1 THE WHIPPS CROSS DISCHARGE HANDBOOK INDEX Topic …

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1 THE WHIPPS CROSS DISCHARGE HANDBOOK

INDEX Topic Page Number

Introduction, by Professor Alistair Chesser 2

Complex and Simple Discharges & Patient Dignity 3

Discharge Team – Who’s Who 4 Discharge Team 5 Waltham Forest Rehabilitation Services 6 Waltham Forest Social Work Service to Whipps Cross 7 Redbridge Social Work Service to Whipps Cross 8 Essex Social Work Service to Whipps Cross 9 Community Matrons & District Nurses 10 Request for Waltham Forest Social Care Support to start out of hours 11 Contacting Adult Social Care in Out of Hours Emergencies 12 Section 2 notifications 13 Section 5 notifications 14 A quick guide to completing electronic Section 2s and 5s 15 Provision of Home Oxygen 16 Discharge Lounge 17 Arranging Services and Equipment on Discharge 18 Ordering beds and mattresses 19 NHS Continuing Care Checklist 20 London Health Needs Assessment 21 The Decision Support Tool (DST) 22 DST – More Information 23 Fast Track Continuing Care 24 Repatriation 25 Referral to Specialist Rehabilitation Units and Community Rehabilitation 26 Vacuum Dressings 27 Refusing to leave the ward 28 Patients who have no recourse to Public Funds 29 Extra Care & Sheltered Housing 30 Glossary 31 & 32

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This handbook has been designed to help wards at Whipps Cross Hospital with everyday discharge issues. The idea for it came from a similar handbook at the Royal London Hospital, created by Gill Parry, who leads the Complex Discharge Team there. Gill’s work has been amended and adapted for Whipps Cross. If you feel anything is missing, or you would like to suggest any corrections or improvements, please contact Alfred Overy ( [email protected] )

Achieving timely and safe discharge is a very important aspect of work in an acute hospital setting. Most patients want to know when they are likely to be able to go home, so that they and their family and friends can make plans. For more vulnerable people, who would like Social Care support, referrals need to be sent in good time, so that effective plans can be made.

If a patient may be entitled to NHS Continuing Healthcare, it is really important that their assessment is completed quickly and accurately, by each member of the Multi Disciplinary Team. Continuing Health Care assessments have to be signed and agreed by the patient or their next of kin and they must be complete and accurate. Continuing Health Care assessments are rigorously assessed and, because they commit substantial and continuing health funding for a patient, it is really important that they are thorough, or they will be sent back and the patient’s discharge will be delayed. Complete the forms as you would wish such an assessment to be undertaken for a member of your own family, remembering that it is essential for your patient’s future wellbeing to get the right care arrangements in place for them.

If a patient has been in hospital for a long time, it is especially important to make sure that the right arrangements are made for their safe discharge. In addition to sending Section 2 and Section 5 notifications, this could mean involving the British Red Cross (there is a worker at Whipps Cross) the various home from hospital schemes in patients’ local areas (for example, the Waltham Forest Home from Hospital Service) contacting the warden if your patient lives in a sheltered or extra care housing scheme, or making sure that Adult Social Care know that a patient is due to be discharged in the morning, so that their care package is ready to start and they do not have to wait until the evening for a carer to make sure they are alright.

In all cases, Barts Health NHS Trust expects its staff to comply with best practice, as explained in the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care. The full framework document is readily accessible on line for those who want to study it in more detail. You are also expected to follow the Trust’s policy and standards for dignity, privacy and respect for religious and cultural differences. Make sure you know and understand this policy and apply it when patients are discharged, by ensuring they and their next of kin are fully informed about discharge plans and patients are always discharged wearing suitable outdoor clothes, with all their property and their discharge summary and medicines to take away. This handbook is designed to support efforts to get patients discharged from hospital in the morning, well before noon. Early discharge allows patients time to settle at home during normal working hours, when services and support are most readily available and frees up beds so that elective surgery can go ahead as planned. Getting TTAs and diagnostic tests completed early and preferably the day before discharge, is crucial if we are to achieve morning discharges, so do not hesitate to chase up any delays. Wards can report and action any delays through the Barts Health Way Patient Flow Coordinators (Bleeps on page 4). If you are having trouble achieving a morning discharge for your patient, always remember to share any problems or delays with matrons and managers as early as possible, so that problems can be correctly identified and resolved. Make sure that the Discharge Checklist for each patient is completed soon after admission and always let the Discharge Team know about any complications or problems with discharge, so that we can get the best outcome for every patient. If the Checklist is completed correctly, it will provide you with a great deal of the information you may require for other referrals.

Don’t forget – good communication is really essential to setting up a safe discharge for patients. Always inform the Social Workers, District Nurses, Sheltered Housing Wardens, Nursing and Residential Homes, any other key services and of course the patient and their family of your patient’s discharge. Advise them if your patient’s discharge is delayed, even if only for a few hours. This seems like a lot to do, but it is very important for patients and is what you would want for a member of your family.

Good luck!

Professor Alistair Chesser,

Group Director, Emergency Care & Acute Medicine

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Definitions for simple and complex discharges & patient dignity

S

Simple Discharge

Patients who can be discharged back to their usual place of residence with no requirement from the hospital for further support or care

SS

Simple Supported Discharge Patients who need simple care and support which can generally be arranged

within four days of a request being made:

Equipment Bedded short term facility Restart of existing Package of Care Minor changes to existing Package of Care Section 2 / 5 transfers of care, for community care services District Nurse Speciality Nurse Community Matron Community Therapy

Please notify the Discharge Team of all transfers of care (Section 2 & 5)

or if any difficulties arise

C

Complex Discharge

Patients with multiple needs who will require complex packages of care and treatment, including NHS Continuing Health Care and/or where discharge is affected by safeguarding, domestic violence, severe housing problems, no

recourse to public funds or other complex family issues

Please contact the Discharge Team for advice 020 8535 6446 or ext: 6396; bleep 271

REMEMBER – WHETHER A DISCHARGE IS SIMPLE OR COMPLEX, PATIENTS SHOULD ALWAYS BE TREATED WITH DIGNITY. THEY AND THEIR NEXT OF KIN SHOULD ALWAYS BE INFORMED ABOUT DISCHARGE ARRANGEMENTS IN GOOD TIME, SO THAT THEIR CLOTHES ARE AVAILABLE TO WEAR ON DISCHARGE AND EVERYBODY KNOWS WHAT IS HAPPENING. PATIENTS SHOULD NEVER BE DISCHARGED IN HOSPITAL GOWNS: THEY SHOULD HAVE PROPER CLOTHING TO WEAR. IF A PATIENT IS VULNERABLE OR FRAIL AND DOES NOT HAVE CLOTHING CONTACT YOUR SENIOR NURSE OR THE DISCHARGE TEAM TO OBTAIN SUITABLE CLOTHING FOR THEM

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THE DISCHARGE TEAM – WHO’S WHO

The Discharge Team is based on the 1st Floor, Willow Lodge, Whipps Cross Hospital:

Phone: 020 8535 6446

Fax: 020 8535 6447

Secure email: [email protected] Joyce Williams is the Senior Discharge Co-ordinator. You can contact Joyce on: Internal: Ext 6396

Marlene Stone is the Discharge Co-ordinator. You can contact Marlene on:

Internal: Ext 5949

Secure email: [email protected]

Veronica Evivie is the Senior Staff Nurse for Continuing Care

Internal: Ext 6394


Alfred Overy is the Administrator for the Discharge Team & to support Admission Avoidance & Long Stayers’ and Delayed Discharge (DTOC) data management Secure email: [email protected]

Phone: 020 8539 5522 Ext: 6395

Patient Flow Co-ordinators

Sylvania Godfrey 828

Carly Savage 756

Karen Fisher 921

The Admission Avoidance Nurse can be bleeped on 592

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THE ROLE OF THE DISCHARGE TEAM

The Discharge Team assists wards and MDTs to discharge patients when there are complicating factors which may cause discharge problems. Particular issues might be that the patient:

• Will be unable to return to their previous address • Is likely to require specialist rehabilitation or treatment on discharge • Is affected by a complex social situation, such as domestic violence • Comes from a household with multiple needs, including disability and housing problems

What do the Team do?

• Provide advice and support to all wards • Attend Board rounds and MDT meetings when possible, to advise on specific cases • Offer training to wards on Continuing Care Assessments (CCAs) and Section 2 and 5 notifications • Review and advise on completed checklists for continuing health care, advise on and when possible co-ordinate

completion of the continuing health care decision support tool and London health needs assessment form. • Review and pass on completed CCAs to the appropriate CCG/CSU • Monitor the outcome of CCG decision making in continuing health care cases and exchange daily patient data lists with

the CSU • Maintain delayed transfer of care lists • Monitor Section 5 notifications and arrange the invoicing of Adult Social Care Services for delays • Provide details of patients’ local hospitals when necessary, for repatriation • Liaise with out-of-borough Social Care Services, as necessary • Follow up referrals for rehabilitation, repatriation and services • Support the weekly Long Stayers’ meeting by providing advice, information and additional assistance to the wards, as

necessary • Maintain weekly spread sheets and a comprehensive database on the causes of delayed discharges and transfers of care

and brief senior managers and consultants accordingly

How can ward staff support the team?

