discharge responsibilities Following the acceptance of a referral, the following tasks will be completed to ensure a safe and seamless

discharge from the hospital ward or community assessment setting:

Ensure medications are ready for the patient to take home

Ensure the discharge letter has been printed and issued to the patient

Meet and greet the patient, explain the service and issue an information leaflet about the service to

the patient

Gain consent from the patient for Support To Go Home to provide their care at home following their

discharge

Communicate with the patient’s preferred contact to discuss the discharge arrangements and check

that heating is on and food is available at the patient’s property (as required)

Check that the property can be accessed

Arrange appropriate transport for the patient to return home


Section 2.13 Medically Optimised Team

The Medically Optimised Team support the management of patients who no longer require an acute

hospital bed but do have:

Ongoing care and social needs which could be met in another setting, home or through primary,

community, intermediate care or social services

Reablement/rehabilitation needs greater than which the community can support

A need for additional assessments and interventions, but these could be carried out in an outpatients or

ambulatory setting

Discharge from hospital should happen when a clinician decides a patient is medically optimised to leave

the hospital and it is recognised that a delay in discharge is not a good outcome for the patient, their

families or the system. The team consist of an occupational therapist and medically optimised practitioner

who monitor all patients on the medically optimised virtual ward on a daily basis, supporting and

challenging the multidisciplinary team to explore patient pathways, move patients towards discharge

remove barriers and escalate difficulties. The team work closely with acute and community staff to find the

right solution for these patients to support their transfer of care as quickly and smoothly as possible.

The team act as gatekeepers for the forty nine community assessment beds in the West and are

responsible for the administration and coordination of the process. They also ensure patients that live out of

area are referred to the relevant bed in their locality. The team have developed strong links with the

community assessment beds attend their multidisciplinary team meetings, work closely with the therapists

and use their expertise to facilitate timely discharges.

The Medically Optimised Team is actively involved in supporting patient flow on a daily basis and at time of

critical capacity. The team contribute to the Delayed Transfer of Care (DTOC) process; attend twice weekly

stranded patient review meetings, winter escalation meetings.

The team also has significant involvement with Discharge to Optimise and Assess (D2OA) model which is a

mandated NHS England requirement for all trust to implement. D2OA changes the way in which discharges

from hospital is delivered moving the focus of assessment of long term care need and delivery of

reablement from hospital to the individuals home. The medically optimised team play an important part in

the development and implementation of pathway 1 and pathway 2.

Discharge to optimise to assess (D2OA)

Principles of D2OA

The principles of D2OA are to minimise hospital admission, maximise independence and reduce the

need for long term placements

Individuals do not make decisions about their long term care while they are in a crisis or in an acute

hospital setting.

Is underpinned by a ‘home first’ ethos that no decision about a person’s long term care is made

whilst in an acute hospital or while they are in a crisis.

Assessment and care is provided at the right time, right place and by the right person.

While in hospital only an initial plan is determined with the person and their family carers.


A full assessment of somebody's needs should not take place until the person is discharged and in

their own home environment, a community assessment bed or in a more suitable place for this to

take place.

Rapid access to community care that is available on the day the patient is declared medically

optimised.

The Aim

To provide responsive, person centred services for recovery and reablement

Discharge to assess pathways start at the front door to ensure early identification of which pathway

the person would benefit from.

Start recovery activity as early as possible on the wards so that potential so a full recovery is

achieved as soon as possible

• Seamless working with multidisciplinary teams towards discharge without sequential assessments

later down the line.

Step away from traditional goal setting within the acute environment.

Therapists must view all patients as having potential to functionally improve once discharged from

hospital

Assessment begins once the person returns to their own home or community assessment bed and

not in the artificial hospital environment that may mask their potential.

If a person requires both rehabilitation and reablement this can done in one single assessment

Pathway criteria led referrals rather than social worker assessments in hospital


Section 2.14 - General Practitioners

The General Practitioner (GP) requires a letter with discharge details within twenty four hour of the patient’s discharge and this is sent electronically. The completed letter should contain accurate information in order for the GP to ascertain the treatment/management delivered to the patient during their hospital episode. In some specialities the GP will also receive a full report within four weeks of discharge. In complex discharges the GP should be involved in discussions where this is deemed appropriate.


In cases where an emergency admission is required, the GP’s referral letter should contain information highlighting any problems likely to be encountered when the patient is discharged.

If the patient’s GP has not referred the patient and may be aware of important information, which may affect discharge, they should inform the appropriate medical team/nursing staff when they become aware of the admission.

The GP is responsible for continuing medical care of the patient when they have returned to their own home, to a residential or nursing home or sheltered/warden controlled accommodation.


