RCHT Adult Discharge and Transfer Policy - … Adult Discharge and Transfer Policy (including the County-wide Choice, Equity and Fair Access Framework) Version 5 26 May 2016 ... 1

RCHT Adult Discharge and Transfer Policy (including the County-wide Choice, Equity and Fair Access Framework)

Version 5

26 May 2016

Table of Contents

1. Introduction ................................................................................................................... 3

2. Purpose of this Policy/Procedure .................................................................................. 3

3. Scope ........................................................................................................................... 3

4. Definitions / Glossary .................................................................................................... 3

5. Ownership and Responsibilities .................................................................................... 5

5.3. Role of Divisional Management Teams ................................................................. 5

5.4. Role of the Clinical Nurse Specialist (CNS) for Adult Discharge............................ 6

5.5. Role of Ward Sisters and Charge Nurses .............................................................. 6

5.6. Role of the Consultant ........................................................................................... 6

5.7. Role of Individual Clinical Staff Members .............................................................. 6

5.8. Role of the RCHT Clinical Site Team .................................................................... 6

5.9. Role of the Onward Care Team ............................................................................. 6

6. Standards and Practice .............................................................................................. 10

6.3. The Simple Discharge Processes ........................................................................ 13

6.4. The Complex Discharge Process ........................................................................ 14

6.7. ED Discharges ..................................................................................................... 18

6.8. RCHT Internal Transfers ..................................................................................... 19

6.9. Patient and Carer Communication ....................................................................... 19

6.10. Discharges between 11pm and 6am ................................................................ 20

6.12. Self-Discharge ................................................................................................. 20

7. Dissemination and Implementation ............................................................................. 20

8. Monitoring compliance and effectiveness ................................................................... 21

9. Updating and Review .................................................................................................. 21

10. Equality and Diversity .............................................................................................. 22

10.2. Equality Impact Assessment ............................................................................ 22

Appendix 1. Governance Information ................................................................................ 23

Appendix 2.Initial Equality Impact Assessment Screening Form ....................................... 27

Appendix 3-Staged Process of the Choice Framework ..................................................... 29

• The alternative discharge arrangements are agreed with you (this may not be your preferred choice) and a maximum of 3 days will be afforded for you to leave hospital ...... 29

RCHT Adult Discharge and Transfer Policy v5 Page 2 of 29

1. Introduction 1.1. Discharge planning is a multi-professional and often multi-agency process essential to every patient in our care. Maintaining a structured process to each and every discharge is a sign of a quality service, both delivering good patient experience alongside maximising Trust resource and efficiencies. 1.2. This policy is based on the guide from the Department of Health ’Ready to Go?’ and promotes ‘The 10 Steps’ essential in discharge and transfer of care planning.

1.3. This policy is underpinned by the SAFER Patient Flow Bundle, a framework to deliver structured discharge planning to our patients with the aim of having the right patient in the right environment at the right time.

1.4. This policy incorporates the Cornwall-wide Choice, Equity and Fair Access Framework and sets out how this is delivered in RCHT. 1.5. The policy will now use the word ‘discharge’ on the understanding this equally refers to any ‘transfer of care’ from the Trust to any health and social care setting. 1.6. This version supersedes any previous versions of this document or its associated documents, including Trust strategy and clinical guidelines.

2. Purpose of this Policy/Procedure 2.1. The purpose of this policy is to ensure the Trust meets strategic and clinical best practice standards in delivering structured discharge planning.

3. Scope 3.1. This policy applies to all Trust staff involved directly or indirectly with structured discharge planning. 3.2. This policy covers all adult patients (16 years plus), it covers ‘in-hours’ (9am to 5pm) and ‘out-of-hours’ (5pm to 9am) discharges and transfers of care. Specific discharge planning requirements are established for discharges between the hours of 11pm and 6am (see section 6.9) 3.3. When a young person has on-going care needs and is reaching the age where adult services will be assuming responsibility for this the transition of care should be recorded in the notes. A named person known to the young person and their family should be identified where possible for contact in case of difficulty and the Paediatric Discharge and Transfer Policy should be referred to, to support the needs of the young person. This would include children who have been in care.

4. Definitions / Glossary 4.1. Simple Discharge – Patient is able to return to their normal place of residence (80% of discharges fall in to this category). There are four categories of ‘Simple Discharge’ and these are explained in Section 6.3.


4.2. Complex Discharge – Patient is unable to return to their normal place of residence or requires a considerable change to their existing care arrangements (20% of discharges fall in to this category) this may include:

• A funding stream needs to be established • A NHS Continuing Healthcare(CHC) Checklist may be required as CHC

eligibility needs to be considered • A ‘Best Interest’ decision is required • A formal ‘Discharge Planning Meeting’ (DPM) may be required • Safeguarding concerns have been identified

4.3. Fast Track Discharge – In response to a rapidly deteriorating condition, this may be in a terminal phase, with an existing level of dependency. Life expectancy can be measured in days or weeks, not months

4.3.1. The Fast Track Pathway is not appropriate for individuals with long term/chronic conditions such as COPD, heart failure, dementia etc. unless there is a step change in their condition which results in a rapid deterioration and NHS Continuing Healthcare funding is required to enable their needs to be urgently met.

4.4. Emergency Department (ED) Discharges – This category of patient differs from the Simple and Complex discharge categories, as ED patients are not admitted to inpatient services. Occasionally these patient present with complicated discharge needs which require thorough planning and execution.

4.5. Internal Transfers – These are formal general ward and department transfers where a new base ward or department will be established and care will be handed over form one clinical team to another (this can occur between the RCHTs three sites and could involve the transfer of a critically sick patients (see RCHT Clinical policy for safe transfer of patients between care areas or between hospitals).

4.6. External Transfers – These are formal care provider- to -care provider transfers of care e.g. between RCHT and a community hospital/ a tertiary provider/ care home.

4.7. SAFER Patient Flow Bundle – Is a set of seven interventions that come together to help deliver the right care to the right patient in the right environment at the right time. Further details are provided in 6.2

4.8. ‘Estimated Date of Discharge’ or EDD – The date the patient is expected to leave the hospital setting safely, with everything appropriate in place.

4.9. ‘Clinically Stable for Discharge’ or CSD – The patient has reached their optimal clinical state, in this setting, given their underlying clinical condition and the patient’s baseline status (was known as ‘Medically Stable’ or ‘Medically Fit’).

