,

Joint Protocol for the Transfer of Care

(Adults)

NHS Leeds

Leeds Teaching Hospitals NHS Trust

Leeds City Council

Harrogate & District NHS Foundation Trust

Mid YorkshireHospital NHS Trust

Signed off by:

KEVIN HOWELLS
Acting Chief Executive
NHS Leeds / MAGGIE BOYLE
Chief Executive
Leeds Teaching Hospitals NHS Trust / SANDIE KEENE
Director
Adult Social Care Services
Leeds City Council

Contributors: Representatives from the above agencies

Revised: March 2009

Version: 2

Date of Production: April 2009

Date for Revision: April 2010

Table of Contents

1 / Introduction / Page 3
2 / Purpose / Page 4
3 / Principles / Page 4,5,6
4 / Definitions / Page 6
5 / Housing/ Homelessness / Page 6,7
6 / Community Intermediate Care Beds / Community Unit / Page 7
7 / Information Sharing / Page 7
8 / Multi-Disciplinary Assessment / Page 7
9 / NHS Continuing Care / Page 7, 8
10 / Transfer / Discharge Assessment / Page 8
11 / Medical Transfer of Care / Page 8, 9
12 / Process / Page 9
13 / Specific Requirement for Planned Admissions / Page 10
14 / Documentation / Page 10
15 / The Care Communication Centre / Page 10
16 / Discharge Referral Points / Page 10, 11
17 / Education / Training / Page 11
18 / Reimbursement / Page 11,12,13
19 / Patient Disputes / Page 14
20 / Inter- Agency Disputes / Page 14
21 / Cross Boundary Issues / Page 14
Appendix 1 / Delayed Discharge Codes / Page 15
Appendix 2 / Escalation Policy / Page 16, 17, 18
Appendix 3 / Escalation Flowchart / Page 19
Appendix 4 / Flowchart for S2 & S5 process / Page 20
Appendix 5 / Patient Information Letter 1 / Page 21,22
Appendix 6 / Patient Letters 2 / Page 23, 24
Appendix 7 / Responsibilities on issue of Section 5 / Page 25,26,27,28
Appendix 8 / Referral Process to Housing Services / Page 29

1Introduction

Safe and effective arrangements for patients leaving hospital are essential and are every body’s responsibility. All patients will be treated equally regardless of age, disability, race, religion or belief, gender or sexual orientation.

Good hospital discharge arrangements are central to providing the amount of support that people leaving hospital may require. All organisations (NHS Leeds, LTHT and Leeds City Council) have agreed that community care assessment of people being discharged from hospital will be carried out in line with:

  • Agreed Hospital Discharge Policies
  • the protocols and timescales laid down in the Community Care Delayed Discharges Act (England) 2003
  • The principles and responsibilities outlined in The Mental Capacity Act 2005
  • The National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care 2007
  • Where relevant within the principles of the Single Assessment Process.

When a patient is medically fit for discharge we will aim to do this as soon as it is safely possible. Discharge could be to their own home or to an appropriate care setting.

This means that:

  • Patients will not be discharged from NHS hospital care until a hospital doctor or appropriately qualified nurse has decided that they are medically fit for transfer/discharge and no longer need hospital care.
  • Patients willnot be discharged from hospital until appropriate arrangements for their care immediately following dischargeare in place. If a patient is discharged “out of hours”ward staff must ensure that all relevant people/agencies are informed as soon as possible to ensure the patient’s needs are met and will continue to be met.
  • Patients who do not have the capacity to make a decision about their future care on discharge will be supported to take part in discharge planning along with the relevant individuals in line with the Code of Practice for The Mental Capacity Act 2005.
  • The NHS jointly with Social Services will be responsible for securing continuing health and social care for all people whose needs fall within agreed eligibility criteria and priorities consistent with local needs and national guidance.
  • All community care assessments undertaken with patients who are in hospital will be carried out in accordance with the timescales laid down in the Community Care Delayed Discharges (England) Act 2003.
  • Where a patient is identified as homeless on admission, with the patient’s permission information of their pending transfer/discharge should be notified to the relevant Primary Healthcare Services, the Homeless Services Providers and where appropriate Social Services.
  • The patient and their carer will be fully informed and involved in discharge planning throughout their episode of care. They will be given information on how to obtain further advice post transfer/discharge.
  • The General Practitioner will be informed in writing of transfer/discharge arrangements, in a timely manner, when the patient is discharged.

