SURREY JOINT PROTOCOL OF CHOICE
FOR GOOD PRACTICE TO FACILITATE TIMELY DISCHARGE FOR PEOPLE NEEDING LONG TERM CARE
PURPOSE

1. The purpose of this joint protocol is to minimise delays in acute and community hospital discharge across Surrey for all patients assessed as needing to return home, to return home with a package of care, a care home placement or transfer to another hospital.

2. It is designed to ensure that choice is managed fairly throughout the discharge planning process; that a clear escalation process is in place for when patients remain in hospital longer than is clinically required; and that there is a consistent approach across Surrey.

3. The protocol is designed as best practice guidance to be implemented across acute and community hospitals in Surrey. It is designed to be part of each organisation’s wider discharge policies and procedure. It sets clear expectations and identifies target timescales from the multi-disciplinary assessment to the date of discharge. It describes the process for resolving problems if discharge is not achieved within an appropriate timescale.

4. The protocol follows standard procedures relating to patient confidentiality. Where the protocol refers to carers, family or the patient’s representative, those providing information, advice or letters of confirmation must ensure that patient confidentiality is maintained.

PRINCIPLES

In managing choice on discharge the following principles should be applied:

5.The hospital environment is not designed to meet the needs of people who have reached their potential for discharge. The consequences of remaining in a hospital bed beyond the Estimated Date of Discharge (EDD), or when the individual is assessed as ‘medically fit for discharge’, are:

  • The risk of increasing dependence and greater demand for social care and support in the community
  • Potential for prolonged exposure to an unnecessary risk of hospital-acquired infection
  • Frustration and distress caused by uncertainty during any wait for a preferred choice to become available.

6.Discharge planning is an integral part of patient care that should start upon admission and be ongoing. The protocol of choice should be explained to the patient and their carer, family or representatives upon admission and at each step in the process to ensure they have a clear understanding and expectation. By the time a patient is ready to leave hospital, consideration will already have been given to their ongoing care provision and they, their carer, family or representative should understand that they cannot continue to occupy the hospital bed.

7.Those self-funding their care will be offered the same level of advice, guidance and assistance regarding choice as those fully or partly funded by social services or the NHS.

8.Dependent on the type of funding agreed, the named lead worker will aim to identify and advise the patient and their carer, family or representatives of a selection of up to two support packages, or care homes where vacancies exist which meet the patient’s needs and Care Quality Commission (CQC) quality standards. In some cases it will not always be possible to offer two options. In these cases it is recognised that a smaller number will have to be offered and the rationale for this explained.

9.This protocol applies equally to all patients in acute and community hospitals in Surrey, irrespective of the source of their funding for out of hospital care and support.

10.No decision will be made without the individual and/or, where appropriate their carer, family or representatives, being involved. Consideration will be given to the need for an advocate or Independent Mental Capacity Advocate (IMCA), where appropriate.

11.Where the person lacks the mental capacity to make decisions about their care, support, accommodation or discharge arrangements, then all decisions will be made in their best interests, compliant with the principles and guidance of the Mental Capacity Act 2005. Further guidance is provided in Appendix 3.

12. The Multi Disciplinary Team (MDT) will assess the risk to the individual and their circumstances associated with discharge.

13.Roles and responsibilities will be defined locally by the acute or community hospital using this joint protocol.

14.If a patient can continue their recovery in a more suitable setting, it is not appropriate that they remain in hospital after they are medically fit for discharge, ready for transfer and no longer require hospital treatment[1].

15.A named lead worker will be identified, dependent on the type of funding approved, as follows:

15.1Social services will lead on:

  • Social services funding, with Funded Nursing Care (FNC) for a nursing home
  • Social services funding, with no health funding entitlement for a care home or package of care

15.2A named lead worker from the MDT will support and facilitate on:

  • Self funders with FNC for a nursing home
  • Self funders for a residential home
  • Self funders for packages of care
  • NHS Continuing Healthcare (CHC) funding for placement or packages of care
  • Interim NHS funding for placement or packages of care
  • Other NHS funding streams.

16.The role of the Surrey NHS Funded Care Team is to support the named lead worker in assessing eligibility and commissioning packages of care for patients funded by CHC; and to make the decision on CHC and FNC eligibility.

PROCESS

STEP 1 – PROVIDING STANDARD INFORMATION

17.The named lead worker or another member of the MDT will explain the discharge planning process to the patient and their carer, family or representative on admission. If a discharge planning information leaflet has been agreed locally, this will be given to the patient.

18.The named lead worker will ensure the patient and their carer, family or representative is aware of this protocol and of the circumstances in which a move to alternative or interim accommodation or care might be necessary. All communication will set and reinforce the expectation that patients will leave the hospital as soon as their need for inpatient treatment ends.

19.All patients will be given an Estimated Date of Discharge (EDD) set as soon as possible after admission. Regular review and discussion about the EDD will ensure all parties understand when support will be required to facilitate discharge.

