| Health - Residential Aged Care Facility Placement ... · Web viewHealth Insurance Act 1973 (Commonwealth) Health (Fees) Determination 2015 (ACT) Health Act 1993 (ACT) Charter of

CHHS16/080

Canberra Hospital and Health ServicesOperational Procedure Residential Aged Care Facility Placement from HospitalContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Alerts.........................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Application for residential aged care......................................................................3

Section 2 – Process for discharge of patient to RACF................................................................4

Section 3 – Declining Placement...............................................................................................5

Section 4 – Roles and Responsibilities......................................................................................6

Section 5 – Nursing Home Type Patient (NHTP) Fees...............................................................7

Implementation........................................................................................................................ 7

Related Policies, Procedures, Guidelines and Legislation.........................................................8

References................................................................................................................................ 8

Definition of Terms...................................................................................................................8

Search Terms............................................................................................................................ 9

Attachments..............................................................................................................................9

Attachment 1: Flowchart for a patient to be considered as waiting for Residential Aged Care Placement (RACP).......................................................................................................10

Attachment 2: Discharge of Patient to Residential Care Facility - Process Flow..................11

Attachment 3: Letter 1A – The Residential Aged Care Application Confirmation Letter.....12

Attachment 4: Letter 1B - Residential Aged Care Application Confirmation Form..............13

Attachment 5: Letter 2 – Residential Aged Care Application Confirmation Follow-up Letter............................................................................................................................................ 14

Doc Number Version Issued Review Date Area Responsible PageCHHS16/080 1 22/06/2016 01/07/2019 RACC 1 of 15

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Purpose

The purpose of this procedure is to ensure that a standardised approach is adopted in ACT Health Public Hospitals, when dealing with inpatients requiring placement in a Residential Aged Care Facility (RACF) in the ACT, Queanbeyan, Yass or other regions.

In these circumstances a RACF has been deemed to be the most appropriate place to best meet the patient’s current care needs. An acute care hospital setting is not considered appropriate as a long term option for ongoing care or support.

For these patients transfer to a RACF will enable them to receive care in an environment that can best meet their long term care needs. Timely transfer of patients to a RACF allows the hospital to admit and treat patients waiting who have acute care needs.

Benefits that can be gained from facilitating timely transfer to residential care include: A model of care that specifically caters for the needs of older people staff appropriately skilled in the provision of residential care decreased vulnerability to hospital acquired infections increased interaction, socialisation and personal well being; appropriate care with ongoing options/choice to transfer between residential care

facilities.

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Scope

Alerts

Fees The Medical Officer must inform the patient /Enduring Power of Attorney (EPOA)/Guardian of the decision to change the care type to a Nursing Home Type Patient (NHTP) and remind them of the financial implications. Further clarification of fees or entitlements can be obtained by the patient /EPOA/Guardian from the Patients’ Accounts Office staff and/or Social Workers.

Significant delays to transfer of a patient to a RACF due to either staff’s inability to contact the patient’s EPOA/Guardian or delays in processing RACF applications should be escalated. This process is outlined in further detail in Section 4 - Roles and Responsibilities.


This procedure relates to the management of inpatients who, after being medically/clinically stabilised and: Have been approved by the Aged Care Assessment Team (ACAT) as eligible for

residential aged care placement are unable to be safely discharged back to their pre-admission environment.



This Standard Operating Procedure (OP) describes for staff the process to

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This procedure is applicable to staff of the Canberra Hospital and Health Services who are involved in the care and discharge of patients transferring from hospital to a RACF.

During this process there is a need to consider Aboriginal and Torres Strait Islander older people to ensure these clients receive appropriate care through provision of information and access to services. This could include the Ngunnawal Aboriginal Corporation which provides aged care services and support to Aboriginal and Torres Strait Islander people in the ACT, Yass and Queanbeyan. ACT Health recognises that the poorer health status and the health care and support needs of older Aboriginal and Torres Strait Islanders differ from those of other Australians, and they may require support to access health services at both higher rates and younger ages.

Patients who meet the eligibility criteria for the National Disability Insurance Scheme (NDIS) should be referred accordingly.


Section 1 – Application for residential aged care

Application for residential aged careOnce a patient has been approved by the ACAT as eligible for residential aged care, the patient /EPOA/Guardian will be requested to complete and submit the ‘Combined Assets and Income Assessment’ to Centrelink as well as lodge written applications to a minimum of three (3) RACFs. Social Workers and the Residential Aged Care Liaison Nurse (RACLN) are available to assist patients and their family/carer/EPOA/Guardian through this process. These discussions should be recorded in the patient’s clinical record. Where consent has been provided for RACLN involvement, the RACLN should regularly follow-up with the selected facilities as to the availability of beds. The patients are required to accept the first offer of an available bed from one of these facilities.

Preparing the transfer of a patient to residential aged care should be part of the standard discharge planning process. Discharge planning should begin at the earliest phase of the in-patient admission along with involvement with the patient/EPOA/Guardian and RACF.

The patient /EPOA/Guardian may not always receive their first placement choice for residential aged care. However, as residents are able to transfer between facilities, they are required to take the first available place with a view of transferring when a bed becomes available in their preferred facility. Patients whose care type has changed to Nursing Home Type Placement may be transferred to another ward in the hospital that specifically caters for the needs of older people.


Section 2 – Process for discharge of patient to RACF



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Process for discharge of patient to RACFThe discharge of patients to RACFs will take place in a timely manner and appropriate discharge processes should be in place to ensure that the transfer will be safe and comfortable for the patient, along with effective communication and information sharing between the patient/EPOA/Guardian and the RACF as well as the patient’s General Practitioner (GP). See page 6 for further details regarding the process for discharge of a patient to a RACF.

Influenza and pneumococcal immunisation should be offered prior to being discharged to residential aged care.

In the event that a patient/EPOA/Guardian opts to be discharged home rather than to residential aged care, hospital staff must follow discharge planning processes and confirm that all essential community services and supports are in place. This includes confirming the ability of the carer/family/EPOA/Guardian to provide the required level of care and/or confirming the commencement date for the introduction or renewal of community services e.g. domestic assistance, personal care, respite care, Community Nursing etc. These discussions and/or decisions should be recorded in the patient’s clinical record.

For a patient to be considered as waiting for Residential Aged Care Placement (RACP) all seven questions require a YES answer (this is illustrated in further detail in a flow chart at Attachment 1): Q1 Patient has a formal discharge plan? Q2 Is the patient clinically stable? Q3 Has the treating team recommended RACF? Q4 Has the patient /EPOA/Guardian been consulted about RACP as being the discharge

plan? Q5 Has the patient /EPOA/Guardian consented to placement in a RACF as the discharge

plan? Q6 Has the patient been assessed and approved by ACAT as an eligible RACF

placement? Q7 Is the patient still clinically stable and ready for immediate transfer to an

appropriate RACF?

The details for the process for discharge of patients to a RACF is outlined in further detail at Attachment 2 - Discharge of Patient to RACF - Process Flow Chart.




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Section 3 – Declining Placement

Declining PlacementWhile is it acknowledged that the patient/EPOA/Guardian may have a preferred facility for RACF placement, it is a requirement that the first RACF vacancy offered is accepted which will meet care needs. The patient/EPOA/Guardian is required to accept this placement while they await a vacancy in their preferred RACF. As the care needs of the patient would be met in these circumstances, this is consistent with the patients’ rights under the Human Rights Act 2004 and the Charter of Rights (Aged Care Act 1997).

Where a patient/EPOA/Guardian fail to apply to RACFs or does not accept a bed when it is offered by a facility to which they have applied, the hospital will request the patient/EPOA/Guardian consider other discharge options and the matter should be escalated to the appropriate person (refer to Roles and Responsibilities).

The risk associated with non-compliance with acceptance of an available RACF bed is that: Patients who remain in hospital for a long period of time may be at risk of functional

decline and/or hospital acquired infection acute care beds are occupied with patients who no longer require acute care while

those who are in need of such care are refused due to limited capacity acute care hospital resources are not optimised.

Early recognition triggers for potential barriers to transfer to RACF/non-compliance may include: Inability to contact family no family or EPOA available family not attending scheduled meetings or unresponsive to contact(s) frequent changes to discharge plan by family, EPOA or RACFs lack of flexibility with RACF preferences lack of available RACFs due to complex needs of patient or culturally sensitive

requirements approaching estimated discharge date with no agreed discharge plan in place identified complex internal home environment including financial hardship respite or Transitional Therapy and Care Program (TTCP) options unsuitable difficulty accessing equipment or special services delay in accessing guardianship where required citizen or residency issues delays to submission and return of means tests with relevant Department.

If issues emerge that will negatively impact expected length of stay, an escalation plan should be initiated. At this time, the Medical Team supported by the Multidisciplinary Team including the Social Worker and RACLN should develop a detailed plan to manage the situation inclusive of a timeframe for an outcome to be reached (see Alerts section on p3 for escalation plan).



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A meeting led by the Medical Team, and supported by other members of the Multidisciplinary Team including the Social Worker and RACLN will be arranged with the patient/EPOA/Guardian. This meeting will be documented and should address the following: The patient/EPOA/Guardian should be given the opportunity to explain their perceived

barriers to placement. Check that patient/EPOA/Guardian is aware that the patient will not be able to stay in

hospital and RACF placement is appropriate for their care needs. Advise patient/EPOA/Guardian of hospital bed capacity issues. Advise/remind patient/EPOA/Guardian regarding potential fees. Provide

patient/EPOA/Guardian with a list of RACFs even though this may have been provided previously.

Ensure that the patient/EPOA/Guardian is aware of requirement to visit potential RACFs and where possible visit within 24hrs of being notified of a vacancy.

Documentation in the patient’s clinical record is required and should include the events and actions taken and to whom the issues have been escalated. A positive outcome of the escalation should be discharge within the agreed timeframe.

(Note: If the EPOA/Guardian cannot be contacted, the escalation process should be triggered. In this cases the Office of the Public Advocate may be consulted if no one is acting as a patient advocate)


Section 4 – Roles and Responsibilities

It is expected that Canberra Hospital and Health Services staff and patient/EPOA /Guardian will work in partnership with the Medical and multidisciplinary team. This will take place under the leadership of the Medical Team with the assistance of Social Workers and the RACLN.

It is the responsibility of the Medical Officer to inform the patient /EPOA/Guardian of the decision to change the care type to a NHTP and remind them of the financial implications that were discussed on admission. This should be completed as part of informed consent. A record of this conversation including incurring of financial implications should be recorded in the patient’s clinical record.

Further clarification if required, can be sought from the staff of the Revenue and Financial Services Admissions Administration office. The role of the Revenue and Financial Services Admissions Administration office staff is to provide supporting documentation and information to the patient/EPOA/Guardian regarding charges that may be incurred as a patient contribution as per the current disallowable instrument Health (Fees) Determination under the Health Act 1993 following the decision by the Medical Officer to modify the care type to NHTP.

Escalation (Roles and Responsibilities)



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The patient’s Medical Officer along with the multidisciplinary team including the RACLN is responsible for implementing this procedure. If a meeting led by the Medical Team with the patient/EPOA/Guardian fails to address a plan for discharge with an agreed timeframe escalation is required. This should be directed in the first instance to the Assistant Director of Nursing (ADON) and Director of Nursing (DON) through the Clinical Nurse Consultant (CNC) and then to the relevant Executive Director (ED). If required, this matter may need to be escalated to the Director General (DG). Formal letters may need to be sent outlining details of recommended discharge arrangements within agreed timeframes (See Attachments 3 and 4).


Section 5 – Nursing Home Type Patient (NHTP) Fees

It should be noted that fees may apply to patients whose care type has been classified as a NHTP care type. No fees are payable if the patient reverts to an acute episode: These patients will be assigned a care type of ‘Non Acute Care’ with a management

intention of ‘Nursing Home Care’ if the patient has elected to use private health insurance, then their Acute Care

Certificate needs to indicate that they no longer require acute clinical care.

Patients classified as NHTP and in receipt of a pension from Centrelink or Veterans Affairs may be eligible for payments/entitlements from these services. Upon the reclassification of patients by Medical Staff, the Social Work Department can assist in providing information to patients and their families on potential entitlements.


Implementation

This procedure will be incorporated into existing training programs and orientation plans for staff working in adult inpatient wards involved in the care and discharge of patients transferring from hospital to a RACF. The procedure will also be easily accessible via the Policy/Clinical Guidance Register on the intranet.