On transfer/discharge the patient will receive a provisional discharge letter that should be communicated with the General Practitioner. The letter will identify the nature of the admission, the diagnosis on discharge including a list of medications and contact details fro the person or agency that the General Practitioner should contact in the event of requiring further advice. The patient should be informed that GPs do not routinely visit patients after they have been discharged from hospital.

2Purpose

The aims of this protocol are:

2.1To ensure that all transfers of care support dignity and ensure effective outcomes for the patient.

2.2To support the principles of the hospital discharge policy.

2.3Set out the principles of reimbursement and the health economy agreement on the expenditure for purposes of joint investment.

2.4To ensure that people are cared for in the most appropriate environment.

2.5To recognise that a whole system approach is necessary to eliminate delayed transfers of care.

2.6To focus mainly upon acute beds but to recognise that it also supports the A & E 4 hour standard and ensures best use of overall bed capacity.This in turn supports a well organised admission and discharge process.

2.7To recognises that systems and process might be different for out of Leeds hospitals. However, the principles remain the same.

3Principles

The protocol is based on the following principles:

3.1The transfer of care process will focus on the patient’s needs. Both they and their carers should be involved and kept informed of what is happening at all times. Leeds Teaching Hospital Trust together with Adult Social Care and NHS Leeds are committed to taking account of the needs of carers in the discharge process. The multi agency Leeds Carers Charter acknowledges a carers right to be recognised, identified and valued in their caring role, their right to be treated with dignity and respect and to a carer’s assessment. If a carers assessment is not undertaken at the point of discharge then clear information should be given to the carer about how they can obtain one at a later stage by providing them with the leaflet, Caring in Leeds, the Carers Discharge Pack and / or the telephone number of the Call Centre on: 0113 2224401

3.2 A carer is someone who, without payment, provides help and support to a partner, child, relative friend or neighbour, who could not manage without their assistance. This could be due to age, physical or mental illness, addiction or disability. The term carer should not be confused with care worker, or care assistant, who receives payment for looking after someone.

3.3At all times throughout the discharge process we will aspire to meet the Department of Health’s 10 point “Dignity Challenge”

  1. Have a zero tolerance for all forms of abuse.
  2. Support patients and carers with the same respect we would want for ourselves or a member of our family.
  3. Treat each person as an individual by offering a personalised service.
  4. Enable people to maintain the maximum possible level of independence, choice and control.
  5. Listen to and support people to express their needs and wants.
  6. Respect people’s right to privacy.
  7. Ensure people feel able to complain without fear of retribution.
  8. Engage with family members and carers as care partners.
  9. Assist people to maintain confidence and a positive self-esteem.
  10. Act to alleviate people’s loneliness and isolation.

3.4Safeguarding - To be read in conjunction with:

NHS Leeds Safeguarding Vulnerable Adults policy:

and

Leeds Teaching Hospitals Trust Safeguarding Adults (Adult Protection) Policy and Procedures:

All health care professionals and support staff have a duty of care to safeguard vulnerable adults. Registered Practitioners must adhere to their own Codes of Professional Conduct.

Health Care Professionals must remember that they are not only accountable for their actions but also for omissions in their practice. Failure to recognise and manage abuse (whoever the perpetrator) is seen as an omission in practice.

Abuse is a violation of an individual’s human or civil rights by another person(s). Anyone can experience abuse and anyone can be a perpetrator of abuse. Abuse can be a single act or repeated acts. It may be behaviour that is deliberately or unknowingly causing harm or endangers life or rights. It may be perpetrated by an individual, a group or an organisation.

Abuse in any form is a serious crime which could result in serious consequences for all those involved.

Health and Social Care organisations also ensure that all staff receive safeguarding training appropriate to their role and level of responsibility and that refresher training is provided on a regular basis as agreed with the Council, NHS or any other regulatory bodies.

3.5All Health and Social Care organisations are committed to a whole systems approach, whereby responsibility for effective patient care, the discharge process, eliminating delays to transfer of care and effective outcomes is a shared responsibility across organisational boundaries.

3.6Planning for discharge should begin prior to or on admission.

3.7The management (including assessment) of a person’s health and social care needs should be a single process.

3.8Full recognition must be given to people with communication difficulties and appropriate help sought. Full support must be given to patients who do not have capacity to make a decision about their future in order to allow them to participate as much as practicable.

3.9Appropriate support must be given to people whose first language is not English.

3.10Discharge arrangements should take account of patients who are being transferred to other hospitals, wards or nursing homes and should cover arrangements for their transportation, the transfer of property, valuables, medications and information concerning treatments. All appropriate professionals and carers must be informed of the move.

3.11Care must be taken in planning transfer / discharge arrangements for all patients, particularly the most vulnerable, out of hours and around weekends and public holidays, any religious or cultural festivals / holidays, to ensure that there is no breakdown in continuity of care and service arrangements during this period.

3.12Optimum use of bed capacity resources.

3.13A commitment to the development of community resources to avoid inappropriate hospital admissions and to prevent A & E being used as the main gateway to health and social care services.

3.14Acute hospital beds are for people with acute medical care needs. People who do not have acute medical care needs should not be admitted to acute beds and those who have acute medical care needs on admission should be transferred as soon as they are medically fit and safe for discharge.

3.15On transfer following acute care the first consideration should be for the patient to return home, safely and with the appropriate support. If necessary, a transitional / interim placement will be offered whilst appropriate support or adaptations are put into place.

3.16Only in exceptional circumstances should the patient transfer directly to long term residential or nursing home care. Attempts will be made to avoid admission to long term care by maximising independence, wellbeing and choice.

4Definitions

  • Whilst the principles apply to all patients, the legislation only applies to patients in receipt of acute care. Acute care is:
  • “Intensive medical treatment provided by or under the supervision of a consultant which is for a limited time after which the patient no longer benefits from that treatment”.
  • For the purpose of this protocol, acute care does not include any of the following:
  • Care in respect of which the patient has given an undertaking to pay (or for whom such an undertaking has been given)
  • Maternity care. That is, care of expectant and nursing mothers
  • Mental health care (defined as psychiatric services or other services provided to a patient for the purposes of the prevention, diagnosis or treatment of illness where the person primarily responsible for arranging those services is a consultant psychiatrist).
  • Palliative care
  • Intermediate care (a structured programme of care provided for a limited period of time to assist a person to maintain or regain the ability to live in his / her home)
  • Care provided for the purposes of recuperation or rehabilitation.

5Housing / Homelessness

To be read in conjunction with the Homelessness and Insecure Accommodation Protocol 2009.

Vulnerable people of no fixed abode, asylum seekers (where the local authority has duties under the Human Rights Act, National Assistance Act, and NHS Community Care Act) are the responsibility of the local authority from which the patient was admitted and the appropriate Adult Social Care Department will be held accountable for any delays in the assessment or provision of service.

Leeds City Council, Environments and Neighbourhoods will provide a specialist assessment service and will provide advice and support to health and social work professionals involved in the discharge process, where it has been identified that:

  • the patient is unable to be discharged to their current home
  • Or where discharge to their current home would prove detrimental to their heath. Primarily this will be achieved through referral via Easy Care to the Medical Rehousing Team (see Appendix 8). In the interim discharge processes and, if necessary, the Escalation Policy will apply.