4.10.SWiftPlus – Is the Trust’s Patient Administration Systems (PAS) interface. In ward areas interactive touch screen displays are in place that hold individual patient information on admission and structured discharge plans in a series of columns to aid multi-disciplinary and clinical site team communications.

4.11.eOnwardCareReferral – Is an electronic referral form within MAXIMS (the Trust’s electronic patient record system) used to alert the Onward Care Team of a patient requiring their assessment and intervention (this form was previously


called eBICA) and is recognised as a formal ‘Section 2’ notification under the Community Care Act (Delayed Discharges etc.) 2003.

4.12. eDischarge – A system module in MAXIMS has been deployed so that all inpatients discharged from hospital will have a discharge summary electronically sent to their GP at the point of discharge. As part of this system, all patients’ prescriptions, now electronically recorded in this discharge summary via EPMA (Electronic Prescribing and Medicines Administration system), where the discharge medications are prescribed.

4.13.Choice Framework – Where choice has become a barrier to discharge and appropriate options have been refused by the patient and / or their family, and requires timely Multi- Disciplinary Team (MDT) intervention across all bed based settings. All organisations involved in the MDT for a patient will need to collaborate, record action and communicate following a formal staged process to manage discharge expectations.

The framework is a county-wide process, which seeks to equitably manage and support timely effective transfers of care for patients ready for discharge to the most appropriate setting, irrespective of funding arrangements for on-going care. Further details are in 6.5.

4.14.‘Sisters Shelf’ – This is an electronic resource on the Trust’s Intranet, hosting links to policies, guides and paperwork to support discharge - Click the desktop icon and follow the link to ‘Discharge and transfers’

5. Ownership and Responsibilities 5.1. The Chief Executive and wider Trust Board have key roles and responsibilities to ensure the Trust meets requirements set out by statutory and regulatory authorities (for example: the Trust Development Authority, Commissioners and the Care Quality Commission). These responsibilities are delegated to an Executive Lead with supportive structure to ensure and assure standards and expectations are met. These are described below. 5.2. Role of the Executive Lead – Director of Operations The Director of Operations is the nominated Executive Lead and will be responsible for ensuring structures and processes are in place to assure delivery a high quality and effective structured discharge process. The Executive Lead will report to Trust Board as required.

5.3. Role of Divisional Management Teams Divisional Management Teams (Divisional Director, Divisional General Manager and Divisional Nurse) are responsible for ensuring their clinical workforce is capable to deliver the requirements of this policy and do so. Performance monitoring mechanisms are in place and essential to guarantee the highest standards of service relating to the discharge planning, these should be reviewed regularly and action taken if improvement is required.


5.4. Role of the Clinical Nurse Specialist (CNS) for Adult Discharge The CNS for Adult Discharge supports the facilitation of the most complex discharge patients in the Trust. A key role is to support the on-going implementation and monitoring of the National Service Framework for Continuing Health Care (CHC). The role is currently integrated within the Onward Care Team. They are responsible for reporting the STEIS SitRep for the Trust on a weekly basis.

5.5. Role of Ward Sisters and Charge Nurses Ward Sisters and Charge Nurses are responsible for efficient patient flow through their clinical area, in line with the SAFER Patient Care Bundle. They play a key role in communication. All efforts should be made to ensure that the workforce is equipped to deliver the requirements of this policy, including access to ‘MAXIMS’ and competency with the ‘Ready to Leave’ module, in order to ensure that each patient under their care receives high quality discharge planning with a positive outcome.

5.6. Role of the Consultant The consultant in charge of the patient’s medical care is responsible for initially setting the patient’s Estimated Discharge Date (EDD) in conjunction with the MDT and documenting the outline Discharge plan in the clinical notes. They are also responsible for declaring the patient Clinically Stable for Discharge (CSD) and confirming the reason or for providing the Clinical Criteria for Discharge so that MDT led discharge can safely occur. It is also their responsibility to ensure that their patients electronic discharge summaries, including discharge prescriptions (TTAs), are completed and communications are sent to GP’s in a timely manner, within 24 hours of discharge.

5.7. Role of Individual Clinical Staff Members Each individual clinical staff member is responsible for ensuring that they understand and comply with this Trust policy and that their learning and development needs are identified at their annual appraisal with regards to efficient and structured discharge planning.

5.8. Role of the RCHT Clinical Site Team The Clinical Site Team has an overall remit to ensure efficient patient flow is maintained at the three Trust sites. It provides operational and clinical support to all hospital areas regards patient flow. It is responsible for the co-ordination of all out-of-area transfers in and out of RCHT and a central point for securing emergency transport.

5.9. Role of the Onward Care Team This multi-professional and multi-agency team exist to support the interface between secondary care and community health and social care services. Processes for communication exist to manage efficient information sharing to enable prompt service response that will contribute to individual patients’ discharge plans. Often these communications evidence legal requirements regarding the process of discharge between agencies. 5.10. Role of the Therapy Team


The RCHT Therapy Team contribute to the Multidisciplinary Team (MDT) discharge process using Occupational Therapists, Physiotherapists, Dieticians and Speech and Language Therapists who assess and aid: patient independence; safe mobility; timely discharge; effective nutrition and communication needs. Processes are also in place with other MDT teams in the community to aid the Trust’s patient flow and enable effective discharge strategies to be implemented and delivered. Occupational Therapist Responsibilities 5.11. Occupational Therapy in ED/MAU

5.11.1. Referrals for ED patients can be made during normal working hours via Bleep ED 3221 or verbally to staff in ED. Response to referrals is within the same working day, the priority is to see within 3 hours of referral as clinically indicated. 5.11.2. Referrals for MAU patients can be made via the daily morning ward round, the daily MDT, and verbally to staff on ward. Response to referrals is within the same working day. 5.11.3. Please refer to the ‘Clinical Guideline for the safe discharge of patients from the emergency department outside of Occupational Therapist working hours’ which provide nursing staff in the emergency department with appropriate guidance to enable a patient to be safely discharged from ED outside of Occupational Therapy working hours.

