DISCHARGE PLANNING POLICY

Version / 9
Name of responsible (ratifying) committee / Senior Management Team
Date ratified / 28 June 2017
Document Manager (job title) / PHT Lead for Discharge Services
Date issued / 18 July 2017
Review date / 30 September 2017
Electronic location / Clinical Policies
Related Procedural Documents / See Section 8
Key Words (to aid with searching) / Simple Discharge Policy; Discharge Planning; Leaving Hospital Policy; Going Home Policy; Patient discharge; Patient transport services; Primary care teams; Pharmacy; Occupational therapy; Physiotherapy; Speech and language therapy; Social services; Nutrition; Dietetics; District nurse services; IDS Fit to Leave an Acute Bed, EDD.

Version Tracking

Version / Date Ratified / Brief Summary of Changes / Author
9 / 28.06.2017 / Full review and amendments.
To be located under Clinical Policies on the Trust webpage / C Bramhall
8.1 / 03.02.2015 / Minor changes and extension of review date / R Davies

Contents

QUICK REFERENCE GUIDE

1.INTRODUCTION

2.PURPOSE

3.SCOPE

4.DEFINITIONS

5.DUTIES AND RESPONSIBILITIES

6.TRAINING

7.REFERENCES AND ASSOCIATED DOCUMENTATION

8.EQUALITY IMPACT STATEMENT

9.MONITORING COMPLIANCE

APPENDIX A: Ready to go

APPENDIX B: 10 Step Plan

APPENDIX C

EQUALITY IMPACT SCREENING TOOL

QUICK REFERENCE GUIDE

Discharge Planning Policy
Version: 9
Issue Date: 18 July 2017
Review Date: 30 September 2017 (unless requirements change)Page 1 of 21

1.INTRODUCTION

Portsmouth Hospitals NHS Trust (the Trust) recognises that to facilitate a smooth discharge from care in hospital to care in the community, the discharge plan must be well defined, prepared and agreed with each individual patient. To allow sufficient time for suitable and safe arrangements to be made, discharge planning should begin on admission, or at pre-admission clinics, with an expected date of discharge (EDD) being identified within 48 hours of admission and communicated to patients and, if appropriate, their carers/relatives.

This policy is written in accordance with the NHS and Community Care Act 93/98, the Department of Health Discharge from Hospital: Pathways, Process and Practice 2003, The Community Care Act (Delayed Discharges) 2003, NHS Continuing Care 2004 and Achieving Simple, Timely Discharge from Hospital 2004 (refer to Section 8).‘Ready to go?’ - Department of Health, 2010and Transforming Social Care – Department of Health, 2008. The principles of discharge apply to all patients who have stayed, for however long, in the Trust. However, there are some departments such as the Children’s unit that have specific processes.

Over-riding principles include:

• Right patient, right place, right care;

• Home first (wherever possible);

•Person- centred and a maximising independence approach;

•Releasing time to care;

•Reduced duplication of assessment through Trusted Assessor/Professional and ward link

roles.

2.PURPOSE

The purpose of this policy is to set out the process requirements and staff responsibilities to support well-organised, safe and timely discharge for all patients. It aims to fully involve patients and their carers/relatives in the discharge process and ensure that patients receive appropriate assessment, planning and information about their discharge and after care.

3.SCOPE

Patient discharge must be seen as an interdisciplinary and/or multidisciplinary issue. Therefore, this policy applies to all permanent, locum, agency and bank staff of Portsmouth Hospitals NHS Trust and the MDHU (Portsmouth), including doctors, nurses, allied health professionals, social care professionals and managers. Whilst the policy outlines how the Trust will manage effective discharge implementationit does not replace the personal responsibilities of staff with regard to issues of professional accountability for governance.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

4.DEFINITIONS

4.1The Integrated Discharge Service (IDS): A Service which has been developed in order to implement an expert complex discharge team, working in a seamless and integrated way across partner organisations both health and social care. The Integrated Discharge Service (IDS) will proactively ‘pull’ and case manage a range of patients with complex discharge needs and progress these patients safely to discharge via an appropriate pathway (usually Discharge to Assess – D2A).

4.2 Patients with Simple DischargeNeeds:

Patients with simple discharge needs make up at least 80% of all discharges.This will be lower on some wards with a larger number of elderly and/or frail patients.

They are defined as patients who:

  • Will usually be discharged to their usual place of residence
  • Have simple ongoing care needs which do not require complex planning and delivery.

Many of these patients will be discharged from the Acute Medical Unit (AMU), Short Stay Unit (SSU), or the Emergency Department (ED) as well as medical and surgical wards. Time in hospital does not determine whether a patient has simple or complex discharge needs. The key criterion is the level of ongoing care required – and therefore the complexity/simplicity of the discharge arrangements.

4.3Patients with Complex DischargeNeeds:

Patients in hospital who have more complex needsapproximately 20%,(this can be significantly higher up to 90% on some wards with a larger number of elderly and/or frail patients) require referral for assessment by other members of the multidisciplinary team.