STEP 2 – ASSESSING NEED

20.The likelihood of the patient needing health, social care, housing, mental health or other support after discharge will be considered as soon after admission as possible.

21.If the patient is likely to have ongoing health or social care needs after discharge the named lead worker will ensure timely referral to other services for assessment. This may include, for example:

  • Social care assessment
  • Financial assessment and benefits advice
  • Eligibility for NHS Continuing Healthcare and Funded Nursing Care

STEP 3 – PREPARING FOR DISCHARGE

22.Following relevant assessments and an EDD having been agreed, letter 1 (Appendix 1A, 1B or 1C depending upon funding arrangements) will be prepared and given to the patient by a hospital representative. It is important that the letter is addressed to the patient and is personalised to reflect their circumstances. Explain the process to the patient and their carer, family or representative and ensure they understand that they must accept an available discharge option, either on an interim or permanent basis. Where the person lacks mental capacity then a copy of the letter should also be given, where appropriate, to their carer, family or representative.

23.The named lead worker will advise the patient and their carer, family or representative at the earliest appropriate opportunity, about available of up to two packages of care or care home options that meet agreed Care Quality Commission (CQC) standards. There might be only one option, dependent on availability and the rationale for this must be explained.

24.If more than one care option is available when the patient is ready for transfer or discharge from hospital, the named lead worker will offer to support the patient and their carer, family or representative to choose. If there is currently only one available option this should be accepted by the patient, their carer, family or representative, either on a permanent or interim basis.

25.If the placement is to be funded by the NHS, the Surrey NHS Funded Care Team representative will advise the patient and their carer, family or representatives of their right to look at alternative nursing homes that fall within the criteria set by the CCG based on the individual patient’s needs.

26.If the placement is to be funded by social services, a social services representative will advise the patient and their carer, family or representatives of the usual fee paid by social services and the need for a financial assessment to determine the amount of their contribution towards this fee level, whether the identified needs of the patient can be met within this fee level and their rights under the National Assistance Act 1948 (Choice of Accommodation) Directions 1992.

27.The patient and their carer, family or representative should be directed to the Patient Advice and Liaison Service (PALS) for advice and information regarding advocacy if required.

28.Discuss discharge plans with the patient and their carer, family or representative regularly. The named lead worker will encourage resolution of any potential barrier to discharge and seek support from MDT members involved.

STEP 4 – SEVEN DAY WINDOW

29. Once funding is agreed and packages of care or vacancies have been given, a period of a maximum of seven consecutive days is provided for the patient and/or their carer, family or representatives to view a vacancy or service which is suitable to meet assessed needs and available funding, and to make a decision. In exceptional circumstances, a period of a maximum of ten consecutive days may be agreed locally. Regular communication will be maintained throughout this period by the named lead worker.

30.The named lead worker will advise the patient, their carer, family or representative that the hospital will expect discharge to be achieved within the agreed timescale.

31.The named lead worker will proactively support the patient and their carer, family or representative during this process and will offer advice and support regardless of how the placement is to be funded.

32.Patients do not have the right to remain in hospital longer than required because they or their carer, family or representative has not reviewed available options.

STEP 5 – INTERIM PLACEMENT

33.Where discharge is not achieved within a maximum of seven consecutive days of funding being agreed and up to two care home vacancies or packages of care having been offered by the agencies involved. Members of the multi-disciplinary team will liaise within two working days and they will advise the patient, their carer, family or representative that an interim placement or service, which meets the assessed needs of the patient, has been arranged and a date for transfer will be given. Consideration of interim arrangements must be accompanied by a risk assessment and a best interest assessment as appropriate.

34.This interim placement will allow further time for the choice of placement to be resolved outside of an acute or community hospital as explained in letter 1. This interim placement would normally be in one of the initial placements offered if still available.

35.This will be confirmed with letter 2 (Appendix 2A, 2B or 2C depending upon funding arrangements). Letter 2 will be prepared and given to the patient by a hospital representative. It is important that the letter is addressed to the patient, is personalised to reflect their circumstances and that the process is explained to the patient and their carer, family or representatives. Where the person lacks mental capacity then a copy of the letter should also be given, where appropriate, to their carer, family or representative.

STEP 6 – ESCALATION PROCESS

36.If no agreement has been reached regarding discharge arrangements after steps 1-5, and transfer arrangements are challenged by the patient and/or their carer, family or representative, the local director or senior manager in the hospital will support the named lead worker to continue plans for transfer to an interim placement or alternative care provider.

37.The named lead worker, supported by the local director or senior manager in the hospital will consult local legal advisors regarding legal proceedings and escalate as required to ensure discharge from hospital, in order to safeguard the health and wellbeing of the patient and other patients.

AUDIT TRAIL

38.The nominated lead worker will store the Protocol of Choice letters on an agreed central log, with a copy placed in the patient’s notes and a copy sent to the appropriate agency responsible for funding care.

OPERATIONAL DATE AND REVIEW

39.This protocol will be operational from 1 July 2014.

40.This protocol will be reviewed six months after publication. This initial review will be hosted by Surrey County Council in partnership with the acute and community hospitals in Surrey. The protocol will be reviewed every three years or earlier if national policy or guidance changes are required to be considered.

GLOSSARY

Care Home – Offer accommodation and personal care for people who may not be able to live independently. Some homes also offer care from qualified nurses or specialise in caring for particular groups such as younger adults with learning disabilities

CHC - NHS Continuing Healthcare

EDD - Estimated or expected date of discharge. The date the patient is most likely to be ready for safe transfer

Financial Assessment – An assessment by Social Services to determine the amount the patient will be required to pay towards their care and support.

Interim care – A provisional placement that is suitable and able to meet the patient’s assessed needs whilst they wait for their preferred option.

IMCA - Independent Mental Capacity Advocate, who will represent patients assessed as lacking capacity under the Mental Capacity Act 2005 to make important decisions, such as change of accommodation and who have no family and friends to consult

IMHA - Independent Mental Health Advocate, who will support patients who have been detained under the Mental Health Act 1983 to be involved in important decisions, such as change of accommodation

MDT - Multi-Disciplinary Team of health and social care professionals involved in the case and assessment of patients

Named Lead Worker – A named health or social care professional who supports and facilitates the patient’s discharge and who is their key contact

Patient - An individual who has been admitted for NHS inpatient services

Representative – A family member, person granted a relevant and valid power of attorney, court appointed deputy, friend that the patient has asked to be involved or another advocate. Appropriate consent will be needed before discussing confidential information with a representative

Self-Funder - A person who financially meets the full cost of their social care needs, whether because their financial capital exceeds the threshold for adult services funding, or because they or their representative choose to pay for their care

Social Care Assessment – The assessment of a person’s social care needs that all adult patients are entitled to, regardless of financial status. A social care professional will help identify suitable care and support and will assist with discharge from hospital if asked.

CONTEXT

In applying this policy, account will be taken of all related legislation, policy and guidance documents issued by the Department of Health including:

  • 1990 National Health Service and Community Care Act
  • 1992 National Assistance Act 1948 (Choice of Accommodation) Directions
  • 2002 National Service Framework for older people
  • 2003 Community Care (Delayed Discharges etc.) Act
  • 2003 Community Care (Delayed Discharges etc.) Act Guidance for Implementation
  • 2003 Discharge from hospital pathway, process and practice
  • 2003 ‘Discharge from Hospital – A matter of choice’ - Supplementary checklist on implementing the Direction on Choice of Accommodation:
  • 2004 Achieving timely simple discharge from hospital: A toolkit for the multi-disciplinary team
  • 2004 Guidance on National Assistance Act (1948) (Choice of Accommodation) National Assistance (Residential Accommodation) (Additional Payments and Assessment of Resources) (Amendment) (England) Regulations 2001 “Choice Directive
  • 2005 Mental Capacity Act
  • 2008 NHS Institute for Innovation and Improvement Discharge Planning Toolkit
  • 2009 Common Assessment Framework for Adults. A consultation on proposals to improve information sharing around multi-disciplinary assessment and care planning
  • 2009 (revised 2010) The Handbook to the NHS Constitution
  • 2010 Ready to Go? Planning the Discharge and Transfer of Patients from Hospital and Intermediate Care
  • 2010 Guidance on Eligibility Criteria for Adult Social Care DH
  • 2010 Equality Act.
  • 2012 National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care
  • 2012 NHS Continuing Healthcare Checklist
  • 2012 Decision Support Tool for NHS Continuing Healthcare
  • Fast Track Pathway Tool for NHS Continuing Healthcare
  • 2013 The NHS Continuing Healthcare (Responsibilities of Social Services Authorities) Directions
  • 2013 The Delayed Discharges (Continuing Care) Directions
  • 2014 Care Act

Appendix 1a - People TO BE Funded by Continuing Healthcare - Protocol of Choice Letter 1

Hospital Logo

This template letter should be personalised to reflect the patient’s individual circumstances. Should a patient be assessed under the Mental Capacity Act 2005 as not having capacity to make decisions regarding their discharge, then a copy of this letter should be given to their representative but should be addressed to the patient.

Address Date

Dear Mr/Mrs………………………

Re: Patients name and hospital number

I am pleased to confirm that you are now ready to [leave hospital/transfer]. The team caring for you have recommended that you should now be transferred [home with a package of care/to a care home/to another hospital] where your needs will be best met. I would like to confirm the process for organising this.

As discussed [over the telephone/at the meeting] we are now waiting for the NHS Funded Care Team to agree the funding for your care. Once we receive this funding confirmation the NHS Funded Care Team will make contact with you and will help you to find a suitable [package of care/care home].