5.12. Occupational Therapy Acute Assessment & Discharge Team (OT AADT)

5.12.1. The responsibilities listed below apply to wards referring patients to the Occupational Therapy Acute Assessment & Discharge Team. This team provides the occupational therapy service for acute medical, acute surgical, eldercare and oncology patients at the Royal Cornwall Hospital. 5.12.2. Referrals are routinely accepted at daily rapid round meetings. This is the preferred referral mechanism. Where a patient’s situation changes during the day referrals can be made directly to therapists on the ward and via voicemail as a final option. Urgent referrals can be made via the bleep for Occupational Therapist (OT) covering the ward. The voicemail and bleep numbers are held at ward level. 5.12.3. Referrals will be acknowledged within 1 working day. Referrers will be notified if referrals are inappropriate and will not be accepted. 5.12.4. Using the discharge categories set out in the in the SAFER Patient Flow Bundle under Criteria Led Discharge, nursing staff are expected to complete nurse led assessment of a patient’s needs for simple self-care and simple return (to care home) discharges. The OT service has provided a nurse discharge checklist tool guide them with this process*. 5.12.5. The Team will accept appropriate referrals for patients that meet the criteria below that fall into the Simple-restart +/-, Simple –Reablement, and Complex discharge categories. 5.12.6. To prioritise new referrals daily using the OT AADT response times; within 2 working day for red priority, 3 working days for amber priority, and 5 working days for green priority patients* 5.12.7. The nurse discharge checklist tool, referral/exclusion criteria and criteria for prioritisation can be found in the ‘Guidance to support Nurse Led Discharges and the Appropriate Referral of Patients to the Occupational Therapy Acute Assessment and Discharge Team’, accessible via the Sister Shelf.


5.13. Occupational Therapy T&O (RCH and SMH)

5.13.1. Blanket referral system. The OT attends the daily rapid round and will commence OT assessment process as clinically indicated. 5.13.2. Medical outliers on T&O wards at RCH can be referred by any member of the MDT verbally or via written referral in the medical notes to the OT. 5.13.3. Response to medical outlier referrals will be within 2 working days as clinically indicated.

5.14. All other Occupational Therapy Services (Phoenix, WCH and Marie Therese House)

5.14.1. To prioritise new referrals at daily board meeting and respond within 3 working days 5.14.2. Patients seen by an OT as part of wider MDT care pathway will be seen in line with agreed national and local standards, e.g. stroke patients to be seen within 72 hours from admission and for 45 minutes of rehabilitation per day.

5.15. Assessment and Interventions of All Occupational Therapy Services include:

5.15.1. Completion of assessments in order to determine pre-admission level and current functional ability with activities of daily living. 5.15.2. To ensure safe transfers e.g. from bed, chair and toilet. 5.15.3. To undertake cognitive and perceptual assessments where indicated. 5.15.4. To provide education and coping strategies for patients with anxiety and depression. This may include signposting to services in the community and ensuring that the patient has the correct resources in place to maximise independence. 5.15.5. To perform home visits when clinically indicated from the OT assessment (carried out with the patient present). 5.15.6. To perform environmental visits when clinically indicated from the OT assessment (carried out without the patient). 5.15.7. To assess and provide a patient with the necessary equipment to ensure a safe discharge. 5.15.8. To advise package of care recommendations for longer term care needs. 5.15.9. To provide splinting and bracing with/without patient follow up as clinically indicated. 5.15.10. Perform wheelchair assessments, short term provision and/or referral to wheelchair services. 5.15.11. Identify the need for alternative accommodation/adaptations’ to current accommodation. 5.15.12. To identify patients suitable for rehabilitation in the community in conjunction with the MDT. 5.15.13. To complete a reablement plan for STEPs package of care if rehabilitation takes place at home or a residential home, send this to STEPs and the Onward Care Team, following the STEPS pathway. 5.15.14. To take part in regular Multi-Disciplinary Team meetings and participate in case conferences as appropriate. 5.15.15. To plan and provide appropriate rehabilitation programmes for stroke and neurology patients.


5.15.16. To highlight need for generic and specialist inpatient rehabilitation. 5.15.17. To write specialist care plans for continuity of specialist care provision for stroke and neurology patients.

5.16. Physiotherapist Responsibilities

5.16.1. To prioritise new referrals daily using the recommended response times for physiotherapy assessments; within 1working day for high priority e.g. acutely unwell respiratory patients which the physiotherapy service will respond appropriately as clinically indicated, 2 working days for medium priority, and 3 working days for low priority patients. (A copy of the prioritisation within physiotherapy document is currently under review). 5.16.2. To perform initial assessment to determine pre-admission or potential capabilities and current functional ability considering potential for improvement. 5.16.3. Plan and provide appropriate rehabilitation programmes as an in-patient with the patient / carer /nursing team and ensure all activities that are essential for discharge are completed. This may include stairs/step assessments. 5.16.4. NB: Physiotherapists will only assess patients who are/have been struggling with their mobility, or where there have been concerns raised about the patient’s ability to manage them (from the patient or the patient’s family). 5.16.5. Provide mobility equipment / aids essential for safety and education to patient / carer ensuring this is documented on the Discharge Checklist to ensure nursing staff are aware of what should be taken home on discharge. 5.16.6. Ensure patients have the correct mobility equipment, labelled with their name and stating if it is to be taken home or left in hospital, ensuring loan forms are completed for all equipment issued for home. 5.16.7. Ensure continuity of rehabilitation is met through regular communication with the MDT during in-patient stay. 5.16.8. To take part in regular Multi-Disciplinary Team meetings (where appropriate) and participate in case conferences as clinically indicated. 5.16.9. To recommend and refer patients requiring external on-going therapy services such as intermediate care at home or further rehabilitation and refer to onward care team if necessary.

5.17. Dietitian Responsibilities

5.17.1. This section details information on response times and service delivery to the in-patient setting provided by the Dietetic service to the Royal Cornwall Hospital Trust; including the Royal Cornwall Hospital, West Cornwall Hospital, Marie Therese House and specialist in-patient dietetic services only.

5.17.2. To prioritise new referrals daily and respond within1- 3 working days as clinically indicated. 5.17.3. To assess patients nutritional requirements, establish the aims of nutritional intervention and where clinically indicated formulate an appropriate nutritional plan. 5.17.4. To provide appropriate dietary information to the patient and nursing staff. 5.17.5. To prescribe modified diets and nutrition supplements as appropriate. 5.17.6. To arrange follow up at hospital, community clinic or home, as appropriate. 5.17.7. To liaise with the patients GP when there is a requirement for supplements or specialist products.