• Inform the Discharge Team as soon as it becomes clear that a patient’s discharge will not be simple • Complete required referrals, reports and sections of the continuing health care decision support tool and London health

needs assessment forms as accurately and quickly as possible • Always seek the team’s advice on difficult discharge cases, so that any problems can be resolved sooner rather than later • Send or deliver all completed Checklists to the Discharge Team. The Discharge Team email address is:

[email protected]

What the Discharge Team is unable to do:

The team is not able to complete Continuing Care Fast Track, London Health Needs Assessment and Checklist forms. The team can help to co-ordinate completion of the forms but the content must be provided by the health professionals within the MDT.

PLEASE REMEMBER TO SEND ALL CHECKLISTS, FAST TRACK PAPERS, HNAs and signed DSTs to the Discharge Team as soon as they are ready, so that they can be checked and sent on for ratification as quickly as possible.

How to contact the Discharge Team:

Phone: DDI 020 8535 6446 or 020 8539 5522 extn: 5949


Fax: 020 8535 6447

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WALTHAM FOREST REHABILITATION SERVICES (WFRS)

WFRS Rehabilitation beds are for patients who:

• Are over the age of 18 • Live in Waltham Forest • Are medically fit for transfer • Have agreed to transfer to a rehabilitation bed • Would benefit from a short period of rehabilitation and • Need 24 hour support by nursing/care staff.

Referral Process:

All referrals must be made on the WFRS referral form. This can be found at the end of the Handbook for copying.

Once complete the form must be faxed to: 0208 556 0690; telephone referrals can also be made to: 0208 535 6546

The referrer must liaise with the patient and their relatives, to ensure they consent to the referral

The assessor on duty will assess the patient for suitability and will liaise with the referrer/ward

If the patient is suitable for transfer, then the referrer/ward is responsible for arranging transport, making sure the patient and family know the date of transfer and ensuring that the patient transfers with a copy of their most recent medical notes, drug chart, OT, physiotherapy and social work assessments if applicable.

TTAS (medication and dressings) for 14 days or the duration of the course must be sent.

There should be no infection control issues on the day of transfer.

If the patient has a pressure ulcer, or is vulnerable to pressure ulcers, include a body map.

The medical team should send a discharge summary.

The WFRS Community Rehabilitation Service is for patients:

Who require a time-limited, short term rehabilitation service as their condition does not warrant acute hospital care / as an alternative to hospital admission. Whose rehabilitation needs can be met and carried out in their own home Who do not require 24 hour support.

Referral Process:

Referrals are by fax or telephone and are taken between 9am-7pm seven days per week. Referrals are via the WFRS Single point of access number which is: Telephone 020 8535 6546 or Fax 020 8556 0690 using the WFRS referral form. WFRS cannot accept referrals for patients who: Have a medical condition deemed by the responsible Medical Practitioner or GP to require acute in-patient care; Have long-term conditions and are not in crisis; Have a home environment that is unsuitable for WFRS interventions to be carried out safely AND alternative suitable environments, such as a community bed, have been declined; Have mental health conditions that mean they cannot be suitably managed within WFRS. This includes behavioural problems that require constant supervision and significant cognitive impairment that would prevent successful participation in the WFRS intervention. All referrals for either Inpatients or Community service should be made direct to Tel: 02085356547/6 or Fax: 0208556 0690.

REDBRIDGE, NEWHAM AND WEST ESSEX REHABILITATION SERVICES

Referral forms for these services can also be found at the end of the Discharge Handbook.

Redbridge referrals must be scanned and emailed to [email protected]. If you do not have access to these facilities, the referral can be brought to The Discharge Team (Ext 6395) for scanning and sending.

West Essex referrals should be faxed to Dr Ambepitiya’s Secretary on 01279 827833/7832 (Tel: 01279 827206/7831)

Newham referrals can be faxed to 0208 475 2031

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HOSPITAL SOCIAL WORK SERVCE FOR WALTHAM FOREST RESIDENTS

Two social work teams, based at Whipps Cross Hospital, provide a social work service to residents of Waltham Forest aged 18 years and over. There is a single point of access to the service: all contacts will be screened and referred on to one of the two teams. There is social work cover from Monday to Saturday, during office hours. The social work service is responsible for carrying out community care assessments when the hospital team consider that it is unlikely to be safe to discharge a patient home without one or more community care services. The service is also responsible for carrying out safeguarding investigations for patients, regardless of any community care need. Restarts of existing support packages are carried out by the administrative officers on extension 5429.

RAPID DISCHARGE TEAM What is the role of the team?

• To provide a single point of access to the social work service • This service is provided to A+E / pre admission units and wards ( except for DMEP) • To provide a single point of access for patients in Out of Borough hospitals and provide a screening and assessment

service as appropriate. What do they do?

• Process Section 2 notifications; screen to determine possible complexity around planning hospital discharge. • Where the discharge planning will not be simple, pass cases to the Complex Discharge Team with a robust summary of

presenting issues and actions taken. (For out of borough hospitals complex discharge planning is passed to the Enablement and Care team in the community.)

• Plan and facilitate discharge for patients with social care needs where there is no obvious complexity that may require a case conference.

• Commission reablement support at home services for up to 6 weeks post discharge. • Carry out safeguarding procedures. • Assist in completing checklists and reports for the continuing care process. • Provide 4-6 week follow up review for patients discharged with social care services.

How to contact the team - DUTY PHONE 5800 Team Manager – Bruno Lai extn 5698 Senior Practitioner – Lynda Green (lead on wards) extn 5806 Email address for Section 2 & Section 5 referrals: [email protected] COMPLEX DISCHARGE SOCIAL WORK TEAM What is the role of the team? The team provide Social work support to the DMEP wards. Each DMEP ward has a named social worker. The team plan and facilitate discharge for people with social care needs where there is some complexity and risk in the discharge planning. They take over complex work from the Rapid discharge team.

What do they do? • Attend MDT meetings on the DMEP wards • Monitor the issuing of Section 5 notifications. • Maintain a weekly Sitrep list, including delayed transfer of care. • Provide a specialist social work service for Palliative care, Stroke and rehab on Ainslie and Victory • Carry out Safeguarding procedures. • Plan and facilitate discharge for patients with complex social care needs and where there may be a family dispute or

environmental/social factors that indicate possible risk. • Carry out a 4-6 week review of patients post discharge.

How to contact the team: Team Manager – Bruno Lai extn 5698 Senior Practitioner – John White extn 5798 Re-imbursement officer – Grace Grant extn 5321

Email address for Section 2 & Section 5 referrals: [email protected]

Don’t forget – good communication is essential when setting up Social Care Services and for a safe discharge. Always let the Social Workers know if your patient’s discharge is delayed, even if only for a few hours. Always advise the Social Workers when patients are getting ready for discharge.

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LONDON BOROUGH OF REDBRIDGE – SOCIAL WORK SERVICE AT WHIPPS CROSS HOSPITAL

What is the role of the team?

The team provide a single point of access to the social work service to residents of London Borough of Redbridge (LBR) aged 18 years and over at Whipps Cross Hospital. This includes referrals from A & E, pre admission units and wards.

The team is responsible for carrying out community care assessments and setting up services, if required, to facilitate safe and timely discharges. It is also responsible for carrying out safeguarding investigations for patients regardless of their community care need.

What do they do?

The team process all Section 2 and 5 notifications issued by the hospital. The team:

1. Plan and facilitate discharge for patients with social care needs. 2. Restart services 3. Attend MDT/Case Conferences to discuss discharge planning for complex discharges. 4. Contribute to the completion of checklists and Continuing Care applications. 5. Provide advice and support to the residents of LBR. 6. Process Safeguarding Alert referrals 7. Arrange escort services home with Age Concern Escorted Service 8. Review cases

Manager: Christina de-Heer 0208 970 8149

Senior Practitioner: 0208 539 5522 extn 6890

Referral Coordinator: Timothy Natafgi 0208 539 5522 extn 6684

Email address for Section 2 & Section 5 referrals: [email protected]

PLEASE NOTE THAT THIS IS THE CORRECT EMAIL ADDRESS FOR REDBRIDGE SOCIAL WORKERS SUPPORTING WHIPPS CROSS PATIENTS. THE EMAIL ADDRESS IN THE LONDON DIRECTORY, IS FOR ALL OTHER HOSPITAL PATIENTS WHO COME FROM REDBRIDGE

Out of Hours Services

The London Borough of Redbridge out-of-hours services are available after working hours on weekdays and weekends for emergency support. The telephone number for the service is 0208 708 5568.