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Related Policies, Procedures, Guidelines and Legislation

LegislationHuman Rights Act 2004Commonwealth Aged Care Act 1997Health Insurance Act 1973 (Commonwealth)Health (Fees) Determination 2015 (ACT)Health Act 1993 (ACT)Charter of Rights (Aged Care Act 1997)

PoliciesACT Health Discharge Planning Policies and Procedures


References

1. National Immunisation Program Schedule, 1 November 2005 (Australian Government Department of Health & Ageing)

2. Residential Aged Care Placement Policy Directive, SA Health July 20153. Immunisation Strategy 2007 – 20104. Opportunistic Influenza Immunisation for Aged Care Rehabilitation Services (ACRS)

Inpatients, April 2010 5. Northern Sydney Central Coast NSW Health Residential Aged Care Placement Policy 20106. Melbourne Health Discharge of Patient to Residential Care Facility Policy 2011

www.myagedcare.gov.au7. 5 Steps to Entry into Residential Aged Care

http://www.health.gov.au8. Northern Sydney Central Coast NSW Health Residential Aged Care Placement Policy 20109. Melbourne Health Discharge of Patient to Residential Care Facility Policy 2011


Definition of Terms

Nursing Home Type Patient - A patient who has been in one or more approved hospitals (public or private) for a continuous period of more than 35 days, with a maximum break of seven days, and who is not deemed to be receiving acute care; but does not include a compensable patient or a non-eligible person. (Source: authorised by the ACT Parliamentary Counsel-also accessible at www.legislation.act.gov.au)

Residential Aged Care Facility (RACF) - In this document the term RACF refers to a special-purpose facility which provides accommodation and other types of support, including assistance with day-to-day living, intensive forms of care, and assistance towards independent living, to frail and aged residents. Facilities are accredited by the Aged Care



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Standards and Accreditation Agency Ltd to receive funding from the Australian Government through residential aged care subsidies. (Definition sourced from AIHW)


Search Terms

Discharge, Transfer, Residential Aged Care, Long stay, Residential Aged Care Facility, Nursing Home, Enduring Power of Attorney


Attachments

Attachment 1: Flowchart for a patient to be considered as waiting for Residential AgedAttachment 2: Discharge of Patient to Residential Care Facility - Process FlowAttachment 3: Letter 1A – The Residential Aged Care Application Confirmation LetterAttachment 4: Letter 1B - Residential Aged Care Application Confirmation FormAttachment 5: Letter 2 – Residential Aged Care Application Confirmation Follow-up Letter

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair



All seven questions require a YES answer:

Q1 Patient has a formal discharge plan? No

Q2 Is the patient clinically stable?

Q3 Has the treating team recommended RACF?

Q4 Has the patient/EPOA/Guardian been consulted about RACP as discharge plan?

Q5 Has the patient/EPOA/Guardian consented to placement in an RACF as the discharge plan?

Q6 Has the patient been assessed and approved by ACAT as eligible RACF placement?

Q7 Is the patient still clinically stable and ready for immediate transfer to an appropriate RACF?

No

No

No

No

No

No

Complete D/C Plan

Yes

Yes

Yes

Yes

Yes

Yes

Continue treatment

Treating team to make decision re discharge destination

Treating team to consult patient /EPOA/Guardian

Treating team to consult patient and/or person responsible to seek consent for discharge to RACP

Refer to ACAT

Continue treatment

Yes to all seven questions YesEnter patient status as “waiting” for RACP (care type - NHTP)

CHHS16/080

Attachment 1: Flowchart for a patient to be considered as waiting for Residential Aged Care Placement (RACP)



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Attachment 2: Discharge of Patient to Residential Care Facility - Process Flow



Treating Team recommends patient for discharge to Residential Aged Care Facility.

Patient confirmed clinically stable.

Patient /EPOA/Guardian consulted by the Medical and the Multidisciplinary Team re RACF discharge plan.

Patient /EPOA/Guardian consents to placement in an RACF.

Patient assessed and approved by ACAT as eligible RACF placement.

Social Worker meets with patient /EPOA/Guardian to:Discuss that residential care is the preferred discharge plan;Explain the process and ensure that the patient /EPOA/Guardian is aware of the steps and requirements and is resourced with relevant residential care information. Ensure that a referral is made with consent to the RACLN to assist the /EPOA/Guardian in the process of finding a suitable RACF placement. The RACLN will assist by liaising with appropriate RACFs.