5.17.8. Notify GP if patient was referred and is discharged prior to dietetic assessment, or completion of dietetic care plan. 5.17.9. For patients requiring enteral feeding on discharge to liaise with the patient, carer, ward nursing staff, GP, home enteral feeding dietitians, gastrostomy nurse, and district nurses. To register the patient with the home enteral feeding company, and contact the home enteral feeding nursing service. All of the above is essential to ensure safe discharge to home.

5.18. Speech and Language Therapist (SLT) Responsibilities

5.18.1. To respond to referrals and prioritise patients, aiming to assess within 2 working days (Mon – Fri) from receipt of referral as clinically indicated. 5.18.2. To assess for oro-pharyngeal swallow and communication problems 5.18.3. To provide a treatment plan and intervention as clinically indicated and within the resources provided 5.18.4. To provide a management plan for communication / swallowing difficulties liaising with the MDT 5.18.5. To provide information, advice and support to the patient / relatives / carers. 5.18.6. To provide recommendations regarding swallow safety and guidance on how this can best be achieved whilst an inpatient and for safe transition to other locations 5.18.7. On discharge liaise with community colleagues to arrange on-going speech and language therapy input as required. 5.18.8. Early Supported Discharge Service (Stroke) 5.18.9. Facilitates early discharges from hospital for stroke patients with mild to moderate symptoms. 5.18.10. Accepts referrals from therapists within the acute stroke unit (RCH), Emergency Department (ED)/Medical Admissions Unit (MAU) and stroke rehabilitation units (Bodmin and Camborne) 5.18.11. Specialist stroke rehabilitation (OT, Physio and SLT) in the home environment over 5 days. 5.18.12. Rehabilitation is co-ordinated around patient specific goals and provided for up to 6 weeks

6. Standards and Practice 6.1. Central to the Trust policy are these ten steps (Department of Health 2010)

The Ten Essential Steps to Effective Discharge

1. Start planning for discharge or transfer before or on admission.

2. Identify whether the patient has simple or complex discharge and transfer

planning needs, involving the patient and carer in your decision.

3. Develop a clinical management plan for every patient within 12 hours of admission.

4. Co-ordinate the discharge or transfer of care process through effective leadership

and handover of responsibilities at ward level.


5. Set an expected date of discharge or transfer within 12 hours of admission, and discuss with the patient and carer.

6. Review the clinical management plan with the patient each day, take any

necessary action and update progress towards the discharge or transfer date.

7. Involve patients and carers so that they can make informed decisions and choices that deliver a personalised care pathway and maximise their independence.

8. Plan discharges and transfers to take place over seven days to deliver continuity

of care for the patient.

9. Use a discharge checklist 24–48 hours prior to transfer.

10. Make decisions to discharge and transfer patients each day.

6.2. Core Actions for all Discharges

6.2.1. The seven elements of the SAFER Patient Flow Bundle must be implemented and followed:

• Criteria Led Discharge • Board Rounds • EDD • Patient Information and Expectations • Ward Rounds • Length of Stay Reviews • Communication and Teamwork

6.2.2. An initial assessment and discharge plan must be started before admission for elective cases and from the point of admission for unscheduled admissions. Within 12 hours of admission a Registered Healthcare Professional will have commenced a written discharge plan.


6.2.3. All patients must be given an Estimated Date of Discharge (EDD) within 12 hours of admission. This must be documented on the ward’s SwiftPlus screen at the first Board Round and discussed with the patient / their relative / carer as appropriate.

6.2.4. A Getting Ready to Leave Hospital leaflet must be given to the patient and or family / carer on admission; this must be documented and walked through with the patient/carer. If the patient or carer need the leaflet in in large print, braille, audio version or in another language contact PALS on 01872 252793.

6.2.5. All discharge relevant information must be recorded in the ‘Discharge and Transfer Plan’ 6.2.6. A Consultant level review is the required within 12 hours of admission and is the minimum standard of all discharged patients.

6.2.7. The patient and/ or carers must agree the discharge plan. This must be documented in the ‘Discharge and Transfer Plan. There is currently no formal consent documentation for the patient to sign so please record the date and time of the discussion and who was present. 6.2.8. Likely Equipment needs must be identified early utilising the Occupational Therapy; Physiotherapy; and Adult Speech and Language Therapy team as needed. Community arrangements should be made in line with the RCHT Policy for Pressure Ulcer Prevention and the RCHT Medical Devices & Management Policy as appropriate, for nursing equipment.

6.2.9. Medical staff must review and document that the patient is Clinically Stable as their consent for the patient to be discharged.

6.2.10. Transport arrangements for discharge must be discussed with the patient and arrangements recorded in the Discharge and Transfer Plan. If hospital transport is required booking is expected to be made in line with the first EDD set. For longer anticipated stay patients the expectation is that transport is booked 72 hour before planned discharge. Ambulance transport must only be used in the event of clinical need, please refer to the RCHT Patient Transport Policy. Liaison with RCHT Patient Transport Services via phone is essential if alterations to EDD are made.

6.2.11. Medical staff must be timely in prescribing discharge medication in the MAXIMS e-Discharge/EPMA system. The discharging nurse must ensure the patient has been provided with prescribed medication to take away in line with RCHT Medicines policy.

6.2.12. On the day of discharge, patient should vacate their beds by 10am (or in accordance with their clinical pathway e.g. Post-operatively afternoon or evening discharges). Access to the Discharge Lounge is an option if a patient needs to wait for transport, TTA’s or equipment prior to leaving.

6.2.13. The discharging nurse is responsible for communicating verbally and in writing the handover of patients whose care will transfer to another clinical


care team using the Patient Inter-Healthcare Transfer / Discharge Information Form (CHA 2702).

6.2.14. If discharge arrangements change, all members of the multidisciplinary team, the patient and the patient’s family /carer must be informed as the changes. All changes must be documented in the ‘Discharge and transfer plan’.

6.2.15. The patient’s GP and any other community health care providers must be involved prior to discharge if continuing healthcare plans are vital to the patient well-being and continuity of care. 6.2.16. The nurse coordinating the discharge must ensure all valuables held in the General Office are returned and signed for before discharge. 6.2.17. The discharging nurse should ensure that the patient has a sufficient supply of dressings and continence pads if necessary.

6.2.18. The discharging nurse should check how the patient will gain access to the property and ensure any keys are sent with the patient. 6.2.19. The patient should be requested to have suitable clothes for their journey. The discharging nurse must ensure that the patient is fully clothed before discharge as the patient must not be discharged in their night clothes. In an emergency, where clothing is needed prior to discharge this can be arranged. Should the patient refuse to change or decline the offer of clothing suitable for transfer, this should be documented in the notes prior to discharge. If the patient lacks mental capacity this should be discussed with their advocate.