Section 2.15 - Pharmaceutical Services

Discharge Roles & Responsibilities

To take out (TTO) medicines should be prescribed as soon as is practicable once the decision to discharge has been made. The pharmacy department aims to dispense all TTO’s during the standard pharmacy opening hours (Monday to Friday 8.30am - 6.30pm, Saturdays, Sundays and Bank Holidays 9.00am - 4.30pm). Outside of these hours, TTOs will only be dispensed in exceptional cases, for which there is a specific ‘Dispensing Emergency TTOs’ procedure - available in the emergency drug cupboard and on the intranet - (CG10045).

The normal supply will be a ‘one patient pack’ for items that are to continue, which therefore relates to a supply of at least 14 days. Due to pack sizes, this may mean that some items on a patient’s TTO may run out sooner than others, and patients should be made aware of this. For antibiotics and steroids etc., the course length should be stated and pharmacy will usually supply the full course.

In order to facilitate discharge, pharmacy staff use EDD data to attempt to provide as much medication as possible in patient ready packs prior to the TTO being written. The pharmacy team may be able to manage some TTOs at ward level without the need to send anything to the pharmacy department. It is important, therefore, that the ward pharmacist should be made aware of all patients due to be discharged that day when they arrive on the ward.

On wards that use e-Care, the ‘Medication for Discharge’ task should be sent electronically to pharmacy as soon as possible after the TTO is written. If a member of the pharmacy team is on the ward they should then be informed. If there is not, the patient’s own medication and any additional paper charts should be sent to the pharmacy department. Where a controlled drug (CD) has been prescribed, the ward CD stock book should also be sent to pharmacy.

On wards that do not currently use e-Care, if a member of the pharmacy team is on the ward they should be informed of the discharge. If there is not, the ward should send the patient’s prescription chart, along with any additional charts, and any patient’s own medication to pharmacy as soon as possible after the TTO is written. Where a controlled drug (CD) has been prescribed, the ward CD stock book should also be sent to pharmacy.

Pharmacy staff (either on the ward or in the dispensary) must clinically screen all TTOs within pharmacy opening hours. If there are any problems identified then the appropriate person will be contacted; this may extend the time taken to dispense and check the TTO.

Once in pharmacy, TTO’s will be dispensed in strict order of receipt into the department, and can take up to 120 minutes to be completed. The medication will be sent on the next porter’s delivery round, or can be collected from pharmacy by ward staff or a bleep volunteer. Patients, or the relatives/carers, should not be sent to pharmacy to collect TTOs – it must be a member of staff.

Permission to prioritise a TTO may only be given by a Senior Manager. Prioritisation can be done by contacting the dispensary manager (Ext 3111) with a list of patients.

The TTO tracking system available within e-Care should be used to see when a TTO is ready. Wards are asked not to telephone pharmacy to ask whether a TTO is ready, as this telephone call will take someone away from the process and may delay the work further

Ward pharmacists in many cases will counsel patients about their medication where it is deemed appropriate; otherwise this should be carried out by the nurse caring for the patient.


SECTION 3 DEPARTMENTAL ISSUES

Section 3.1 - Emergency Department (ED)

Those patients who attend Emergency Department (ED) who do not require admission or a bed may have discharge arrangements to be considered, particularly when they have been identified as potentially vulnerable.

On discharge all patients have a letter automatically generated for their GP if they are referred back to their GP (only about 20%)

The department does not have a designated social worker; therefore the duty social worker can be contacted. Between the hours of 09.00 – 17.00 hours, Monday to Friday. Outside of these hours ED can contact the on-call social workers via switchboard.

Particular consideration is given to elderly patients. The department has the ability to refer to community based support networks for older people. This service is provided by intermediate care services. Their notes are flagged and a copy of their ED details retained for review daily by community nurses, who will contact the patients if necessary for follow up. The assessing doctor will decide whether direct contact with the GP is needed.

ED are able to access the Early Intervention Team Monday to Friday between 09:00 and 17:00. They will assist with assessing patients for support from ED. They have the ability to provide patients with equipment/aids to facilitate safer discharge.

ED has assessment criteria for patients over the age of 75 who attend the department with the complaint of ‘Falls’. A tick box assessment is completed which will then trigger a letter to be sent to the GP for primary care follow up.

A health visitor and the child protection nurse will review copies of the notes for all those who attend under the age of sixteen.

ED can refer patients to the Discharge Planning Team, (which include admission prevention scheme) by phone or fax if this is deemed necessary.

Advice regarding charitable services and help lines is available in ED. NHS Direct Information leaflets are available.

Discharge information leaflets are available and given to patients regarding their injury/problem.

Medical certificates and reports – see Appendix 2


Section 3.2 - Day Surgery

The patient spends an average of 4-8 hours in the Day Surgery Unit. All admissions are planned, elective surgery and home circumstances are assessed prior to admission.

Transport to and from hospital is the responsibility of the patient and will have been discussed during the pre-assessment appointment. Patients who have undergone an operation with local anaesthetic can travel home alone, although they are advised not to drive themselves. Hospital transport is acceptable for local anaesthetic patients.

Patients who have had a general anaesthetic must be collected and transported home either by private transport or a taxi if they have a carer to accompany them. They should have a carer at home for 24 hours post-surgery. Any patient who does not have sufficient support at pre-assessment will not be considered suitable for day surgery. Any patient who fails to have sufficient support in place on the day of operation will be cancelled. If a support issue is discovered after the surgery, the patient will not be discharged home. The surgical team therefore will admit the patient overnight or until sufficient support is in place.

The day surgery department provides if required:

Outpatients appointment

Dressings if required

Equipment if required eg crutches

Information leaflets/advice sheets

To Take Out (TTO’s) medications

Ensure a copy of the completed E-CARE is sent with the patient

Referral to Practice, District, or other Specialist Nurses

A contact number is given to all patients on discharge for postoperative enquiries during working hours: Monday – Friday, 8am-8pm, as well as advice by means of information leaflets/booklets. Should patients need advice outside these hours they are advised to contact their GP, 111, or relevant in-patient Ward.

Patient are advised in an emergency to attend nearest A and E or dial 999..


Section 3.3 - Maternity

Discharge home of antenatal Women

The midwife documents all relevant information in the Maternal Health Records, white ghost card and woman’s hand held notes. Relevant appointments are made, Wardex completed, contact numbers given and hand held notes returned to the woman.

An antenatal discharge form is completed and the information is conveyed to the team / community midwife for information and/or a home visit if requested.

If investigation results require treatment post discharge, it is the responsibility of the senior midwife/person in charge to ensure the general practitioner is contacted.

Any medicine prescribed is dispensed from pharmacy. On their receipt it is the midwife’s responsibility to ensure that the appropriate information is conveyed to the woman.

Discharge from postnatal wards and transfer to Team/Community Midwife’s care

The midwife and/or doctor assess that mother and baby are fit for discharge.

Mothers are encouraged to make an appointment with their General Practitioner for a six-week postnatal examination. When requested by the Obstetric staff the midwife may arrange a follow up appointment at West Suffolk Hospital, which is then sent to the mother.

Follow up appointments are made for babies when requested by paediatricians. These appointments are sent to the mother’s home address.

Medication, if prescribed, is dispensed from pharmacy; the midwife being responsible for ensuring that the appropriate information is conveyed.

The Wardex, which includes a labour summary and care plans, is given to the mother to take home for the team/community midwife. If the mother lives out of area only a photocopy of the labour summary is given to the mother.

Relevant leaflets, contraceptive advise if appropriate, emergency contact telephone numbers, and breast-feeding support numbers are given.

Mothers are advised that a team/community midwife will visit within 24 hours.

Team/Community midwife is informed of the discharge, if out of area then relevant maternity unit is notified.

Mothers are advised to be accompanied home, with the baby in a suitable car seat.


Parents are encouraged to fit a baby seat into the car prior to discharge and not to bring the baby car seats up to the ward area.

Personal belongings are taken to the car before discharge and partners are asked to wait at the front entrance for arrival of mother and baby. Staff escort mothers and babies to the front entrance, and members of staff carry the babies.

Discharge from Midwifery care

The community midwives visit up until the 10th day, but can extend this period if appropriate for up to 28 days, as per legal requirements.

The health visitor is informed through the child health system and visits around the 10th/14th day.

Social Care Services

In Social Care Service or Child Protection cases, a code is highlighted in the case notes and computer. Social Care Services must be informed of admission, delivery and prior to discharge.

The agreed plans of care following case conferences should be adhered to with clear documentation of essential aspects. The liaison health visitors must be informed to ensure that the baby is placed on the child protection register in casualty and the named Health Visitor is aware of all details prior to discharge.


Section 3.4 - Mental Health

For any person identified as having a diagnosed or undiagnosed disorder of the mind the Psychiatric Liaison Team is available to undertake a holistic review and assessment. This would consider risk and any potential safeguarding concerns. Timely referral to the team, including presentation, concerns and any particular questions you would like considered would greatly assist the team in reviewing.