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ESSEX COUNTY COUNCIL

SOCIAL WORK SERVICES - WEST ESSEX:

OFFICE HOURS:

The West Hospital Assessment Team (Epping/ Harlow /Uttlesford ) has a Duty Social Worker is available from Monday - Friday on 01279781639 or 01279781634

The team provide access to a social work service for Essex residents aged 18 years and over, who are patients at Whipps Cross Hospital. This includes referrals from A & E, pre admission units and wards.

The team is responsible for carrying out community care assessments and setting up services, if required, to facilitate safe and timely discharges. It is also responsible for carrying out safeguarding investigations for patients regardless of their community care need.

There is a fax number for OT functional assessments (to go at the same time as or precede electronic Sec 5 notifications). It is 01279432707

There are generally Essex social workers based at Whipps Cross Hospital. They can be contacted through the main telephone numbers or by bleeping: 870

The Team Manager is Tony Sheill, HAT Team Manager (West) Goodman House, Station Approach, Harlow, Essex CM20 2ET, Telephone: 01279 404673; Mobile: 07500 990339 (sms)

Alternative telephone numbers: 01279 781638 or 01279 827317 or 01279 781509

For Section 2 and Section 5 notifications: [email protected]

HOW TO CONTACT ESSEX SOCIAL WORKERS OUT OF HOURS:

Outside office hours contact Essex County Council on 0845 606 1212 and ask for the Emergency Duty Social Work service.

To access the Emergency Duty Social Work service, you usually have to leave a message and your contact details with an administrator


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COMMUNITY MATRONS & DISTRICT NURSES When should referrals be made? As soon as the discharge date is known, alert the District Nursing Service. As discharges should be planned for the morning, remember to advise the service of this. Who makes the referral? One of the nursing team involved in the patient’s care, the ward clerk or ward discharge support staff For Community Health (District Nursing) Service Waltham Forest: Referrals to District Nursing service ring PELC on 08442 09 09 09 (24/7 number). If the patient requires medication to be administered a Community Nursing Prescription form must be completed and faxed to PELC on 0208 911 1149 when a referral is being made to the service. If a patient is known to a Community Matron, the matron should be notified prior to discharge, to enable a seamless discharge home. To contact the Community Matrons ring PELC on 08442 09 09 09 (24/7 number). Referrals can be urgent (within 2 hours - for A&E, not wards) priority (within 24 hours, agreed documentation to follow) or routine (initial contact within 48 hours, face to face contact up to 5 working days, email referral documentation before patient is accepted) The community clinical cluster leads for Waltham Forest District Nursing service are Nerys Bellefontaine: 020 8430 7487 (mobile: 0771 138 9547) and Theresa Evans 020 8430 8063 (mobile: 0773 496 7452) The Waltham Forest Rapid Response Team can be contacted directly through PELC as above, for short term intensive input to prevent readmission and facilitate early discharge. You can make referrals to the Rapid Response team by telephone. The team can sometimes provide short term input before a package of care is in place, but this must be arranged in advance and only in emergencies as a last resort. Redbridge: Fax to: Central Appointments: Fax No. 020 882 24097: Mon-Fri 08.00hrs-17.00hrs For queries/confirmation- if necessary, please tel. 020 822 4241 during office hours. Out of hours: Please fax to LBR Control Centre: Mon-Fri 17.00hrs-08.00hrs: 020 8708 5757 For queries if necessary call 020 8554 9172 The Redbridge CTT (Community Treatment Team) takes referrals for intensive input to prevent readmission. You can contact them on 0203 644 2799; (mobile: 07940 301396) between 8am and 10 pm, 7 days a week. They generally require a referral form to be completed by the ward. Essex: Central point of access for Essex District Nurses, 8am – 9 pm, tel: 01279827524 Fax: 01279827827 District nurses are working until 10.30 so you can leave answerphone messages until 10.30 How should the referral be recorded? The referral should be documented in the patient record What should the response be? The District Nurse or Community Matron should confirm the service to be provided, before discharge What is the escalation procedure if things go wrong?

• Advise your matron • Notify the Site team • Report and action any delays, including through the Barts Health Way Patient Flow Coordinators (Bleeps 828, 829, 921

and 756) • Notify the relevant Social Care Team, including out of hours social worker, if necessary

Don’t forget – good communication is essential when setting up District Nursing Services and for a safe discharge. Always let the District Nurses know if your patient’s discharge is delayed, even if only for a few hours. Always advise the District Nurses when patients are getting ready for discharge.

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REQUEST FOR SOCIAL SERVICES SUPPORT TO START OUT OF HOURS – WALTHAM FOREST Which patients is this for?

• Patients who are residents of Waltham Forest and aged 18 years or over • Have an existing Social Care package of support in place • Who are likely to require social services involvement as an initial assessment

When should referrals be made?

• As soon as possible on Mondays to Fridays, between 9 am and 5 pm. • Ideally before midday on the Thursday before discharge • To make a referral at the weekend: on Saturdays there are duty social workers on call. Outside office hours, you can

send a Section 2 or Section 5 notification, but it will not be effective until 9 am on the next working day. • To make an emergency referral (this will normally be from the Emergency Department, but ward staff may become

aware of a serious situation that needs urgent intervention outside office hours – for example, your patient’s next of kin is frail and elderly and not coping safely in the community – telephone Waltham Forest Direct Team (weekends/public holidays) on 020 8496 3000. Be aware that, sometimes, it takes time for the phone to route to the correct answering point: be patient and do NOT hang up if you do not connect immediately!!

Who makes the referral? A nurse or doctor involved in the patient’s care

How is the referral made?

• For Adult Social Care, use Section 2 and Section 5 forms, in the usual way • The forms should be completed and sent electronically • The information given should explain the patient’s problems, accommodation, relevant past medical history and current

care plan and not just request a specific package or intervention • In emergencies, have all the key details to hand and advise the emergency duty social worker or their reception service,

giving them a telephone number to call back and the name of a senior nurse who will be able to take their call

How should the referral be recorded?

• When saved according to the guidance, an electronic copy of the Section 2 and 5 notifications will be stored in the ward S drive

• A printed copy of the notification should always be placed in the patient’s records • The notifications should also be forwarded to the Discharge Team at [email protected] • The referral should also be recorded on the whiteboard and notified at the weekly Long Stayers’ meeting

What should the response be? On the last ordinary working day before discharge, a social worker should advise the ward of the services to be provided for the patient and confirm in writing that weekend discharge is possible. The social worker should provide the patient with a letter advising them of the services to be provided.

What should the MDT do at least the day before discharge?

• For weekend discharge, the Section 5 notification should have been sent to Adult Social Care by Thursday – or 48 “normal working” hours before discharge.

• Ensure community health services and equipment are in place • Review the Discharge Checklist – to ensure that vital aspects of discharge planning are not missed • Medical staff should ensure that all relevant investigations have been performed and that any required on the morning of

discharge will be sent to the lab, undertaken by radiology, etc, in good time • TTAs must be written and validated prior to 3pm the day before discharge (or earlier if a Dosette box is required) • Transport should be planned in consultation with Social Care to coincide with first scheduled care visit • Nursing staff should ensure the patient is dressed and ready for transport • The patient and family should be reminded of the planned discharge time and prepared for it • The allocated social worker (or department) and family must be informed of any delays


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ADULT SERVICES - REFERRALS FOR SOCIAL WORK SUPPORT AT WEEKENDS & OUT OF HOURS Out of hours referrals for social work support may be made for the following urgent reasons: By any part of the Emergency Department if a patient has no medical agenda for admission but may be at risk. (Examples might include: a frail elderly patient or other vulnerable adult who has been brought in to hospital because they have been found wandering, or are not able to look after themselves at home; a vulnerable adult – perhaps someone with learning difficulties or who is disabled - who is homeless and is unable to look after themselves.) Social Care Services have been arranged to support a patient on discharge to their own home, but for some urgent reason the patient has not been able to be discharged and it is necessary to cancel or delay the services. If in these circumstances, Adult Social Care is not advised of the delayed discharge, carers visiting the home may assume that they are indoors but have been taken ill and it is possible the patient’s door might be forced by the police – please always advise Adult Social Care if a discharge is delayed, preferably in working hours, but if necessary, outside working hours! If you realise the relative of a patient who has been admitted may be left at risk at home, because of your patient’s admission to hospital. It is not uncommon for a vulnerable person to be left at risk in their own home, when their main carer is admitted to hospital. Normally any referrals in such circumstances should be made in working hours, but if you feel someone may be at risk and the situation is urgent, a referral should be made out of hours. Be aware that these services are often very busy. Sometimes, it takes time for the phone to route to the correct answering point; you must be patient. Do NOT hang up if you do not connect immediately!!