6.2.20. Any concerns over a safe discharge should be escalated to the nurse-in-charge in the first instance. Out-of-hours discharge safety concerns must be discussed with the clinical site co-ordinator, the outcome of this must be documented.

6.2.21. The discharging nurse must complete and sign, date and time the Discharge Checklist at the point of ultimate discharge. 6.2.22. The Consultant and medical team are responsible for ensuring a timely ‘discharge summary’ communication is documented in the Maxims e-Discharge system prior to discharge. The Discharge Summary will be electronically sent to the GP by the nursing staff at the point of discharge and a copy given to the patient to take home.

6.2.23. The discharging nurse must ensure that the ‘Ready to Leave’ tab on the Maxims e-discharge summary has been completed correctly and two copies have been printed off (one copy to be given to the patient on discharge and one copy to be filed in the patient’s healthcare records).

6.3. The Simple Discharge Processes

6.3.1. Simple Discharges fall into one of four categories (see 4.1 above for definitions):


• Simple – Self-Care • Simple – Return • Simple – Restart • Simple – Reablement

6.3.2. The recording of the Discharge category must documented on the patient’s ‘Discharge and transfer plan’ CHA3488 and entered on the ward’s SwiftPlus screen at their first Board Round.

6.3.3. Leadership of the four simple pathways is key to driving the structured discharge processes (criteria led discharge):

Simple Self-Care – this is a nurse-led pathways, led by the Nurse in charge of the ward each shift.

Simple Return – this is a nurse-led pathway, with the Nurse in charge of the patient co-ordinating discharge back to their care home.

Simple Restart – this is a nurse-led pathway with a simple restart request being phoned through to the Onward Care Team, or if small adjustments to an existing package of care is needed an eOnwardCareReferral is completed detailing this request (This complies with the formal notification of ‘Section 2’). N.B. on WCH and SMH sites the clinical teams contact the Adult Social Care Broker Service directly to request the re-start.

Simple Reablement – this can be a nurse- or therapy-led pathway. An eOnwardCareReferral should be completed within 24 hours of admission (this complies with the formal notification of ‘Section 2’ for any social care considered support). RCHT Occupational Therapy staff assess for STEPS support care packages on discharge.

6.3.4. The Onward Care Team will evaluate those needs and determine the best care pathway for the patient which may include:

• Short Term Enablement Programme (STEPS) at home. • A longer term Social Package of Care. It is planned that new

packages of care are always commenced via STEPS. • 24 hour supportive inpatient care alongside reablement e.g.

commencing in a Community Hospital • A short term health Package of Care • Short term step down placement into a Nursing/Residential Home

funded by health

6.4. The Complex Discharge Process

6.4.1. Complex Discharges fall into one of two categories (see 4.2 and 4.3 above for definitions):

• Complex • Fast Track


6.4.2. The recording of ‘Complex Discharge’ (for either Complex or Fast Track) must documented on the patient’s ‘Discharge and transfer plan’ CHA3488 and entered on the ward’s SwiftPlus screen at their first Board Round.

6.4.3. Leadership of the two complex pathways is key to driving the structured discharge processes (criteria led discharge):

Complex – this is an Onward Care Team-led pathway. An eOnwardCareReferral is completed online and emailed to the Team (this complies with the formal notification of ‘Section 2’).

Fast Track - This is an RCHT ward based function supported by the Palliative Care Team as there is a legal responsibility for the current healthcare organisation to document the care needs of the patient.

6.4.4. For all ‘Complex Discharges’ the actions set out at the bottom of the front page of the ‘Discharge and transfer plan’ must be followed through. This includes ensuring all multi-disciplinary team referrals are made (refer to local therapy team referral criteria) 6.4.5. A Continuing Health Care (CHC) Checklist should be considered and documented in the ‘Discharge and transfer plan’ by the clinical team caring for the patient ion the ward. When completed this will indicate if a formal Decision Support Tool (DST) will be required for discharge. (Trigger points for this are Two or more domains in column A or; Five or more domains selected in column B, or one selected in column A and four in B or; One domain selected in column A in the boxes marked with an asterisk with any number of selections from the other two columns)

6.4.6. For involvement of Community Health Services, the ward MDT can make direct contact / referral to those teams e.g. physiotherapy services/ District Nursing services.

6.5. Recording and reporting reportable Delayed Transfers of Care (DToC)

6.5.1. When a patient is given a Clinically Stable Date (CSD) an entry on SWiftPlus for the ‘reason for delay’ must be recorded. 6.5.2. ‘Reasons for delay’ codes follow the national domains and a list is available on ‘Sister’s Shelf’ to download. 6.5.3. Daily and weekly, the outputs of these ‘reasons for delay’ are reviewed by the CNS Adult Discharge and the Onward Care Team to identify formal reportable delays that are recorded on STEIS SitRep

6.6. The Choice Framework in Practice

6.6.1. Reference to the County-Wide Choice, Equity and Fair Access Framework is important to provide wider context to this section. THE CHOICE PROCESS Stages 1 and 2 are the ‘informal stages’ to the choice process. They apply to


every patient, operationalised at ward level, in order to provide support and prevent the need for further formal escalation. Appendix 3 is a Flow Chart of the Choice Process. Stage 1 – Provision of information to patient. The Trust’s leaflet ‘Getting Ready to Go Home’ EROS – RCHT 1006 will be issued to each and every adult inpatient admitted to hospital. This helpfully sets out clear expectations of the discharge process with patient, family or carer expectation regarding discharge choices and time scales for action once the patient is clinically stable. Information in the Getting Ready to Go Home leaflet is in line with the county-wide Choice Framework ‘Choice Letter Stage 1’. Stage 2 – Daily patient review stage. As the patient becomes Clinically Stable and if barriers are being identified to prevent effective discharge for example:

• patient refusing or delaying planned next discharge steps; • family becoming reluctant to support next step in discharge plan; • no first choice availability in preferred placement or • lack of capacity in community services availability in the patients locality

the following actions must be taken. A case conference needs to be arranged by the ward, led by the Nurse in charge, to include the patient and their representative and appropriate members of the multi-agency multi-disciplinary team within 3 working days, to discuss options for discharge. If potential delay is due to the patient/relative/carer action or response to alternatives to care, the Choice Process will be clearly explained and information will be given to support the case conference’s discussions. The case conference will clarify the nature of any anticipate delays and the expectations of the patient, family or carer with regards to discharge decision making now. A maximum of 3 working days will be afforded to either consider new options (or engage in the process if necessary) and prepare for discharge. This case conference is recorded in the Discharge Plan and followed up over the next 3 working days. It is recognised that difficulties in securing an onward placement may rest with health and social care organisations, and not the patient or their family. If the delay in onward transfer of the patient is due to such reasons, this will be discussed with the patient and family. Following the conference the outcome must be confirmed via a letter.