Letter 1A & 1B “The Residential Aged Care Application Confirmation Letter” & the “Residential Aged Care Application Confirmation Form” is delivered to the patient /EPOA/Guardian and explained by Social Worker to the patient /EPOA/Guardian. The patient /EPOA/Guardian will be requested to complete and submit the “Combined Assets and Income Assessment” to Centrelink as well as lodging written applications to a minimum of three (3) RACFs within 28 business days. Documentation of the process and communication is to be recorded in the patient’s record.

The Social Worker or RACLN is to record the patient’s Residential Aged Care Facility choices in the record.

Letter 2 “Residential Aged Care Application Confirmation Follow-up Letter” is to be delivered and explained if the patient/EPOA/Guardian has not completed the Letter 1A & 1B “The Residential Aged Care Application Confirmation Letter” & the “Residential Aged Care Application Confirmation Form” and returned by the due date. The RACLN will keep track of the due date and return of Letter 1A and 1B as well as arranging for Letter 2 to be issued if required.

Placement becomes available in a nominated and suitable Residential Aged Care Facility.

The Treating Team led by the Treating Medical Officer is to facilitate the patient’s discharge to an RACF in a timely and safe manner. Valuables, belongings, medications and transfer/discharge letters are to accompany the patient on discharge to RACF in accordance with the CHHS discharge processes. Prescriptions can be faxed to community pharmacy for dispensing/delivery directly to the RACF if required.

The patient/EPOA/Guardian is to be notified of impending discharge date by treating team.

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Attachment 3: Letter 1A – The Residential Aged Care Application Confirmation Letter

Name: ________________________________________



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Address: ________________________________________

________________________________________

________________________________________

Dear _________________________________

We acknowledge that the decision for residential care means a significant life change and we will endeavour to help you through this process.

To assist in this process ACT Health requests that you submit applications to a minimum of three appropriate facilities within 28 business days from the date of consent to be placed in a residential aged care facility. It is important only to submit applications to facilities for which you are prepared to accept a vacancy, as ACT Health requires that you will take the first vacancy offered.

Please complete and return the Residential Aged Care Application Confirmation Form (attached) to the Residential Aged Care Liaison Nurse (RACLN) by ________________________________ (insert date).

If you have any questions please do not hesitate to contact the RACLN on 6244 4148.

Yours sincerely

Ian ThompsonDeputy Director-GeneralCanberra Hospital & Health ServicesACT Health

Date: ______________________



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Attachment 4: Letter 1B - Residential Aged Care Application Confirmation Form

I _____________________ (patient/family member/carer/EPOA/Guardian) advise that

_______________________________________________ (insert patient’s name)

Has submitted applications to the following facilities:

No Name of Facility Suburb

1

2

3

I understand that ACT Health requires that

_______________________________ (insert patient’s name) will take the first

available vacancy offered from this list.

Signed: __________________________Print Name: _________________________

Relationship to Patient_________________________________________________

Please return by: ___________ (insert date) to the Residential Aged Care Liaison Nurse.



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Attachment 5: Letter 2 – Residential Aged Care Application Confirmation Follow-up Letter

Name: ________________________________________

Address: ________________________________________

________________________________________

________________________________________

Dear _________________________________

We wrote to you on ________________ (insert date) about the need for

________________________ (insert patient’s name) to seek appropriate Residential Aged Care Facility placement.

We also asked for a Residential Aged Care Application Confirmation Form to be completed and returned to the Residential Aged Liaison Nurse (RACLN) by__________________ (insert due date) but as yet we have not received this.

If you are having difficulty and need assistance with your application for RACF placement please contact the RACLN on 6244 4148 as they may be able to assist.

We look forward to receiving your Residential Aged Care Application Confirmation Form by no later than ____________________ (insert date).

Yours sincerely

Ian ThompsonDeputy Director-GeneralCanberra Hospital & Health ServicesACT Health

Date: _____________________



Documents

| Health - Residential Aged Care Facility Placement ... · Web viewHealth Insurance Act 1973 (Commonwealth) Health (Fees) Determination 2015 (ACT) Health Act 1993 (ACT) Charter of