WALTHAM FOREST: There is a small social work service at the weekends. This is for Waltham Forest residents aged 18 years or over only. This service is available from 9am to 4pm on Saturday and Sunday. How to contact the weekend social workers Weekend Manager mobile: 0777 613 0956 Bleep: 672 Extension: 5800 HOW TO CONTACT WALTHAM FOREST SOCIAL WORKERS OUT OF HOURS The Waltham Forest out of hours duty team is available for emergencies only outside of usual working hours. They can be contacted on 0208 496 3000.

REDBRIDGE: Out of Hours Services

The LBR out-of-hours services are available after working hours on weekdays and weekends for emergency support. The telephone number for the service is 0208 708 5568.

WEST ESSEX:

Outside office hours contact Essex County Council on 0845 606 1212 and ask for the Emergency Duty Social Work service. To access the Emergency Duty Social Work service, you usually have to leave a message and your contact details with an administrator

ANY OTHER LOCAL AUTHORITY:

If you do not have the emergency duty social work telephone number, it is usually possible to obtain this outside office hours by ringing the main Council switchboard or contact number. You may get a voicemail message or you may get through to a telephone reception service, but you should be able to obtain the emergency duty social work number. These staff often work alone, so they will prioritise calls, depending on each situation presented to them.


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REFERRAL FOR ADULT SOCIAL CARE SUPPORT – SECTION 2 NOTIFICATIONS

Which patients is this for?

• Any patient aged 18 years or over, who is likely to need social care services following discharge from hospital, whether or not they have been receiving social care services before.

When should the referral be made?

• As soon as the need for social care is identified • The patient’s (or next of kin’s) consent must be obtained before making a referral • The patient does not have to be medically fit for discharge • Consideration must have been given as to whether the patient is likely to need Continuing Health Care, usually by the

Consultant, but it is not necessary to complete a checklist • For planned admissions, a referral may be made from the pre-admission clinic (up to 8 days prior to admission)

Who makes the referral?

• Any health professional involved in the patient’s care


• SEE QUICK GUIDE ON PAGE 15 • The referral is made using the “Section 2” form. It should be sent electronically • Even if you have to fax the form (in emergencies only) you should complete it electronically. The guidance for Whipps

Cross is available electronically and in this handbook • The electronic Sec 2 form includes a directory to assist you on identifying the correct local authority from the patient’s

home address post code and the correct secure email for each local authority Adult Social Care Department • The information given on the form should describe the patient’s presenting needs, not request a specific care package or

intervention. You should note any risks, such as multiple falls and admissions. • Always double check that you have sent the referral to the right local authority and check as soon as possible

that it has been received. • IF YOU NEED HELP WITH SECTION 2 & SECTION 5 NOTIFICATIONS, contact the Discharge Team on 6395


• The referral is saved automatically, using the IG Spectrum system • Always file a hard copy of the referral in the patient’s records • Record the date & time of the Section 2 referral on the whiteboard • Bring a record of all Section 2 & Section 5 notifications to the Long Stayers’ meeting each Wednesday.

What should the response be?

• The relevant local authority social work team should contact the ward • A social worker will visit the patient on the ward, undertake an assessment and record this in the medical record • The social worker will advise the ward of the outcome of their assessment and recommend next actions, including whether

it is safe to discharge, whether there are any safeguarding issues, and onward referral for reablement, or planned return home with support

How should the MDT contribute to the discharge process?

• The allied health professionals involved, particularly OT & PT, should contribute to the assessment to ensure that all the patient’s needs have been addressed, so that the patient will be ready for transfer on discharge

• This means that a functional assessment should be sent to Adult Social Care before the Sec 5 notification • Participate in case conferences, ward meetings with family and so on • Keep the social worker up to date on health changes which may affect discharge • Communicate discharge plans clearly to the patient/carers • Ensure that all necessary referrals for equipment, to community health, etc have been made in good time • DO NOT tell the patient/carers that they should receive a specific service.

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REFERRAL FOR ADULT SOCIAL CARE SUPPORT – SECTION 5 NOTIFICATIONS (ALL PATIENTS)


• The Section 5 notification alerts Adult Social Care Services that a patient is medically fit for discharge and ready for transfer, so that they can ensure that the required care package will be in place in time for the patient’s planned discharge

• It is a legal requirement that NHS Trusts complete Section 5 notifications for all patients who require Adult Social care support.

When should a Section 5 notification be sent?

• A completed Section 5 notification form must be sent to the relevant Adult Social Care Service at least 24 hours before discharge and preferably 48 hours in advance, so that a care package can be organised if necessary

Who makes the referral? A member of the nursing team involved in the patient’s care


• SEE QUICK GUIDE ON PAGE 15 • On the IG Spectrum system, enter the patient’s NHS number in the NHS number field • Click “Section 5”, then “add new” the Sec 5 form will appear if you have completed and sent a Sec 2 form • Complete the remaining necessary fields. • Choose the correct target email address and send • Always complete the form electronically, even if you have to send it by fax (in emergencies only) • It is good practice to telephone at the end of the day, to make sure your notifications have been received.


• The referral will be saved electronically • Record the date & time of Section 2 & Section 5 referrals on the whiteboard • Bring a record of all Section 2 & Section 5 notifications to the Long Stayers’ meeting each Wednesday.


• The relevant local authority social work team should contact the ward within 24 hours • If you do not receive a response from the social work team within 24 hours, please call them or contact the Discharge

Team

What needs to be done the day before discharge?

• Clearly explain to the patient and family what further health input is to be provided, as well as any planned next steps • Keep the social worker up to date on any health changes which may impact on discharge • Ensure that all relevant discharge processes have been followed (TTA completed, equipment in place, GP notification

ready, etc) • Make sure that the social worker and any support staff – for example, the warden in warden controlled

accommodation and carers and relatives – know when the patient is likely to be discharged or if there are any last minute changes. Otherwise services will not be cancelled and this can result in a patient’s door being broken down (as it may be thought they have collapsed) or a patient having to pay for services that they have not received

What is the escalation procedure if things go wrong?

• The ward should contact the relevant Adult Social Care Services urgently by telephone • If you have not received a response to the Section 5 within 24 hours, contact the Discharge Team

15

SECTION 2s and 5s WARNING: Do not withdraw section 5 unless patient is medically unfit.

How to locate

Click on Internet Explorer Homepage (Barts Health Intranet) will appear Click I want to”, then Click on “Access a system or application”. Double Click on the Shortcut found below

Log In

Enter the email address that you were registered with and password. For instance: [email protected]

If this is the first time you have logged in with these credentials, you will then be asked to reset your password.

How to Self‐Register

Click “New Registration” icon located at the “Log in” page. Fill in your personal details. For instance, First name and Surname. You will need Trust/Organisation Code: 5000 The user’s email id and password are needed too. The email id should be similar to: [email protected]

You will not be able to use the system until your credentials been activated by the Service Administrators, Alfred Overy or Sylvania Godfrey.

How to fill in new Admission Notification forms (Section 2) / Discharge Notification forms (Section 5) / Withdrawal Notice

1. Enter the patient’s NHS number in the “NHS no:” field. 2. Click the “Admission Notification” form icon for Section 2. A large image of the form will appear in the right box as

confirmation of the form being selected. 3. Click “Add New” button, or click Enter in the “NHS no:” field. 4. Complete the form, including the mandatory fields (in red text). 1. Click “Discharge Notification” form icon for Section 5 and follow the same steps seen above. However, if there is

no Section 2 form for the patient already in the system, or the mandatory fields are not completed, then the Section 5 form will not work. You must raise and submit a Section 2 form first.

2. Click “Withdrawal Notice” form icon for withdrawal of either Section 2/5 and follow the same steps seen above. However, if there is no Section 2/5 form for the patient already in the system, then the notification will not go ahead. You must raise and submit either a Section 2 or 5 form first.

How to Save

You can save the form at any time if, say, you want to come back to it late to complete it. To do this, Click the “Save” button at the bottom. The form will be saved and can be retrieved at anytime. I do not advise this, please complete and then send form in one go.

How to Send

When you have completed the form, use the drop down menu to select the target email address that you wish to send the form to.

Click “Submit & Send form” button. This will check that all fields have been completed. If the details are correct, then click “OK”.

How to print:

You will be able to print the form after submitting by clicking Search within the Home page. This will display all forms

sent by date order. Then, click “View” to access the form that you want to view. At the bottom of the screen, click

“PRINT” icon to print.

16

PROVISION OF HOME OXYGEN

Which patients is this for? Patients who have been assessed by competent clinicians and found to be likely to benefit from home oxygen, according to the relevant evidence based guidelines. Before a decision is made, please ensure the following has been attempted: • Weaning the patient from oxygen

• A blood gas test on air has been completed

Remember home oxygen is used to treat chronic hypoxia and not breathlessness

When should the order be placed?