The Psychiatric liaison Team works in partnership with our colleagues in the general hospital to ensure people attending the West Suffolk Hospital have access to timely, holistic care and assessment of their mental health needs.

The team undertakes both the emergency assessment function for people presenting in crisis to the ED department and also the liaison function to all other inpatient areas of the Hospital.

The team is multi-disciplinary including, social work, nursing staff and medic.

The team have recently been able to expand to cover Monday – Friday 08:00hrs to 21:00hrs with the Crisis Team (0300 123 1334) then covering.

The team would complete all required liaison work with other NSFT teams and wider partner agencies as required to enable a supported and safe discharge from the WSH.

If a person is identified as requiring a Mental Health bed the team would liaise directly with NSFT bed managers and ensure the WSH is kept updated until transfer is completed.


3.5 Patients with Learning Disabilities and/or Autism

– Discharge Planning

In addition to the procedures laid down in the WSFT’s Discharge Planning Operational Policy PP(12)062 supplementary actions may need to be taken. Planning for discharge should commence as soon as a patient with Learning Disabilities and/or Autism (PWLD/A) is admitted. On admission, the patient and/or his/her carer will be advised of a provisional date for discharge. This date will be reviewed on a daily basis and may involve a number of staff from the hospital team. The nurse in charge will liaise with the individual and/or his/her carer about safe discharge to home from hospital. The Learning Disability Liaison and Adult Safeguarding Nurse (LDLASN) should be informed of any admission of a PWLD/A and dialogue established with the Discharge Planning Team. Any factors which may prevent discharge back to the patient’s home should be flagged up to the Discharge Planning Team and the LDLASN as soon as possible. It is possible that the patient will require additional after care on discharge. PWLD/A may recover better within their own home environment but must only be discharged when it is safe to do so and when adequate support can be provided for both the patient and carer. For comprehensive discharge planning the process must include the individual, their family and/or paid supporters and other professionals who are involved in their care e.g. Community Learning Disability Nurse, Social Worker, Specialist Speech and Language Therapist, Occupational Therapist, Physiotherapist etc. They can support the gathering of accurate information and identification of potential risks to safe discharge. The Learning Disability Liaison and Adult Safeguarding Nurse should also be involved in the discharge of PWLD/A. A PWLD/A may live with a partner or family member who also has a learning disability and//or autism and in these circumstances detailed planning of the discharge and support will be required to ensure a safe discharge. Careful consideration must be given to providing advice for after-care and treatment. A PWLD/A may not understand information provided on medication, management of dressings or follow-up appointments. The nurse planning the discharge must ensure that all these issues are addressed so that the discharge is safe and appropriate. Staff must ensure that they check how the individual usually takes their medications and arrange Pharmacy to dispense their tablets in the format they are used to i.e. Blister packs, dosette boxes, boxes with larger print and additional accessible information leaflet etc. Clinical must check with residential care homes if documentation is required to allow care staff to administer any new medication.

A copy of the Discharge Summary should be given to the primary care provider and advice should be given with regard to any changes in health need, treatment, medication and follow- up.

It is essential that all follow-up appointments are discussed with the primary carer to ensure a clear understanding of who will be responsible for the patient’s care once they have left hospital. The primary carer must be involved in discussions relating to discharge arrangements. It is crucial that the primary carer attends any multidisciplinary discharge meeting to ensure effective co-ordination. Prior to discharge, a multidisciplinary meeting of all key parties (including family members as appropriate) involved in the care of the patient should be considered to plan the discharge, especially where there has been a significant change in the patient’s health needs. The community learning disability practitioners involved may have to co-ordinate training for carers to manage the changing health needs and/or review the need for temporary respite care or a permanent


alternative placement. Community learning disability practitioners may also need to provide details of specialised equipment that is used regularly, such as a wheelchair, feeding equipment, splints etc.

If the patient has no representative, family member or friend, it may be appropriate to request the involvement of an Independent Mental Capacity Advocate (IMCA). [See the Mental Capacity Act 2005 and the Independent Mental Capacity Advocate (IMCA) Policy and Guidance [PP(19)223]. For further information and general guidance on supporting patients with Learning Disabilities and/or Autism please refer to the Trusts Policy for the Care and Support of Patients with a Learning Disability and/or Autism.