• Choice Letter – Stage 2 Package of Care • Choice Letter – Stage 2 Care Home

The Stages 3 and 4 now represent the Formal Choice process:

Stage 3 – Formal letter stage. If the 3 working day Stage 2 period ends with no outcome regarding move or a confirmed discharge date. The next stage of the framework is evoked. This clarifies, that at a further formal case conference (as before) the onward care options and the identification of any appropriate alternative discharge destination was discussed. This destination may not always be the patient’s, family’s or carers’ preference.


This stage Choice Letter is sent to the patient, family or carer after the case conference and sets out a maximum of a further 3 days to comply. Choice Letters at this stage may need to be more personalised than the available Trust template letters; an appropriate Stage 3 Choice Letter will be prepared and signed by the Divisional Director or their deputy. There are two letters available depending on the discharge pathway:


Stage 4 – Formal legal notification letter stage. If after a further 3 working days there has still been no information or action regarding discharge from the patient, family and or carer, a final letter will be issued with either the name of an available care provider or care home that is able to meet the patient’s care needs and a confirmed date for discharge. The patient will be discharged in accordance with this letter. The appropriate Stage 4 Choice Letter will be signed by the Director of Operations / Medical Director/ Executive Nurse.


If the patient refuses to go after this Stage 4 letter is issued, the legal advice obtained in evoking the Stage 4 of the Choice Framework will be followed-up by the Executive lead in conjunction with the Divisional Director, the Nurse in charge and the trusts legal advisors.

6.6.2. Communications and the Choice Framework The multi-professional team must ensure that discussion between the patient and their family, carer, advocate (as appropriate), have been undertaken prior to initiating Stage 2 of the Choice process. Emphasis should be placed on accessing available support, clarification of the process and the possible need to transfer to an interim placement if the preferred option is not available. 6.6.3. Mental Capacity Act and the Choice Framework It is recognised that most patients have the capacity to participate in making choices relating to planning their discharge from hospital but in cases where, despite efforts to help them communicate their wishes, there is doubt regarding their capacity, a formal process under the Mental Capacity Act 2005 (MCA) must take place. Following a Level 3 assessment, if the patient is found to lack the capacity to make choices regarding discharge, the MDT will consult advocates, e.g. family or an Independent Mental Capacity Advocate (IMCA), in line with the Mental Capacity Act (2005), and make a Best Interest Decision as appropriate. Staff will be mindful of the obligation to seek the least restrictive option for the patient’s discharge and should follow Trust policies and procedures relating to Mental Capacity, Best Interest and Deprivation of Liberty Safeguards. If the Health screening Level 3 MCA Assessment and the CHC Checklist are both positive the Best Interest Meeting is led by a Healthcare professional.


If the Assessment is positive but the CHC screening does not identify complex on-going health care needs then the responsibility for the Best Interest meeting is with Adult Social Care. 6.6.4. Detained Patients and the Choice Framework Patients detained under the Mental Health Act 1983 (amended in 2007) receiving care in an Acute General Hospital setting should be transferred to a mental health unit when their physical health permits safe transfer. This must be done in collaboration between the acute and mental health services, under the direction of the Responsible clinician. All statutory paper work needs to be completed in line with the Mental Health Act Code of Practice.

6.7. ED Discharges

6.7.1. All ED attendees being discharge directly from the department require an individual assessment to identify any complicated discharge needs they have. 6.7.2. Issues that must be considered are:

• Previous care needs • Changing medication needs including compliance aids • Likely changes as a result of admission • Transport needs • Previous and current social needs • Possible vulnerability of patients’ e.g. frail, elderly, terminally ill,

learning disability, mental health problems. • Infection prevention and control issues and the possible need for

consultation with the infection prevention and control team • Equipment needs

6.7.3. Any concerns over a safe discharge should be escalated to the Nurse-in-Charge of the Department in the first instance. Out-of-hours discharge safety concerns must be discussed with the Clinical Site Co-ordinator, and Senior On-Call Manager for the Hospitals if necessary, the outcome of these must be documented. 6.7.4. Out-of-hours an option to consider is admission to the overnight stay area or an alternative overnight bed in the hospital, but justification in such circumstances needs to be clearly documented. Clinical responsibility for the patient remains with the ED medical team. 6.7.5. Transport considerations:

• Ask the patient if there is anyone who can collect them from the department

• If the answer is no then the hospital staff will discuss the options: o Use our preferred provider taxi service ‘A to B Taxi Service’

(immediate payment required) o Use the following secure car services TAP (Transport for

Patient Access - Age Concern); or Cornwall Volunteers. Both


however if not paid at the time will invoice the patient. (telephone numbers held by reception staff in the department)

• Under the National guidance the hospital does not pay for patient transport unless they fall under the Medical Eligibility Criteria (RCHT Patient Transport Policy)

6.7.6. All communications relating to the co-ordination of the complicated discharge needs to be documented in the ED healthcare records of that patient.

6.8. RCHT Internal Transfers

6.8.1. Please refer to the ‘RCHT Clinical policy for safe transfer of patients between care areas or between hospitals’. This will require a:

• Clinical risk assessment of every patient prior to any transfer (based on NEWS (National Early Warning Score) which should be recorded in the patient’s notes.

• Appropriate preparation and conduct of the transfer to maintain maximum patient safety.

6.8.2. In addition, all wards and departments when transferring a patient internally (this includes to other Trust sites), the receiving ward will be contacted and a verbal handover will take place (SBARD-D). 6.8.3. The receiving ward will complete an Internal Telephone Handover Form (CHA 2938) to document the patient’s status and requirements. The exception being transfers from the Emergency Department to admissions wards, in which case a verbal handover is always given and the receiving areas will be responsible for documenting an appropriate handover entry relevant to the complexity of the patient’s needs.

6.8.4. On arrival to the receiving ward the Internal Telephone Handover Form will be filed in the patient’s healthcare records.