As soon as the assessment confirms the need and an order is placed, oxygen can be delivered next day

Who makes the order?

Oxygen should be ordered by the clinician who assessed the patient.

How is the order made?

The clinician must complete the Home Oxygen Consent Form and file it in the medical notes, then contact the Respiratory Registrars on bleep 159,027,028. If they are not available, contact the Respiratory Nurse Specialist, on bleep 558 or the Oxygen Lead Consultant (Dr Raines). All these staff have access to the new electronic order form for home oxygen.

If patients require ambulatory oxygen this will be assessed at home by specialist respiratory teams.


Completed forms should be scanned or photocopied and filed in the patient’s paper record.


Air Liquide should contact the patient or their family to arrange a delivery date. Relatives need to be available to accept delivery. To check whether the order has been received, contact Air Liquide on 0808 202 2099

Some West Essex patients are covered by BOC – telephone 0800 136 603

What needs to be done the day before discharge?

Staff should ensure that:

The patient and their carers have received full information and confirm that the oxygen has been delivered or due to be delivered.

Any community services that will be caring for the patient are aware that the patient is receiving oxygen.

An outpatient review appointment is made with the team that ordered the oxygen or changed the original oxygen order form.

What is the escalation procedure if things go wrong?

If oxygen is not delivered, it is the responsibility of the team ordering the oxygen to contact Air Liquide on 0808 202 2099 to address and resolve the delay (or BOC for West Essex patients).

17

DISCHARGING PATIENTS - THE DISCHARGE LOUNGE

The Discharge Lounge:

The Discharge Lounge is located at Junction One, by the Main Entrance

You can contact the Discharge Lounge on extn 5610

It is open between 9 am and 6 pm – Please note that doors close at 6 pm

ALL PATIENTS must come with a “Transfer Form”, with all mandatory fields completed.

ALL PATIENTS MUST BE DISCHARGED IN PROPER CLOTHING, NOT BED CLOTHES OR HOSPITAL GOWNS

Only 2 property bags per patient can be accepted

Patients sent to the Discharge Lounge for collection by relatives/friends/carers must have confirmation that PICK UP will be by 18:00.

Service Provided:

TTAs: Once TTAs are written and checked by Pharmacy, patients can be transferred to the Discharge Lounge. Their medication will be collected by Discharge Lounge staff, checked with the ward and dispensed to the patient in the lounge

Times: The Discharge Lounge will accept patients from wards up to 6 pm, if ambulance transport has been booked and confirmed.

Patients can be given breakfast and/or light lunch in the Discharge Lounge.

All nursing care is given as per information on transfer sheet/ assessment.

Relatives are encouraged to collect patients from the Discharge Lounge. Parking is free for up to a maximum of 10 minutes outside the lounge, so the arrangement helps relatives to avoid the additional unnecessary stress of finding a place to park

Ambulance Bookings at Ward Level:

ERS Medical Ambulance Service, General Enquiries 0333 240 4096

To book a new ambulance press “2”

Confirmation of booking is essential prior to transfer.

Patients who are unsuitable for the Discharge Lounge:

(The Discharge Lounge Coordinator can arrange for these patients to be collected directly from the ward)

Bariatric patients

Patients who are in a terminal phase

Patients, who are confused, have behavioural issues and/or are at risk of absconding

Patients with pressure area problems, as there is no access to PR mattresses.

Patients under 16 years old.

If you have any issue or query about whether a patient is suitable, please bleep 412.

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WHIPPS CROSS HOSPITAL – ARRANGING SERVICES AND EQUIPMENT FOR PATIENTS ON DISCHARGE

When the time for discharge is approaching, patients may need a range of equipment or services, such as oxygen, special mattresses, beds or cot sides, hoists, wheel chairs, commodes, zimmer frames, walking sticks, wheel chairs, and key safes.

1. There is a separate procedure for ordering special mattresses and cot sides, etc

2. Walking sticks, wheelchairs, hoists, commodes, special cushions, seat raisers and adaptations should be organised through the OT department.

3. There are occasions when more unusual items are required to facilitate the safe discharge of a patient.

4. Where a key safe is required, so that carers can enter the home, this will be organised by Adult Social Care for all patients using their services. If a patient’s care on discharge is to be fully NHS funded (Continuing Care) this should be organised through the CCG.

5. However, there are times when the CCG arrangements take longer than expected and this should not be allowed to delay a patient’s safe discharge. In these cases, ward staff should contact the Discharge Team on ext:5949 or bleep 271 and they will:

a. Attempt to contact the relevant CCG in order to resolve the issue, including by escalating the concern. b. If necessary order a locksmith to provide the key safe IF this is required as part of the agreed care package AND

there is full NHS funding

6. If necessary, other equipment can be spot purchased, but this can only be done with the approval of a Director and if the patient is considered by the MDT to require the equipment or service to facilitate a safe discharge.

Please remember that patients should be discharged with suitable clothing, bearing in mind the time of year. If a frail or vulnerable patient needs clothing to wear on discharge, their next of kin should be asked to bring this in ahead of the discharge date. If any patients do not have clothes, or anyone to bring suitable clothing in to the hospital for them, please contact your matron urgently, so that clothing can be provided if necessary.

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ORDERING BEDS/MATTRESSES If the OT identifies a need for a bed or mattress, or any other equipment, they will order it in time for the patient’s discharge. For local authority equipment provision, the OT will complete the bed referral form for equipment, and then generally send it electronically.

If there is a nursing need for a profiling bed or mattress (because of tissue viability problems, for example) and the discharge date has been set, requests must be made to the District Nurses as soon as discharge has been agreed. A referral form, Waterlow score and body map should be completed and forwarded to the District Nursing service.

1. WALTHAM FOREST: Local authority equipment store: [email protected]

ALL REFERRALS TO DISTRICT NURSES FOR EQUIPMENT SHOULD BE MADE THROUGH THE SINGLE POINT OF ACCESS, BY TELEPHONING PELC ON 0844 2090909 OR FAXING TO 020 891 11149.

When possible, please allow 48 hours for the order to be actioned and the equipment installed.

Please bear in mind that, if the patient lives in their own home, a relative or other person will need to be available at the home so that the equipment can be delivered and installed

Dynamic mattress request only

This request must be made to the District Nurses, via PELC, as soon as the need has been identified and the discharge date is confirmed. Again, when possible, please allow 48 for the order to be actioned and the equipment installed.

2. REDBRIDGE: The local authority equipment store is Millbrook and equipment orders must have senior authorisation. Equipment usually takes three days, but there is a next day arrangement, if equipment is urgently needed and the order is authorised and sent before noon. You can contact Millbrook Call Centre on 0870 428 2667 If the request is to meet a nursing need, then the District Nurses will order direct to Millbrook, electronically. To contact the Redbridge District Nurses, use the following contact details and the available referral form:

Central appointments: Fax No. 0208 822 4097 Mon-Fri 08.00hrs-1700hrs.

Out of hours: please fax to LBR Control Centre: Mon-Fri 1700hrs-08.00hrs

3. ESSEX:

All equipment must be ordered electronically. Pressure-relieving equipment is to be ordered by ward nurses.

Instructions and forms for ordering other equipment are stored on the S drive under S:\Therapies\OT\Essex

20

COMPLETING THE NHS CONTINUING HEALTH CARE CHECKLIST

Which patients is this for? The checklist should be completed for any patient who needs continuing care and may be eligible for NHS funding, unless an individual has a rapidly deteriorating condition that may be entering a terminal phase, in which case the fast track tool should be used.

When should the checklist be completed? When it is evident that a patient is going to require care over an extended period; but In an acute hospital setting, the checklist should not be completed until the patient’s likely needs on discharge are clear, or the assessment may not be accurate. As the process can take 28 days, it is important to avoid any additional delays

Who completes the form? A health or social care professional who has worked with the patient and understands their needs.

If the completed checklist indicates that the patient may be eligible for NHS continuing health care, the MDT must then complete the London Healthcare Needs Assessment and the Decision Support Tool (see following pages).

The checklist should be signed and dated. It should be a clean copy, with enough detail for the patient and their representative to understand the scoring, then sent to the Discharge Team, who will check it for accuracy and forward it to the relevant Continuing Health Care team or to other agencies, such as Social Care, when appropriate.

The patient or their representative should be given a copy of the completed checklist once it is cleared with the Discharge Team

Completion of the checklist must be documented in the medical record.

Is consent required?

• Yes, the patient’s informed consent is required. (The Mental Capacity Act, 2005 applies.) • The process for completing the checklist should be explained beforehand. • The patient and (where appropriate) their representative should be given a full opportunity to contribute their own views

about their needs.

What evidence is required?

• Compare the descriptions of need on the checklist to the needs of the patient and select level A, B or C, as appropriate, for each domain.