Section 3.6 Discharge Waiting Area

Discharge Waiting Area Inpatient beds should be vacated as early as possible on the day of discharge and transfer to the DWA should be an integral part of the patient pathway. Nursing staff on the units or wards are responsible for ensuring that DWA utilisation is optimal and that beds are released as early as possible. To note: once a bed is vacated DWA staff will notify Patient Flow Team as soon as the bed is empty. What Needs to Happen before Transferring to the DWA? A patient is ready to go to the DWA when:

The Discharge Criteria set by the medical team have been met and either the Medical Team or

Ward Manager for nurse-led discharges has approved the discharge

For Inpatients (including CDU) - the Clinical Narrative/Problems this visit/Follow-up Date sections

of the Depart is completed on e-Care

The TTOs have been written up and communicated to the ward specific pharmacist (in the event of

extreme capacity pressure DWA will agree to accept the patient without the TTO being written)

Any transport required has been booked or a family member has agreed that the patient will be

collected

They have had their final set of observations on the unit /ward. This should be taken within the last

hour of stay on their unit or ward.

For ED Patients awaiting transport and TTOs - ED Depart and discharge from e-Care to be

completed before the patient is taken to DWA for collection.

From the point a patient is admitted we should be planning their discharge. The patient should be assessed for DWA suitability. All patients who meet the criteria should be transferred to the discharge waiting area. Staff will be expected to identify a minimum of 2 patients per ward to transfer to the DWA before 10.00hrs as part of the Golden patient initiative. Staff will be proactive in identifying patients suitable for this area during board rounds, plus additionally throughout their shift. Discharge Waiting Area staff will utilise the Capacity Management on e-Care to identify potential and definite discharge for the day and will go to the wards regularly if necessary. The clinical bed coordinator will go to the ward in the afternoon to get the list of potential / definite discharge for the next day. Patients should be transferred to the DWA on the day of discharge if they are waiting for:

Hospital transport

Collection by relatives or carers

TTOs to be dispensed

Any other patients awaiting imminent discharge

Exclusion Criteria: As a general principle, all adult patients are welcome to use the discharge waiting area. However at the present time the discharge waiting area is unable to accept patients who:

require a 1:1 care

require complex nursing attention prior to discharge

require active vital sign monitoring

require oxygen >4L.


require a side room.

The transferring of patients to the DWA will be facilitated by the DWA staff supported by Patient Flow Team. The DWA staff will endeavour to collect patients in a timely manner after receiving the referral (time taken to collect is influenced by the location of the lounge and the transferring ward), but priority will be given to areas under most pressure as directed by the Patient Flow Team. The DWA team will actively pull patients from the base wards identified as suitable for the Unit. Each day on opening the DWA in Charge will contact the base wards identifying patients for discharge that day assessing suitability against agreed criteria. If any issues arise with discharge planning, the discharge planning team will support by contacting Ext 3369. Clinical Deterioration Should any problems occur whilst the patient is in the DWA in-hours (9:30am- 5pm) the clinical team that patient was caring for that patient continues to be responsible for the care of that patient. After hours (5pm onwards) the on-call team has responsibility for assessing and reviewing the patient. The OPD and ED patients will be booked and transferred to ED for further management. If the patient requires readmission, the relevant professionals should be made aware of this fact, such as clinician responsible for the patient, EIT/Discharge Planning, and the Patient Flow Team. Family or significant other should also be made aware of the change of discharge plan. Opening times The DWA will open at 9.30am Monday-Friday and patients will be accepted and transferred to the unit up to 5.30pm. Patients requiring ambulance transport can be transferred to the DWA up to 5.30pm. The unit will close at 6pm daily. As a general principle, all patients must be discharged by 6pm. If it is looking likely that there may be patients on the unit after 6pm due to transport delays, the nurse in charge will escalate to the Patient Flow Team (358/888). This should be escalated from 5pm onwards to allow Patient Flow Team to liaise with transport providers and make appropriate arrangements for the patients. In the event of extreme capacity pressure, DWA may extend the closing time and may also open on weekend depending on staffing availability. Location and Hours of Service The Discharge Waiting Area is located on the first floor on F2.

Bay 1 x 3 beds and 6 chairs

Bay 2 x 6 reclining chairs

Bay 3 x 3 beds and 6 chairs

Although the chair area will be designated as male or female this can be flexed according to need and in compliance with SSA.

Staffing

The DWA will be staffed by: 1.0 WTE Band 6, 1.0 WTE Band 4 and 2.0 WTE Band 2 staff members to work Mon-Fri 8.00am-8.00pm.

Staff Shift Time

Band 6 10:00 -18:00

Band 4 09:30 -17:30


Band 2 09:30 -17:30

Band 2 10:00 -18:00

Unplanned / planned absences will be covered by bank staff.


SECTION 4 ADDITIONAL INFORMATION

Section 4.1 - Transport Facilities

Please refer to Non Emergency Patient Transport Service Policy.

Section 4.2 - Patient Escorts

If the nurse is required to escort the patient when being transferred or discharged the nurse is responsible for their care whilst they are in transit. The nurse must ensure that they are familiar with the patient’s care needs before leaving the hospital and ensure that all appropriate notes and equipment are taken with them. Any appropriate emergency equipment needed should also be available. The nurse in charge of the ward/area will make all decisions in relation to patient escort and they will assume overall responsibility.

The grade of the nurse escorting the patient will be determined by the patient’s need and dependency, bearing in mind the following:

Escorts to other acute Trusts must be by a trained nurse

Escorts of a non-medical nature or not relating to treatment can be undertaken by the most appropriate person, the decision resting with the nurse who assumes overall responsibility.

If the patient is to be transferred to another hospital or care facility these should be informed when the patient has left. Relatives and carers should also be informed. If the transfer is unplanned or an emergency they should be given details of how to get to the destination and contact numbers

On arrival at the destination the nurse should ensure that an accurate handover is given to allow for consistent continuation of care.

If the patient is transferred to another Trust via an emergency ambulance, unfortunately there is no guarantee that the member of staff will be provided with a return journey by that ambulance back to the hospital. In such cases the senior nurse on duty prior to departure will advise and arrange an alternative means of returning to the Trust.


Section 4.3 - Equipment

If patients require equipment in order to be discharged home safely this must be arranged well in advance and referral made to the Physiotherapist/Occupational Therapist/Specialist Discharge Planning Team as appropriate (please see table below) Where equipment is required to support discharge and/or community services such as District Nurses, care will not commence until the equipment has been installed. No patient should be discharged until the necessary equipment has been provided and installed Community equipment for East and West Suffolk is currently provided by Medequip and is a service provided to supply patients with equipment to support and enable them to return to or remain in their homes. Equipment is assessed for and ordered through the (Transforming Community Equipment Services) TCES system hosted by CSS Europe on behalf of Medequip by prescribers including occupational therapists, physiotherapists and nurses, with the appropriate clinical competences. The community equipment service holds a core catalogue of stock that can be ordered to prevent admission or to assist discharge from hospital including profiling beds, pressure care equipment and daily living aids. It is also possible to order more specialist items through the special order process. In order to gain access to TCES to be able to order equipment please speak to your manager to complete an access form.

Examples of types of equipment provided:

Physiotherapy

Occupational Therapist

Specialist Discharge Planning Team

Walking frame or walking

sticks

Equipment to assist activities of daily living i.e. raised toilet

seat, hoist

Hospital beds, Pressure relieving

mattresses, slide sheets to support nursing need.

Oxygen for Palliative needs

Should you require advice as to which piece of equipment is suitable; you should contact these agencies that will answer any questions.

Where a patient is prescribed nebulisers and does not have one at home already, you should refer the patient to the GP Surgery

For patients who require Oxygen to support their discharge other than those with a palliative need, a single point of access (SPOA) referral should be made via Evolve for assessment by the Community Respiratory Team. For advice and guidance call the Care Coordination Centre, for Suffolk Community Healthcare Referrals on 0300 123 2425.

Where Oxygen is supplied, the distributor will provide condensers or related equipment with instructions for obtaining further supplies and any additional information.

Delivery of equipment must be confirmed prior to the patient being discharged, this is the responsibility of the Nurse discharging the patient.


Section 4.4 - Patient Property

Patients should be advised to allow any valuables (i.e. substantial amounts of cash, bank cards, jewellery etc) to be held in the hospital safe in the General Office for safekeeping. The patient must be advised that the West Suffolk Hospital NHS Trust does not accept responsibility for loss, damage or destruction of items that are not handed in. In these instances it should be documented on the Nursing, AHP assessment booklet that the indemnity policy has been explained to the patient.

Each ward must keep accurate records of patient’s property in the official ‘Patients Property & Valuables record’ book. Details of patient’s property, written in the records book, must be completed/checked and signed by two members of staff. Please also note CLEARLY any items that have been handed over to the General Office for storage in the hospital safe.

NOTE: The blue copy of the Patients Property & Valuables Record must accompany any items going to the General Office.

The patient must have any property returned to them before they leave the ward or department.

It is preferred that the patient themselves collect any valuables stored in the hospital safe on the day of discharge. However, if the patient is incapacitated then a representative from the ward must collect the valuables on the patient’s behalf.

Patients who have a significant amount of cash should be encouraged to deposit it in the hospital’s safe.

For more detailed reference see Trust Policy for Patient Property (PP(19)042.

There is also a patient form on e-Care; in the near future the booklet may refer to e-Care version.

PLEASE NOTE

The General Office is staffed from Monday to Friday:

for Staff: 08.30 to 16.30

for the Public: 08.45 to 16.00


Section 4.5 - Suffolk Family Carers

Supporting Family Carers

A Family Carer is someone who, without payment, provides help and support to a partner, child, relative, friend or neighbour, who could not manage without their help. This could be due to age, physical or mental illness, addiction or disability.

Family carers are key partners in successful discharges from hospital. They need to be supported and involved throughout the discharge planning process.

The ‘Family Carers Pack’ is available on most wards to issue to the family carer once identified. The pack includes information on how the family carer can be supported whilst in the hospital and when out in the community. Details on how to access the hospital-based Family Carer Project Worker are included.

Family Carer sensitive discharge ensures that they are:

involved from the point of admission (or before when appropriate) through to the discharge

consulted and recognised as having knowledge experience and commitment to contribute

provided with opportunities to ask questions

provided with effective information so that they can plan and make choices

able to access training to enable them to provide appropriate care and minimise risk to their own health,

provided with contingency information to support them post discharge

Suffolk Family Carers information line: 01473 835477


Section 4.6 – British Red Cross Support at Home

The British Red Cross Support at Home Service provides practical short term support to patients discharged from hospital. The aim of the service is to help you settle in at home after a stay in hospital and to work with you to build your independence and confidence.

We can support you if

You are over 18 years of age.

Been discharged from hospital within the last 10 working days.

Live alone or have limited support or are a main carer.

Live in Suffolk.

.

We can support you with

Practical tasks such as shopping and light cleaning eg. hoovering.

Signpost to other agencies both Voluntary and Statutory for up to date and accurate information about local services.

Support can be for up to a maximum of 6 weeks dependent on your needs.

How can I be referred to Support at Home?

Any healthcare professional can refer you.

You can refer yourself.

A relative can refer you with your consent.

How you can find us

By telephone: 01284 712942 (internal ext: 2942)

Email: [email protected]

Administration office: British Red Cross Support at Home Social Services Corridor West Suffolk Hospital, Hardwick Lane, Bury St Edmunds, Suffolk, IP33 2QZ

The Support at Home Service is available:

Monday to Friday 9.00 – 5.00


Section 4.7 – Chaplaincy Friend Service

The Chaplaincy Friend Service provides practical short term spiritual support and guidance to patients discharged from hospital. The aim of the service is to follow up patients who have already been seen by the WSH chaplaincy in hospital and who wish extra spiritual support at home following discharge from hospital.

Who can we help?

People over 18 years of age

Clients who would welcome someone to visit from the chaplaincy to provide extra spiritual support and prayer on leaving hospital.

Residents based in mid Suffolk

Clients who would welcome a further chance to discuss matters of faith and spirituality and who wish to explore possible links with others of similar mind.

Clients who may feel somewhat isolated distressed or anxious.

How can we help?

We offer spiritual support and prayer.

Links with other worship centres faith groups and information about local spiritual services.

Provide support for 2 weeks up to a maximum of 6 weeks

How can you be referred?

Speak to a hospital Chaplain

The chaplain will require your written consent and contact details before a Chaplaincy Friend is sent to you.

The senior healthcare professional on your ward will be notified.

How you can contact us:

By telephone: 01284 713771 / 713486

Administration office: The Chaplaincy Department West Suffolk Hospital, Hardwick Lane, Bury St Edmunds, Suffolk, IP33 2QZ

The office (Located in the WSH chapel) is open 8am- 5pm Monday to Friday


Section 4.8 Outpatient Parenteral Antimicrobial Therapy (OPAT)

Please read in conjunction with the Outpatient Parenteral Antimicrobial Therapy (OPAT) standard operating

procedure guideline: CG10242-3. This SOP is currently being updated.

Outpatient Parenteral Antimicrobial Therapy (OPAT) is the administration of intravenous antimicrobial

therapy in an outpatient setting or in the patient’s home. Nationally, acute hospital trusts have introduced

OPAT to support admission avoidance and early discharge from hospital.

If the need for OPAT becomes apparent during clinical assessment a referral can be made electronically

via the patient’s e-care power chart: communicate and consult.

The OPAT nurse specialists work with all members of the multidisciplinary team and external agencies to

provide an integrated approach to OPAT discharge planning.


The OPAT Specialist nurses will assess appropriate patients for OPAT and document all relevant

information in the patients E- care record to include: assessment, treatment and discharge plans

whilst ensuring the patient and their family are kept up to date.

Liaise/ work closely with the multi-disciplinary members involved in the care of patient in the

planning of the OPAT discharge (physiotherapy, occupational therapy, adult care services etc.).