6.9. Patient and Carer Communication

6.9.1. Every patient must be given the ‘Getting Ready to Go Home’ leaflet (available from EROS – RCHT 1006) to start planning for discharge. 6.9.2. An accurate and up-to-date EDD, set by the MDT, must continually be communicated to the patient and their family/ carers (as appropriate). 6.9.3. Section 6.4 – The Choice Framework must be accurately followed and communicated as appropriate to avoid any inappropriate use of acute hospital beds. 6.9.4. Consider giving the Carer Information Leaflet to the patient’s main carer (if they have one identified) to promote their rights and responsibilities.

6.9.5. Additionally, any other treatment specific guidance / patient information will be given to support a safe discharge.


6.9.6. All members of the multiprofessional team involved with the patient must ensure that the patient and carer receive instructions on care / treatment and follow-up arrangements required after leaving hospital. 6.9.7. The patient and carer must be informed if an outpatient appointment is necessary, the time scale in which the appointment is needed and how they will be notified of the appointment date and time. First appointments must be made for INR checks for all patients discharged on Warfarin with the appropriate clinic/GP Surgery. Patients will need to be informed of the time and date of appointment prior to discharge.

6.10. Discharges between 11pm and 6am

6.10.1. Discharges between the hours of 11pm and 6am are more frequent for ED and other direct admission areas. They are infrequent from base wards. Compromise to patient safety is highest for patients discharged between these hours and it is the intention of the Trust to minimise such discharges and only where discharge is necessary, acceptable and in the patient’s best interest should it happen (noting some patients may of course chose to be discharged between these hours). 6.10.2. To ensure patient safety is maximised the following action must be taken for all discharges between the hours of 11pm and 6am:

• All such discharges must have clearly documented rational by both medical and nursing staff as to the reason for discharge between these hours.

• Accurate discharge on PAS (Patient Administration System – SwiftPlus) is required to assure monitoring and reporting is accurate.

6.11. Out of Hours transfers of Patients with Dementia

6.11.1. In line with the South West Dementia Care Standards in General Hospital, the practice of transferring people with dementia and mild cognitive impatient out of hours (8pm to 8am) should only be undertaken for clinical reasons to benefit the individual. All unnecessary transfers need to be minimised and it is required that a DATIX incident report is submitted in these unnecessary cases of our of hours transfers (internal or external). Please refer to the RCHT Dementia Care Policy.

6.12. Self-Discharge

6.12.1. Please refer to the RCHT Trust Policy – Self Discharge of Adults Inpatient Policy.

7. Dissemination and Implementation 7.1. This Policy will be cascaded by Divisional Management Teams to their clinical areas involved in discharging adult patient from the Trust. Communicating and


sharing information within the policy at a local clinical level lies with the areas Ward or Department Sister / Charge Nurses, making all resources available to all relevant staff for implementation. 7.2. Training and Development requirement will be identified by local teams and accessible training is provided via the Trust’s Learning and Development Team.

8. Monitoring compliance and effectiveness Element to be monitored

The policy will be monitored for compliance to NHSLA standards and compliance with communications set out in this policy (use of CHA 2702 and 2938).

Lead Inpatient Ward Sisters and Charge Nurses. The individual wards

are responsible for monitoring their discharge and transfer of care performance. In addition, external review of the policy’s application in practice may be made by an external patient led group on behalf of the clinical commissioning group.

Tool Healthcare Record Audit Metrics uploaded onto QUANTA -Quality Care Indicator portal.

Frequency A sample of ten discharges from each inpatient ward each quarter will be audited to assess performance and policy compliance. Quarter 1 (April to June); Quarter 2 (July to September); Quarter 3 (October to December); and Quarter 4 (January to March).

Reporting arrangements

Quarterly each Division will receive performance data reported at ward level on each wards performance assessment frameworks, results will prompt local action to improve / maintain compliance.

Acting on recommendations and Lead(s)

Ward and if necessary Divisional level action plans would be developed to ensure that any short falls are addressed and monitored. The Divisional Nurse will take lead on monitoring ward and any divisional level action plan.

Change in practice and lessons to be shared

Inpatient clinical teams within each division will lead any process changes and share learning together.

9. Updating and Review 9.1. The policy will be kept under review by the Associate Director of Nursing, supported by senior colleagues across the Trust and wider health and social care community. At a minimum this will be reviewed each three years.


9.2. Any revision activity is to be recorded in the Version Control Table as part of the document control process.

10. Equality and Diversity 10.1.This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website.

10.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2.


http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/RoyalCornwallHospitalsTrust/OurOrganisation/EqualityAndDiversity/HumanRightsEqualityAndInclusion.aspx

Appendix 1. Governance Information

Document Title RCHT Adult Discharge and Transfer Policy v.5

Date Issued/Approved: 26-05-2016

Date Valid From: 26-05-2016

Date Valid To: 25-05-2019

Directorate / Department responsible (author/owner):

Frazer Underwood, Consultant Nurse / Associate Director of Nursing

Contact details: 01872 255043

Brief summary of contents

This policy is based on the guide from the Department of Health ’Ready to Go?’ and promotes ‘The 10 Steps’ essential in planning discharge and transfer of care. It presents the structured discharge process entitled to every patient in our care

Suggested Keywords: Discharge, Transfer of Care

Target Audience RCHT PCH CFT KCCG

Executive Director responsible for Policy: Director of Operations

Date revised: 26-05-2016

This document replaces (exact title of previous version):

RCHT Adult Discharge and Transfer Policy v.4

Approval route (names of committees)/consultation:

RCHT Discharge Operational Group RCHT Trust Management Committee

Divisional Manager confirming approval processes


Name and Post Title of additional signatories None

Signature of Executive Director giving approval Original copy signed

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder

Links to key external standards CQC Outcomes: 1, 2, 4, 6, 7,9, 14, 21 NHSLA Risk Management Standards 4.9, 4.10


Related Documents:

RCHT Guidelines for End of Life Care Discharge and Transfers RCHT Guidelines for transfers of patents back to the Isles of Scilly RCHT Policy on Clinical Record Keeping RCHT Trust Policy – Self Discharge of Adults Inpatient Policy RCHT Pressure Ulcer Policy RCHT Medical Devise & Equipment Management Policy RCHT Paediatric Discharge and Transfer Policy Multi Agency Safeguarding Adults Policy RCHT Mental Capacity Act Policy RCHT Patient Transport Policy RCHT Hospital at Night Policy RCHT Dementia Care Policy RCHT Clinical policy for safe transfer of patients between care areas or between hospitals RCHT The Medicines Policy

Training Need Identified? Yes

Date Version No Summary of Changes Changes Made by

(Name and Job Title)

Jun 09 v.1.0 Existing Policy: “Guidelines regarding the admission, transfer and discharge of patients from adult inpatient areas within RCHT “

Apr 11 v.2.0 New document developed and consulted on focusing only on discharge and transfer of care.