These are defined as patients who:

  • Whom will be discharged home or to a carer’s home, or to intermediate care, or to a nursing

or residential care home, and

  • Whom have complex ongoing health and social care needs which require detailed

assessment, planning, and delivery by the multi-professional team and multi-agency

working, and whose length of stay in hospital is more difficult to predict

Please refer to Appendix A for information on discharging patients with simple and complex care

needs.

4.4 NHS Continuing Health Care (CHC):

Funding will need to be determinedfor health care requirements on discharge for all patients with rapidly deteriorating health problems. Consent and a CHC checklist are completed when a person is fit to leave an acute bed and have reached their optimum level.

The consideration for eligibility for continuing healthcare and NHS funded care needs to form part of the discharge planning in line with requirements in the National Framework (revised November 2012). It is essential that patients, their families and/or carers are fully engaged throughout the process according to best practice as stated in CHC National Framework.

Full assessment for CHC, using the DOH Decision Support Tool (DST) will be completed prior to discharge however this should ideally not take place in the acute hospital setting. To prevent patient decompensation the patient should be transferred to an alternative setting for the assessment to be completed. There are continuing care assessment beds available for both Hampshire and Portsmouth, where the assessment can take place in a more suitable environment – should the client have no challenging non compliant behaviours.

4.5Patients with an End of Life Care Plan:

This applies to patients with specialist palliative care needs, however input may be from a single or multi-disciplinary team depending upon the place of discharge. Specialist advice may be required to ensure prompt access to and availability of equipment or services.

Where the patient’s condition is rapidly deteriorating, the responsible clinician for the patient can use the Department of Health (DoH) Fast Track tool to provide evidence to support rapid response to care needs in the community. Patients can be discharged to existing community services not provided through CHC for end of life care support.

4.6Discharge Lounge:

Non-ward environment which accommodates patients prior to leaving hospital, where care needs can be completed and any communications regarding discharge can be actioned. All patients being discharged home must be considered for transfer to the Discharge Lounge. Please refer to the Discharge Lounge Standard Operating Procedures for more detailed information on the criteria and process.

4.7Expected Date of Discharge (EDD):

A target discharge date to which all agencies can work whilst recognising that the date may change according to the patient’s needs/clinical status. An EDD should be set at the first Consultant review and no later than the first Consultant post take ward round the next morning. If a patient is transferred to specialty team then, as soon as possible the EDD should be reviewed and if indicated re set by the specialty team responsible for discharge

EDDs should be set assuming an ideal recovery pathway without internal or external waits. If the EDD is set embedding anticipated waits and delays the system i.e. Social Care, then these waits become hidden and cannot be highlighted and resolved

The EDD is clinical and describes the objective of the admission and should be used to co ordinate care and minimise unnecessary waits. It is more likely that internal waits within the acute hospital predominate

If a patient stay goes beyond the EDD best practice is to highlight this as EED +1, +2, +3 etc. and clearly identify the constraint that caused this

4.8Self discharge:

Related to patients wishing to self discharge against medical advice. However, this needs to be managed differently in patients with fluctuating mental capacity and/or under DOLs (see separate guidance)

4.9 To Take Out’ Medicines (TTOs):

Medicines which the patients take away when they leavehospital

5.DUTIES AND RESPONSIBILITIES

It is anticipated that everyone will work against the SAFER principles when planning and managing discharge. However, each staff group will hold other slightly differing responsibilities in order to support the patients discharge.

5.1The IDS

The IDS operates through 2 key models which are:

  • ‘Standardised’ working across professional boundaries, sharing key skills across the team and enabling IDS representation at all core daily ward board rounds, and working within a stage 1 Trusted Professional/Assessor framework (where possible);Specialised professional case management through relevant professional structures in accordance with patient need (locality and health vs social care need).

The IDS will deliver responsibilities against these by:

  • Coordinate, monitor and ensure patients are discharged from Portsmouth Hospital safely, as far as possible, in line with EDD.Provide specialist advice and support, signposting to other specialist services.Provide ward links who will act as a point of contact for colleagues within community hospitals, primary care and voluntary agencies in relation to people with complex discharge packages or concerns related to the hospitals discharge procedure and process.
  • Facilitate and support staff with discharge planning of all patients.
  • Monitor progress and advise on the discharge process including identifying and reporting the reasons for any delayed discharges and ensuring that Bedview is updated.
  • Monitor, progress, advise and provide training to the organisation in regard to discharge systems and processes.

5.2Medical Staff

The Consultant or other appropriate doctor with delegated authority has responsibility for:

  • Working against SAFER principles to manage and facilitate discharge
  • Determining an EDD that is communicated to the patient, relatives/carer on admission and recorded in the patient’s notes and on the board within the ward area.
  • All patients to have an EDD based on medical and functional suitability for discharge
  • Daily Senior Decision Maker review of patients at Board Rounds and later in the day follow up of actions
  • Sickest patients first then potential discharges, thennew patients and thenthe ward round of remaining patients
  • Ensuring that the Patient Journey Board is updated and agreed post consent of the patient and relative details being incorporated in this format
  • Confirming the EDD on the first senior clinical review and ensuring that date is communicated to the multi-disciplinary team (MDT), the patient and their relatives/.
  • Keeping the patients/relatives/carers fully informed of their progress and treatment in order to progress assessment needs.
  • Completing Discharge Summaries on ICE.
  • Liaising with the MDT on a regular basis to enable co-ordination of the agreed discharge date.
  • Ensuring any change in the patient’s EDD is communicated to the MDT/patients/relatives and recorded in the medical notes without delay.
  • Documenting clearly in the medical notes when a patient is assessment stable/fit to leave an acute bed.
  • Ensuring all TTO medication is prescribed at least 24 hours before discharge.