Liaise with the Care Coordination Centre (CCC), Community Intervention Service (CIS) and

Community nursing teams as appropriate, to coordinate the provision of IV antibiotics in the

community. SPA Referrals to be sent to the CCC via Evolve and receipt confirmed by phone.

Provide the discharging ward nurse looking after patient with an equipment list for them to supply

the equipment required for administration of IV antibiotics in the community for first 7 days. If ward

stock not available to facilitate this OPAT to support with provision of equipment as required.

Ensure that the patient is discharged with the correct antibiotic TTO’s, consumables for OPAT and a

valid e-care prescription with administration record and guidelines to support OPAT in the

community if required.

Provide the patient with OPAT discharge/follow up information, SOS contact numbers and OPAT

advice leaflets as required.

OPAT Team contact Details:

Telephone 01284 712783 or 01284 713000

08.00-17.30 Monday – Friday


Section 4.9 West Suffolk Housing Options

Some people do not have an address to return to after leaving hospital either because their home is no longer suitable, they lose their accommodation whilst in hospital or they were already homeless. It is important to identify people who are homeless or at risk of homelessness at an earlier stage and refer to West Suffolk councils. West Suffolk councils will assess the situation and where possible prevent the homelessness. If this is not possible, they will offer further advice and there may be an offer of temporary accommodation while the application is assessed. The earlier West Suffolk councils are notified, the more chance there is of finding accommodation before the patient is discharged.

Please contact the Housing Options Team on 01284 757178 or visit www.westsuffolk.gov.uk

http://www.westsuffolk.gov.uk/


Section 4.10 The Warm Homes Fund

Cold homes are not just uncomfortable to live in, they can have a negative effect on health. In Suffolk there are still a large number of houses that do not have a central heating system with a boiler and radiators.

Anyone can have a loan heater if they are at risk of being discharged into a cold home, or this could lead to a DTOC. The assistance we can then offer after this will depend on the financial status. Warm Homes can fund household measure for those who are low income/ in fuel poverty/ in receipt of means tested benefits. But loan heaters and advice and referrals to anyone.

First time central heating systems available to Suffolk residents

Up to 100% fully funded gas and oil systems

For privately owned and privately rented households

Council backed scheme run by Suffolk Warm Homes Healthy People Call local rate telephone 03456 037 686

Email: [email protected]

For more information visit www.greensuffolk.org/whf Office hours: Mon – Friday 0830- 17:00


EQUALITY/DIVERSITY ASSESSMENT TOOL

Title of Document Discharge Planning Operational Policy

Date of assessment August 2019

Date for review August 2021

Division Medicine

Completed by Sally Lawrence

Date 29/08/2019

Yes/No Rationale

Does the document affect one group less or more favourably than another on the basis of:

Race No Applies equally

Gender No Applies equally

Sexual orientation No Applies equally

Age No Applies equally

Disability No Applies equally

Marriage and Civil Partnership No Applies equally

Pregnancy and Maternity No Applies equally

Culture No Applies equally

Does this document affect an individual’s human rights?

No Applies equally

If the answer to any of the above is ‘yes’ then:

Tick Rationale

Demonstrate that such a disadvantage or advantage can be justified

Adjust the policy to minimise the disadvantage identified or better promote equality

If neither of the above is possible, submit to Trust Council for review


GPs are not allowed to issue duplicate certificates relating to social security claims. An exception is where replacements are required from forms, which have been lost. These should be marked ‘duplicate’.

GPs are not obliged to issue Med 3 forms for periods of sickness lasting 7 days or less.

Author(s): Discharge Planning Team Lead, Discharge Planning Administrator Senior Operations Manager, General and Emergency Medicine

Committee responsible for monitoring:

Other contributors: Medically Optimised Nursing Lead, Community Matron, integrated therapies

Approvals and endorsements: Operational Group

Consultation:

Issue no: 6

File name: PP (19) Discharge Planning

Supercedes: PP(15)062

Equality Assessed:

Implementation: Policy will be distributed by the IG Manger to General Mangers, Service managers, and all Ward/Department Managers and will be available on the Trust Intranet Site

Monitoring: (give brief details how this will be done)

Implementation, compliance and effectiveness of this policy will be monitored by the Hospital at Night Team on an ongoing basis. This will be achieved by monitoring the use of the policy in line with agreed local performance and targets.

Other relevant policies/documents and references:

Additional Information:

Documents

Trust Policy and Procedure Discharge Planning Operational ... · Case Conference On occasion, the MDT may consider it beneficial to hold a case conference for a particular patient