• If the patient’s needs are greater than anything in the descriptions, select “A”. • Consider all the descriptions and select the one that most closely matches the patient. • For each domain, provide a brief reference, stating where the evidence that supports your decision can be accessed, if

necessary. • If it can reasonably be anticipated that the patient’s needs will increase in the next three months, this should be reflected

in your selection of level A, B or C. • If the extent of a need may appear to be less because good care or treatment is reducing the effect of a condition, the

need should be recorded as if that care and treatment were not being provided. • Good evidence is required to obtain the correct funding for a patient

Next steps: The Decision Support Tool (DST) must be completed if the needs checklist indicates any of the following combinations of descriptors:

• 2 or more As • 5 Bs • 1 A and 4 Bs • An A in a column marked with an asterisk *

Even if a patient’s needs checklist indicates that a full DST should be completed, this does not automatically signify eligibility for NHS continuing care funding, but the NHS retains responsibility until an eligibility decision is made.

If the patient or their representative disagrees with the scoring and/or a decision not to proceed to a full assessment they may ask the CCG to reconsider the decision. They should be given details of who to contact at the CCG if they wish to challenge the decision.

21

NHS CONTINUING HEALTH CARE – LONDON HEALTH NEEDS ASSESSMENT

What is the London Health Needs Assessment?

• This is one part of the multi-disciplinary assessment required before a full consideration of Continuing Health Care can take place and the Decision Support Tool (DST) can be completed.

• The London Health Needs Assessment (LHNA) together with the Decision Support Tool is the only documentation that the Continuing Health Care Panel will see when they make their decision about funding.

Who can complete the LHNA?

• The NHS Continuing Health Care Needs Checklist can be completed by a health care professional who has worked with the patient and understands their needs. The professional concerned should be experienced and skilled in assessment and multi-disciplinary working.

• The LHNA should be completed when the Continuing Health Care Needs Checklist indicates the need to complete a full DST form.


The patient should be consulted and fully involved in the assessment process.

The requirements of the Mental Capacity Act, 2005, must be borne in mind and the patient’s relatives involved as appropriate.

What is the timescale for completing a LHNA?

The LHNA should be completed quickly if the Continuing Health Care Needs Checklist indicates that a DST is required.

The DST must be completed within 20 days of submission of the Checklist to the Continuing health care Team for the patient’s borough.

What happens to the completed LHNA?

The LHNA will be submitted to the Continuing Health Care Team in the borough where the patient lives, together with the Continuing Health Care Decision Support Tool.

For most wards the LHNA and the Checklist should be sent to the Discharge Team (extn 5949)


The completed paperwork should normally be reviewed by the Discharge Team, to ensure that it complies with requirements and is complete and will then be sent to the CSU for Redbridge & Waltham Forest or West Essex or to another CCG if the patient is from a different area.

22

NHS CONTINUING HEALTH CARE – DST or DECISION SUPPORT TOOL

What is the DST?

An individual will be eligible for NHS Continuing Health Care where it can be said that their “primary need is a health need”. The Decision Support Tool (or DST) is a Department of Health form designed to document the multi-disciplinary assessment of an individual’s care needs. It is a way of bringing together and recording the individual’s various needs to facilitate logical and consistent decision-making. The DST supports, but does not make the decision about whether an individual is eligible for Continuing Health Care. Who can complete the DST? The completion of the DST should be co-ordinated by one individual. However, the form must be completed by the MDT as a whole, bringing together evidence of their assessments. The MDT must provide an agreed recommendation for the patient.

When should the DST be used?

The full DST should be completed whenever indicated by the Continuing Health Care Needs Checklist. The Checklist should always be completed and submitted before the DST is completed.


Consent should always be obtained from the individual who is being assessed. This should include finding out whether the patient is happy for other family members or individuals to be involved.

If a patient lacks capacity to consent, full guidance can be found in the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care and in related Trust policy documents on capacity and consent.

Careful consideration must always be given to the question of assessing a patient’s capacity. The presumption should be that a patient has capacity. If it is believed that they do not have capacity, the MDT should take care to ensure that there is multi-disciplinary agreement on this point and that expert input is sought if necessary.

When a patient lacks capacity, it is acceptable to consult their family. If there are any doubts as to whether the family is acting in the patient’s best interests, separate guidance is available by involving an Independent Mental Capacity Advocate (IMCA)

What is the timescale for completing the DST?

The DST form should be completed by the MDT and submitted to the Continuing Health Care Team, via the Discharge Team, within 20 days of completing the Continuing Health Care Needs Checklist.

The DST form has to be presented to the health funding panel (see flow chart attached for Waltham Forest and Redbridge interim process) within 28 days of completion and submission of the Continuing Health Care London Health Needs Assessment.

For most wards the Checklist, LHNA and DST should be sent to the Discharge Team (extn 5949)

Secure Fax: 020 8535 6447


The completed paperwork will be reviewed by the Discharge Team, to ensure that it complies with requirements and is complete and will then send it on to the relevant CSU or CCG

23

MORE DETAIL ON THE DECISION SUPPORT TOOL (DST) PROCESS

What is the Process for Continuing Health Care Assessment and Completion of the DST?

1. Continuing Health Care Needs Checklist completed, to determine need for completion of DST. 2. Submit Checklist to the Continuing Health Care Team in the patient’s home borough, normally via the Discharge Team. 3. If the Checklist indicates that completion of the DST is required, this must be completed and submitted within 20 days of

submitting the Checklist. 4. MDT must complete the London Health Needs Assessment (LHNA). 5. MDT must complete the DST, with consent and input from the patient and their carer/family. 6. DST and LHNA to be submitted to the Continuing health Care Team for the patient’s home borough, usually through the

Discharge Team.

What evidence is required? The DST allows the MDT to outline and individual’s needs in 11 care domains. All sections and domains within the DST must be fully completed. If the whole DST is not completed on a single date, each section should be signed and dated. The description of needs included within the DST are examples only and may not adequately describe every individual’s circumstances. The MDT must provide evidence and a rationale to support the level of need assigned in each domain. If a patient falls between two levels of need described in a domain, the patient should be assigned to the higher level of need. Individual care needs should only be described in one care domain. For example, if a patient is wandering and thus posing a risk to themselves or others, this should be considered within the behavioural domain and not duplicated in the mobility domain. At the end of each domain, the MDT must justify why a particular level is appropriate, based on the available evidence about the patient’s assessed needs. Needs should be described in measurable terms, using clinical expertise and supported within the results from appropriate and validated assessment tools where relevant. There may be examples, on a case by case basis, where an individual patient may have particular needs that are not easily categorised by the care domains. In this situation, it is the responsibility of the MDT to determine and record the extent and type of this need in the “additional” domain and to take that need into account when deciding whether a patient has a primary health need. At the end of the DST, there is a summary sheet, to provide an overview of the levels chosen and a summary of the patient’s needs, along with the MDT’s recommendation about whether the patient is eligible or ineligible for NHS Continuing Health Care. The DST would be expected to indicate a primary health need if the following are indicated:

• One level of priority need, or • Two or more severe level needs.

A primary health need may also be indicated if there is/are:

• One domain recorded as severe, with needs in a number of other domains • A number of domains with high and/or moderate needs.

Ineligibility would be indicated if needs in all domains are recorded as “low” or “no need”. The DST domains must all be completed. Do not remove any section, but explain clearly, if it is not applicable. Recommendation, signatures and dates must all be completed. The recommendation should be broken down into four sections: NATURE, INTENSITY, COMPLEXITY and UNPREDICTABILITY. The recommendation should reflect the scoring and be an MDT decision. What happens to the completed DST? The DST and LHNA are presented to the Continuing Health Care Panel after they have been considered by the CSU.

24

NHS CONTINUING CARE FAST TRACK TOOL

What is the Fast Track Tool? The Fast Track Tool is used to gain immediate access to funding when a patient needs a package of care urgently, on the basis of a rapidly deteriorating condition that may be entering a terminal phase. Who can complete it? The tool is usually completed by an “appropriate clinician”, such as a nurse or doctor. The practitioner must be knowledgeable about the patient’s health needs and able to provide reasons for the fast tracking decision. When should it be used? The Fast Track Tool must be used when a patient requires an urgent package of continuing health care and is clearly in a terminal phase. The Fast Track Tool replaces the need for a Needs Checklist and a Decision Support Tool. Is patient consent required? The patient needs to give informed consent to completion of the tool. Where an individual is unable to provide consent, the appropriate clinician should make a decision in the “best interests” of the patient, but the MDT must ensure that a capacity assessment has been properly obtained and must decide whether the Deprivation of Liberty Safeguards (DOLS) apply. Guidance on DOLS is available electronically of through the safeguarding team. Fast track tools should be completed without delay, to enable individuals to be in their preferred place of care as soon as possible, but it is always best practice to consult and involve the family. Is the Fast Track Tool dependent on timescales relating to end of life care? There are no time limits specified and a decision to use the tool should not be based solely on the patient’s life expectancy. However, it is important to note that medical evidence that a patient has three months or less to live is helpful in ensuring that a Fast Track funding can be obtained for a patient What evidence is required when completing the Fast Track Tool? If a Fast Track Tool is completed, this is sufficient evidence to establish eligibility. However, careful completion, providing as much detail as possible about the nature of the patient’s condition, their likely life expectancy and their palliative care requirements is always helpful. Delay in ratifying Fast Track forms is a likely consequence of inadequate completion and this is unhelpful for patients. What happens with the completed Fast Track? The “Responsibilities Directions” make it clear that a CCG must accept and action a Fast Track Tool immediately, where the tool has been properly completed. The CCG may however challenge the referral if it considers that the evidence indicating that the patient needs Fast Track care is insufficient. It is therefore very important to ensure that the paperwork is as complete and detailed as possible and that evidence of the patient’s needs and condition is as full and specific as possible. On receipt of the Fast Track Tool, the CCG, in discussion with the Discharge Team, should arrange for the care package to be commissioned without delay. The ward must ensure that appropriate equipment is ordered without delay Marlene Stone (ext: 5949) is available to give advice on suitable nursing homes, if patients require a nursing home placement

25

REPATRIATION TO LOCAL HOSPITALS Which patients is this for? Any patients who live outside Whipps Cross’ catchment area (Waltham Forest, Redbridge and part of West Essex) who require further medical treatment that can be provided within their local hospital. When should the referral be made? As soon as the patient is sufficiently stable to be transferred to their local hospital. Who makes the referral? A doctor involved in the patient’s care. How is the referral made? Identify the patient’s local hospital, using their home post code Medical team refer to respective team at receiving Trust. The receiving consultant’s name must be recorded Some receiving hospitals request a medical letter and infection control form. These should be completed and faxed or emailed. How should the referral be recorded? The medical team should document all details in the patient’s medical notes. The medical team should email a copy of the medical letter and the name of the accepting Consultant to the Site Team – bleep 131 Unless a repatriation form has been completed and submitted to the site team, any necessary escalation will be delayed What should the response be? The site team will contact the bed/site manager at the receiving hospital The receiving hospital should confirm that a bed is available within 24 – 48 hours of the referral. What needs to be done the day before discharge? Patient medical and nursing notes are photocopied Patient and relatives are informed of the transfer. What is the escalation procedure if things go wrong? The Site Team will escalate: 24 hours – to service manager or general manager 48 hours – to CAG operations manager 72 hours – to Chief Operating Officer

26

REFERRAL TO REHABILITATION UNITS

SPECIALIST REHABILITATION UNITS - WHICH PATIENTS IS THIS FOR?

• Patients who are recovering from a severe neurological event, such as brain injury, disease or trauma and • Who require specialist multi-disciplinary rehabilitation to aid their recovery • Referrals should be discussed and agreed by the MDT • The time and date of referral should be noted and passed on to the Discharge Team, who escalate all external delays

COMMUNITY REHABILITATION – WALTHAM FOREST, REDBRIDGE & WEST ESSEX - WHICH PATIENTS IS THIS FOR?

• Any patients requiring community rehabilitation who live in Waltham Forest, Redbridge, or West Essex

Make a referral as soon as:

• A full MDT assessment has been completed and • The patient’s presentation has stabilised and • It is clear that Community Health Services are likely to be required or • The patient is thought likely to benefit

Where should the patient be referred?

• Patients requiring specialist rehabilitation may be referred to multiple units if appropriate, through the London Consortium • The MDT should discuss the most suitable referral(s) and the therapists will organise this • Patient requiring community rehabilitation locally, through the therapists attached to the ward

Who should make the referral? Once the MDT and consultant are agreed on the appropriate referral, the therapists till complete the form How should the referral be recorded? A copy of the completed referral should be kept in the patient’s medical notes and the referral should be recorded on the whiteboard What should the response be? For specialist rehabilitation, the patient will either be assessed in Whipps Cross, or may have to attend an assessment. The patient will either be accepted and placed on a waiting list, or declined For community rehabilitation, a decision to accept or decline the patient should normally be made within two days. What needs to be done the day before discharge? TTAs must be arranged Photocopy the notes from the current admission and send with the patient, along with The community drug chart Inform the family and patient Book transport Undertake a telephone handover to the new team, prior to discharge What is the escalation procedure if anything goes wrong? For waiting list times and delayed assessments, contact the Discharge Team on extn 5949 On the day of discharge, contact the rehabilitation team directly

27

WHEN PATIENTS NEED VACUUM DRESSING MACHINES ON DISCHARGE

Which Patients is this for?

When patients have on-going tissue viability problems, they may need vacuum dressings.

Waltham Forest:

The Waltham Forest Community Tissue Viability Team is on telephone: 020 8430 8251 Fax no: 020 8430 8640.

Nursing staff should complete a tissue viability form for the patient and fax it to Anne Pardoe, then contact her to arrange the patient’s discharge date.

It will be necessary to arrange for a District Nurse to meet in the patient’s home on discharge, so that the Tissue Viability Team can assess the wound and show the District Nurse how to apply the vacuum dressings.

Redbridge:

The Tissue Viability Nurse for Redbridge is Hannah Patten, telephone: 020 8924 6170 Fax no. 020 8924 6582

For Redbridge patients requiring vacuum dressings at home, the referral is made by fax, using the normal District Nursing referral form and then following the case up with the District Nurses to make the final arrangements.

Newham:

Similarly for Newham, request a vacuum dressing machine by faxing a normal District Nursing referral form and then follow this up by telephone.

Essex:

The Community Tissue Viability Team for Essex can be contacted by telephoning on 01279 827477. They will advise on how to organise a vacuum dressing machine for Essex

28

REFUSING TO LEAVE THE WARD


• Any patient who is medically and functionally fit for discharge • Where discharge arrangements are in place to meet the patient’s needs

When should action be taken?

• If it has been documented in the patient’s medical notes that they are medically fit, functionally fit and safe for discharge and, for vulnerable patients, a suitable care plan has been arranged and in place, but either the patient is refusing to leave the ward or their family are refusing to agree discharge plans

• It is important to ensure that all patients have received a copy of the “Leaving Hospital” leaflet, which can be obtained from the Discharge Team, before the decision is made that they are ready for transfer. This leaflet explains the legal position and provides patients and their families with fair warning about the discharge arrangements

Who should take action?

• The nurse in charge of the ward

What action should be taken?

• If the patient is vulnerable, the nurse in charge should carefully review the case, to make sure that there are no outstanding risks or concerns and that the discharge has been well planned, including with Adult Social Care

• The responsible senior nurse should be briefed • The nurse in charge should obtain advice from the Discharge Team (extn 5949) or, if appropriate, raise their concerns

about the situation at the weekly Long Stayers’ meeting, held every Wednesday morning • Once the nurse in charge is satisfied that the arrangements for discharge are safe, she or he should explain to the patient

that they are fit to leave the ward and should leave as soon as possible, so that another patient who requires treatment can be admitted

• The patient should also be told that failure to leave could lead to more serious consequences.

If the patient still refuses to leave

• The nurse in charge should contact the responsible senior nurse, to inform them of the situation and discuss whether the management of violence and aggression policy should be used

• If the patient is vulnerable, contact the Discharge Team and/or report the problem to the Wednesday Long Stayers’ meeting

• If the patient is known to Adult Social Care, keep the social worker fully briefed about the situation • If the patient is not vulnerable, contact Security on extn 6060, to escort the patient off the Hospital site

Who can supply additional support?

• The relevant senior nurse • The Discharge Team extn 5949 • Patient Flow Coordinators (bleep 828, 829, 756 or 921) • Security extn 6060

The Management of Violence and Aggression Policy: Senior nurses and ward staff should familiarise themselves with this policy, which may on occasion be invoked, if a patient aggressively refuses to leave the ward. Such behaviour could be a breach of the Trust’s “Management of Violence and Aggression” policy and may lead to the start of the “red card” process. After warnings, the policy can, if appropriate, ban a patient from all Barts Heath sites for one year, excluding emergency care.

Patient Choice Protocol: There is legal guidance on discharging vulnerable patients whose next of kin refuse to allow or support a discharge. For NHS funded patients, discharge can be organised through the relevant CCG – this will be done by the Discharge Team. For Social Services’ clients, there will be a meeting to determine the patient’s best interests and, if necessary, legal action may be taken to discharge a patient. However these cases are very difficult and it is imperative to make careful and accurate records of all discussions with the patient and their family. Always involve the Discharge Team for advice in these complex cases and make sure there has been a proper capacity assessment or psychiatric report if there is any doubt about the patient’s capacity or mental health needs.

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PATIENTS WHO HAVE NO RECOURSE TO PUBLIC FUNDS

Some patients are not entitled to free NHS care. Others may have an NHS entitlement, but may not be entitled to Adult Social Care, local authority Housing support or income support and benefits.