6Community Intermediate Care Beds / Community Unit

Assessment for Community Intermediate Care (CIC)beds will be determined by NHS Leeds. Patients assessed as suitable for a Community Intermediate Care Bed will be offered a placement from a city wide bed base. Every effort will be made to ensure placement close to the patient’s home. However,it is not in the patient’s best interest to remain in an acute setting and a vacancy in a CIC bed in any area of the city will be pursued.

7Information Sharing

The pan-Leeds information sharing policy will apply to all aspects of this protocol. This is based on the premise that information on a person can only be shared if they give their informed consent.

8Multi-Disciplinary Assessment

A patient is ready for discharge / transfer when:

A clinical decision has been made that the patient is ready for discharge / transfer

AND

A multi-disciplinary team decision has been made that the patient is ready for discharge / transfer

AND

The patient is safe to discharge / transfer.

A multi-disciplinary team in this context includes nursing and other health and social care professionals, who are caring for a patient in an acute setting.

See Appendix 4 for flow chart with triggers for S2 and S5 documentation.

9NHS Continuing Care

9.1On 1st Oct 2007 a new national policy came into effect called the National Framework for NHS Continuing Healthcare and NHS – funded nursing care. This introduces three new national tools to aid decision making:

  • NHS Continuing Healthcare Needs Checklist
  • Decision Support Tool
  • Fast Track Tool

9.2It is important that the NHS can demonstrate that eligibility for Continuing Healthcare funding has been considered prior to the commencement of any discharge process.

9.3To fulfil this need a NHS Continuing Healthcare Needs Checklist should be completed by any member of the professional multi-disciplinary team. This will indicate whether there is a need for full eligibility consideration by NHS Leeds. The outcome of this screening process should be notified to the patient or their representative and documented in the patient’s records.

9.4Where full assessment is indicated the Checklistshould be sent to the Discharge Referral Point (DRP) along with the:

  • Leeds Contact Form ( 2008 version)
  • Specialist Nursing Assessment.
  • Fax cover sheet.
  • S2 notification.

The case will then be allocated to the appropriate Care Manager and Continuing Care Team. A Care Manager can be a: Joint Care Manager, Hospital Social Worker or Community Social Worker.

9.5Where a full assessment is NOTindicated MDT members, including ward staff, should be aware that if a patient’s health condition deteriorates prior to discharge the above Checklistprocess should be repeated and the original S2 withdrawn.

9.6The Care Manager will then facilitate the completion of the national Decision Support Tool, taking account of all the MDT assessment information, including all relevant clinical information provided by ward staff and the patient or their representative, as evidence to inform the recommendations.

9.7Where indicated, the Decision Support Tool recommendation and supporting evidence will be presented to the CHC Panel to determine a patient’s eligibility for CHC funding.

9.8Where a patient has a rapidly deteriorating condition, which may be entering a terminal phase, an urgent referral for care planning should be made. This will require the completion of a Fast Track Tool by an authorised clinician.

9.9The discharge planning process, including any Choice Directive or Escalation issues, should proceed as normal whilst CHC eligibility is determined.

9.10At any point in the process the patient or their representative can appeal the decision and ask for a review. There is an agreed process for this as recommended by the National Framework. The CHC team will offer advice and support in this circumstance.

9.11Where there is dispute between the PCT and the Local Authority as to who is responsible for funding the care, the discharge should not be delayed. The dispute will be managed under the agreed Local Dispute Resolution Process for NHS Continuing Healthcare in Leeds.

The National Framework Document and decision support tools are available on Leeds Health Pathways, or they can be found at:

10Transfer/ Discharge Assessment

10.1The Leeds Contact Form, along with the Specialist Nursing Assessment, is used to share information about the patient and their needs on transfer/discharge. The assessment will then continue in the most appropriate setting which may be the person’s own home, an interim care arrangement or an intermediate care service.