May 11 v.2.1 Small amendments made to meet NHSLA requirements

Beverley Hales, Clinical Site Manager

May 11 v.2.2 Further minor amendments Beverley Hales, Clinical Site Manager

July 11 v.2.3 Amendments to package of care re-start guidance (6.2.8), and minor amendments to Section 8 (titles, grammar)



Nov 11 v.2.4

Emergency Department Discharges (6.4), and RCHT Internal Transfer (6.5) section added. Additional information added to simple and complex discharge sections on escalating safe discharge concerns in and out of hours.

Kim O’Keeffe Deputy Director Nursing, Midwifery and AHP’s Frazer Underwood, Consultant Nurse / Associate Director of Nursing Beverley Hales, Clinical Site Manager

Dec 11 v2.4.1

Expansion of definitions/glossary; role of CNS for Adult Discharge added; revision of section 6.5 Internal Transfers section, to refer to new RCHT Guidelines for Critical Care Transfers; amendments to monitoring compliance section; addition of audit tool.


Dec 11 v2.4.2

Policy title change, the addition of “…and Transfer…”; expansion of definitions / glossary; role of CNS for Adult Discharge added; revision of section 6.5 Internal transfers section, to refer to new the RCHT policy for critical care transfers,; amendments to monitoring compliance section; addition of an audit tool in appendices.


April 12 v2.5

Strengthening of ED safe discharge section (6.4); Additional new section – Discharges between 11pm and 6am (6.7); Revision of audit tool; further minor amendments to maintain compliance with NHSLA standards.


Feb 13 v2.6

Transferred to new policy format; amendments to reflect the roll-out of electronic discharge systems (e-discharge) / and electronic prescribing; additional therapy and specialist nursing related elements included; revision of monitoring grid to reflect new compliance monitoring arrangements (audit tool removed).



All or part of this document can be released under the Freedom of Information

Act 2000

This document is to be retained for 10 years from the date of expiry.

This document is only valid on the day of printing

Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust

Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager.

June 13 V2.7

Revision of 6.5.3 to reflect Emergency Department to admission wards handover requirements; simplification of EDD recording sections; removal of DATIX requirement for discharges between 11am and 6pm (6.7.2) as an ineffective data collection method; and slight amendment to discharge flow chart (Appendix 3) reinforcing patient centeredness.


June 14 v.3

Tri-annual policy review. Service title changes e.g. Onward Care Team added and reference to the electronic referral system now in place for social services – eBICA.


May15 v.4

Major review of policy to incorporate internal and system-wide changes to the discharge processes and inclusion of county-wide Choices Framework.


May 16 V.5 Very minor changes e.g. renaming the quality indicator portal, after being operational for the last three months



Appendix 2.Initial Equality Impact Assessment Screening Form

Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence Age

Sex (male, female, trans-gender / gender reassignment)

Race / Ethnic communities /groups

Name of service, strategy, policy or project (hereafter referred to as policy) to be assessed: RCHT Adult Discharge and Transfer Policy v.5 Directorate and service area: Chief Operating Officer

Is this a new or existing Procedure? Existing

Name of individual completing assessment: Frazer Underwood

Telephone: 01872 255043

1. Policy Aim*

To ensure safe timely discharge of adult patients

2. Policy Objectives*

To ensure the Trust meets strategic and clinical best practice standards in delivering structured discharge planning

3. Policy – intended Outcomes*

That all adult patients are discharged appropriately and safely in consultation with the patient and or the carers

4. How will you measure the outcome?

Audit of the policy and feedback from patients and carers

5. Who is intended to benefit from the Policy?

All adult patients

6a. Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b. If yes, have these groups been consulted? c. Please list any groups who have been consulted about this procedure.

Yes consultation was completed with all senior nurses, discharge team and consultants

7. The Impact Please complete the following table.


Disability - Learning disability, physical disability, sensory impairment and mental health problems

Religion / other beliefs

Marriage and civil partnership

Pregnancy and maternity

Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian

You will need to continue to a full Equality Impact Assessment if the following have been highlighted:

• You have ticked “Yes” in any column above and • No consultation or evidence of there being consultation- this excludes any

policies which have been identified as not requiring consultation. or • Major service redesign or development

8. Please indicate if a full equality analysis is recommended. Yes No

9. If you are not recommending a Full Impact assessment please explain why.

Signature of policy developer / lead manager / director Date of completion and submission

Names and signatures of members carrying out the Screening Assessment

1. Frazer Underwood 2.

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust’s web site. Signed Frazer Underwood Date 26-05-2016


Appendix 3-Staged Process of the Choice Framework

Stage 1: Provision of information to patient stage • You should have been given a discharge information leaflet with your Estimated

Date of Discharge within 12 hours of admission. • A multi-disciplinary team meeting on the ward will agree a date with you where

you no longer need an acute bed (you become clinically stable for discharge). • We will then discuss this with you and offer an appropriate future care plan to

meet your assessed onward care needs as quickly as possible.

Stage 2: Daily patient review stage • If problems arise with your future care plan or planned discharge

arrangements we will meet with you to discuss them and consider alternatives to allow you to move on and for us to use you hospital bed appropriately for sick and unwell patients.

• If you decline the offered care arrangements, we will hold a discharge case conference with you to explore your reasons and agreed a new plan.

• At this meeting you will be given a maximum of 3 days to proceed with the new discharge plan.

Stage 3: Formal letter stage

• If you cannot arrange an alternative within the timescales identified in Stage 2, you will be given a formal Stage 3 choice letter setting out the next agreed actions and time scales

• The alternative discharge arrangements are agreed with you (this may not be your preferred choice) and a maximum of 3 days will be afforded for you to leave hospital

Stage 4: Formal legal notification letter stage • The Trust will start seeking legal advice as to your discharge plan at this

stage.

• You will be given details a Care Home to move to that can meet your on-going care needs and be given 48 hours to move.