For advice on such situations, always contact the Paying Patients Department, on email and contact no’s below:

Whipps Cross Hospital: [email protected]

Telephone no: 020 8539 5522 ext.4536/6802

If patients are homeless or will not be able to survive without assistance, but have no recourse to public funds due to issues with immigration; seek advice from the Discharge Team or the Paying Patients Department.

Homeless patients who are vulnerable but have no recourse to public funds should be referred to the Waltham Forest Hospital Social Work Team on ext: 5800 (duty)

Patients who have no recourse to public funds but have a place to go should be referred to the Adult Social Care Department for that area.

Please note that some patients have an NHS entitlement, but cannot obtain community services on discharge (for example, District Nursing) unless they are registered with a GP. If a patient is not registered with a GP it is best to deal with this on admission and help them to get registered. If necessary, you can contact the relevant CCG for help in getting a GP for a patient

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PATIENTS IN EXTRA CARE & SHELTERED HOUSING

It is important to check whether patients are living in extra care or sheltered housing and to understand that these individuals may have already been identified as vulnerable.

The staff on most extra care housing schemes are not wardens, but Senior Housing Officers and they may not be available 24/7 or at weekends.

Always get the patient’s consent to contact the extra care staff before discharge. They are available to attend meetings or MDTs and can advise on whether a patient’s accommodation is suitable for their discharge (for example, will the heating need checking, does the community alarm scheme need notifying that a patient may be discharged?) If the community alarm service is not informed of a patient’s discharge and that patient is unfortunately taken ill on return home, activation of their electronic alarm may possibly be viewed as a fault – so it is essential to notify housing providers in these cases if at all possible.

Extra Care Housing Schemes in Waltham Forest:

Albany Court: 3 Albany Road, Leyton E10 7EU. Telephone 020 8539 1228

Dames House: 127 Dames Road, Forest Gate E7 0DZ. Telephone 020 8519 3039

Glebelands: 33 Church Road, Leyton E105LY. Telephone 020 8539 9362

Heavitree Court: 20 Brookscroft Road, Walthamstow E17 4LH. Telephone 020 8531 2983

Baytree House: 2 Dells Close, Drysdale Avenue, Chingford E4 7TW. Telephone 020 8529 4579

Gainsfield Court: 18 Cathall Road, Leytonstone, E11 4NS. Telephone 020 8558 5104

Nicholson Court: 32 Forest Road, Walthamstow E17 6JP. Telephone 020 8509 1182

Suffolk Court: 25 Cambrian Road, Leyton E10 7JJ. Telephone 020 8988 0676

Waltham Forest Housing Association (WFHA) provides a range of supported housing, in addition to extra care.

Walthamstow: Electric House, Acorn House, Kevan Court, Millennium House

Leytonstone: Lansan Court, Briscoe Close

Chingford: Libro Court, Wingrove House

Lewis House and Peach Court – WFHA provide support, but are not the landlord

The following properties also have some “sheltered” tenants: Garenne Court, Ridgeway, 41 Victoria Road, 23 Connaught Avenue, 3 Forest Avenue, 9 Woodlands Road

The Support Services Team for WFHA is based at 0208 524 6987. Cheryl Whittle – Support Services Manager 07967 352 950

Jane Howard – Senior Housing Officer – 07967 352 830, Tina Addai Poku - Senior Housing Officer 07525 904 273, Ruth Kintu – Senior Housing Officer – 07967 352 829, Sally Rowe – Senior Housing Officer – 07967 352 831

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GLOSSARY

Medically Fit for Discharge:

The Whipps Cross Discharge Policy is clear that patients will not be discharged unless they are “medically fit or stable” for discharge. Medical staff are expected to ensure that, when a patient is deemed medically fit for discharge; this is documented clearly in the notes and is timed, dated and signed. A patient is regarded as medically fit or stable for discharge when:

• They require no further acute medical care or treatment;

• In-patient investigations have been completed and additional tests and interventions can be carried out in an outpatient or ambulatory setting;

• The patient is no longer able to benefit from continuing hospital-based in-patient services within a secondary care setting.

Ready for Discharge:

A patient is regarded as ready for discharge (or transfer to Social Care services) when:

• The consultant and clinical team agree that the patient is ready for transfer and it is recorded in the medical notes that they are ‘medically fit for discharge’;

• The multidisciplinary team agrees that the patient is ready for transfer or discharge. This means that a functional assessment has been undertaken, when appropriate;

• The multi-disciplinary team agrees that the patient is safe for discharge/transfer. This means that on-going health or care needs can be more appropriately met at home or in another setting, through primary, community, intermediate care or social care.

Section 2 & Section 5 Notifications:

The Community Care (Delayed Discharges, etc) Act 2003, as amended, places a duty on NHS hospitals and local council adult social care services to work together to ensure that safe discharges are coordinated in a timely manner, to prevent patients remaining in hospital unnecessarily. Section 2 and Section 5 notifications can only be sent if a patient consents. The legal requirements are as follows:

Section 2

Must be sent to Adult Social Care no later than 3 days before discharge

Alerts Social Care that a care package may be needed on discharge and asks them to assess the patient’s requirements

Section 5

Must be sent to Social Care at least 24 hours before discharge

Alerts Social Care when care package needs to be in place, in time for patient’s safe discharge

Delayed Discharge:

A patient’s discharge is regarded as “delayed”, when the above criteria have been met. When appropriate notifications (under Section 2 and Section 5 of the Community Care (Delayed Discharges, etc) Act, 2003, as amended) referrals (for example, to rehabilitation facilities) or assessments (for example, Continuing Health Care Assessments or Fast Track Tools) have been submitted, but services have not been provided, the delays will be recorded and attributed in the weekly Delayed Discharges Summary.

Delayed Transfers of Care to Adult Social Care Services will be reimbursable if the correct documentation is in place; Section 2 and Section 5 notifications have been sent within the required timescale; the patient is medically fit, stable and safe to discharge; conditions laid down in the Department of Health Guidance on Choice have been met; but a Social Care assessment has not been undertaken or Social Care services have not been provided, to enable the patient’s discharge within the timescale indicated.

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Expected Date of Discharge:

Agreeing and recording the expected date of discharge is a key component in achieving timely discharge and complying with the Barts Health Way:

• All patients should have a treatment plan within 24 hours of arrival;

• The expected date of discharge should be set within 24 hours of arrival by the multidisciplinary team;

• The patient (and their family, next of kin or carer, as appropriate) should be informed of the expected date of discharge. This is recognised as good practice and a way of improving the patient’s experience;

• Elective patients should be informed of their predicted length of stay at pre-assessment;

• The expected date of discharge should be proactively managed against the treatment plan on a daily basis. Ward rounds will be scheduled to allow a senior review of all patients at least daily; daily board rounds will ensure that this information is formally discussed and reviewed at a multi-disciplinary level and any changes communicated to the patient;

• Inpatient discharges should be planned to occur before 12 noon and on any day of the week, including weekends.

Actual Date of Discharge:

A patient’s actual date of discharge is the date when they are able to leave hospital. It may be a later date than the expected date of discharge and should be separately recorded. The aim of the Barts Health Way is to ensure that no aspect of a patient’s care or treatment is delayed and this can only be achieved if delays are properly identified, analysed and addressed. The expected date of discharge should not be continually adjusted to accommodate anticipated or actual delays, as this approach can hinder work to understand and correct delays.

The electronic display boards in each ward can be used to record the reasons for delayed discharge, on the B and C wards, the Barts health way patient Flow Co-ordinators can assist with tracking down, reporting and addressing internal reasons for delay and, for any patients with a length of stay of more than five days, the issues can also be addressed at the weekly Long Stayers’ Meetings.

NHS Continuing Health Care:

The package of services that is arranged and funded by the NHS for people outside hospital, who have continuing health needs.

Continuing health care can be provided in any setting, including the person’s own home, a residential home or a nursing home

To be eligible for Continuing Health Care, a person’s main or primary need must relate to their health.

For example, people who are eligible are likely to:

• Have a complex medical condition that requires a lot of care and support

• Need highly specialised nursing support

Someone nearing the end of their life is also likely to be eligible, if their condition is rapidly deteriorating and may be terminal, so that they are unlikely to survive more than 3 months.

Eligibility for NHS Continuing Health Care does not depend on a specific health condition, illness or diagnosis, who provides the care, or where the care is provided.

If a person has a disability, or has been diagnosed with a long-term illness or condition, that does not necessarily mean that they will qualify for NHS Continuing Health Care. A number of tools are used to determine the person’s eligibility:

• NHS Continuing Health Care Fast Track Tool or • NHS Continuing Health Care Needs Checklist • London Health Needs assessment • DST or Decision Support Tool for NHS Continuing Health Care

Documents

1 THE WHIPPS CROSS DISCHARGE HANDBOOK INDEX Topic …