Please refer to Appendix B for the 10 Step Plan written by theDepartment of Health, 2010. This outlines the steps that must be taken to promote discharge.

5.3Pharmacy

  • Ward Pharmacist to be informed of any changes immediately, and patients with NOMADs to be identified earlier if possible
  • Ensuring all TTO medication is dispensed at least 24hrs before discharge.
  • Patients transferring under End of Life(with an End of Life care plan) should have anticipatory medications written and dispensed accordingly.
  • Ensuring that when a patient is to be discharged with medication prescribed via injection or an infusion pump an authorisation letter is written to the district nurse confirming details of the prescribed medication to accompany the patient on discharge.
  • Recognising the Electronic Discharge Summary should be completed if unable due to IT breakdown then a hand written should be legible on all copies provided.

5.4Senior Nurse /Nurse in Charge has overall responsibility for:

  • Ensuring every patient has a copy of the Discharge Leaflet.
  • Ensuring the Discharge Checklist is complete (Appendix C)
  • Ensuring that the Management of Expectation policy is adhered to.
  • Ensuring that all patients have an EDD recorded in their notes, detailed on the patients journey and that this date has been communicated to the patient, relatives/carer, as appropriate.
  • All information relating to the discharge is recorded on Bedview
  • Ensuring that systems are in place so that patient discharge is co-ordinated and progresses according to plan.
  • Jointly work with the Senior Decision Maker to ensure review of patients at daily Board Rounds and later in the day follow up of actions
  • Ensuring that information required to plan and manage patient discharges is gathered, and recorded accurately, especially in respect of conversations with the patient, their family and/or carers: including the date and times of those conversations
  • Continuously monitoring the discharge progress of all patients, ensure positive action is taken to expedite discharges for those who are fit to leave an acute bedand have exceeded their EDD.
  • Any delays to patient progress (diagnostics, tertiary opinion, referrals) to be reviewed and escalated as per CSC pathway i.e. through Matron or General Manager
  • Ensuring assessment and discharge notifications are submitted as per Integrated Discharge Service (IDS) standard Operating Procedure (SOP).
  • Ensuring that the correct discharge pathways are identified for the patient and that the relevant pathway forms are completed.

5.5Ward Nurse is responsible for:

  • Discharge planning commences within 24 hours of admission and that progress is appropriate to achieve the EDD.
  • Assessment fit and discharge notifications are submitted as per IDS SOP.
  • The patient and relatives / carers are fully involved in the discharge planning process, their needs and wishes are taken into account and they have at least 24 hours notices of the discharge date, whenever possible
  • In the absence of the Senior Nurse /Nurse in Chargejointly work with the Senior Decision Maker to ensure review of patients at daily Board Rounds and later in the day follow up of actions
  • All information relating to the patients discharge is recorded on Bedview.
  • Consideration of the need for continuing health care assessment for all patients with ongoing care needs before referral to Social Services using the continuing care check list.
  • The patient’s medication is ordered 24 hours before the discharge
  • Appropriate transport arrangements are made and that all pertinent information regarding the patient’s condition is given to the ambulance service transporting patients. (E.g. Do Not Resuscitate [DNAR] status, infections, issues regarding transferring and in respect to manual handling). When arranging transport for discharge it is vital that the discharge address including Post Code is confirmed and checked as correct, as it may differ to the patient's home address. It is equally important to check that the patient can access their destination address e.g. do they have a key, can they manage any steps at the property.
  • Transport for bariatric patients and for property that is difficult to access must be booked 24 to 48hrs prior to discharge.
  • Transport should be made via the On-Line Transport system through the current provider.
  • Transport should only be provided for discharge when there are no family or friends to transport. Transport can be booked 24/7 and all staff should access this system to book accordingly to the patient’s needs and mobility status.
  • If your patient is not eligible you will be signposted to a directory of alternative transport.
  • The receiving hospital, care home or social care facility (or community nurse team, if the patient is returning home) is notified of any known infection and the current infection control practices in place e.g. antibiotic therapy, dressing regime, barrier nursing.
  • The patient has the necessary medication, dressings and relevant information about post discharge care.
  • All arrangements and referrals in relation to discharge planning are clearly documented, signed and dated within the discharge planning documentation
  • All healthcare professionals involved with the patient are notified of any change in the patient’s ward placement and or condition/suitability for discharge with a request for a review as appropriate.
  • Any potential delays in discharge are referred immediately to the IDS as soon as they become known outlining the reasons for the delay or potential delay.
  • All necessary information for discharge/transfer of care and management is gathered, recorded and communicated appropriately

5.6Discharge Planning Team (DPT) will: