Hospital patient discharge [link]
Safe discharge planning of vulnerable adults [link]
Issues to consider when planning discharge for vulnerable adults [link]
Further considerations for the safe discharge of vulnerable adults [link]
Multidisciplinary team meetings (MDT) [link]
Continuing care [link]
Nurse-led or nurse-initiated discharge [link]
Professional and legal implications for nurses and allied health professionals (AHP) initiating discharge [link]
Intermediate care [link]
Further considerations for effective discharge [link]
Hospital patient discharge
Secondary care providers are required by legislation to have a notification and monitoring system in place so that social services departments are aware of key events and decisions affecting individual patients. They must provide an estimated date of discharge for each patient when they are admitted to hospital.
Planning for hospital discharge should start as early as possible and should be a process, rather than an event. The early identification of an estimated date of discharge and the monitoring of progress through a multi-disciplinary process is crucial.
The Community Care Act 2003
The Community Care Act 2003 introduced a system of reimbursement for acute beds that are occupied by people who no longer need to be there; if social services is solely responsible for the delay. The NHS and local authorities in England now have a duty to communicate about the discharge of patients. Communication should be between health and social care systems and include patients and carers.
The NHS is required to notify the local authority of any patients who are likely to need community care services on discharge (a section 2 notice), and of their proposed discharge date (a section 5 notice).
Reimbursement for delayed transfers of care relates initially to adult patients receiving acute care. Delays in mental health, learning disability and intermediate care services, and other non-acute services, such as community hospitals, are currently excluded from the arrangements, although the scheme may be extended to these areas in the future.
If a patient remains in hospital and the local authority is solely responsible for the delay (for example, delayed assessment or social care package), then the local authority must pay the NHS organization £100 per day (£120 in London and certain other parts of the country). This payment came into force on 5 January 2004.
The Community Care Act is intended to promote the independence of older people. Local authorities were provided with additional funding for investment in services for older people, and to help reduce the likelihood of delays, in partnership with their health colleagues. The aim is to improve services and to ensure that more people are cared for in the most appropriate setting, thus avoiding the need to pay reimbursement charges.
As the commissioners for health, PCT's are key to working with NHS bodies and local authorities in order to identify the main causes of delays, and to focus investments into those areas to reduce delays and the need for reimbursement. Many localities have entered into joint agreements on how any reimbursement monies paid will be reinvested into services for older people.
The regulations require that patients be screened for possible continuing health care at the beginning of the process.
Strategic Health Authorities have a specific duty under the act to establish Dispute Resolution Panels and appoint members to them.
Responsibilities of the nursing team
The nursing team co-ordinates the discharge process for patients with more complex needs, and ensures referrals to the multi-disciplinary team are made and co-coordinated. This includes issuing section 2 notices to social services for patients likely to need community care services on discharge.
The nursing team is responsible for initiating timely complex discharges, once the care package has been agreed and put in place.
They should ensure a section 5 notice is issued to social services, giving the proposed date of discharge, with 24 h notice, for those patients already notified under section 2. If a patient's transfer of care has been delayed, this should be jointly discussed with social services and their status jointly agreed, including who is responsible for the delay, before they are included in the weekly SITREP.
If social services are solely responsible for the delay they are subject to the reimbursement charges. Note: nationally about 67% of delays are for NHS reasons, not social services.
A training package on reimbursement is available at www.dischargetraining.doh.gov.uk
Safe discharge planning of vulnerable adults
A vulnerable adult is defined in No Secrets' as:
a person aged 18 years or over, who is in receipt of or may be in need of community care services by reason of ‘mental or other disability, age or illness and who is or may be unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation.
(See Chapter 34, ‘Safeguarding vulnerable adults’, for further information.)
There are often situations within the discharge planning process, where significant concerns exist about the potential for abuse, inappropriate care, self-neglect, or self-harm occurring after discharge to a community setting.
Circumstances may arise that raise significant concerns and may highlight the possibility of a discharge being unsafe. A ‘significant concern’ is based on professional judgement around health, safety, and well-being.
Health professionals have a clear duty of care to do everything within their power to prevent unsafe discharges. This chapter is intended to clarify decision-making around this difficult area, achieve consistent best practice, and address the governance risks posed.
Safe discharge planning case conference
When making decisions about discharge, it is good practice to hold a safe discharge planning case conference, involving the patient and their carers where appropriate..
Decision-making should be undertaken on a multi-agency basis, as social services are likely to be involved in ongoing monitoring of the home/care home situation after discharge.
The relevant social worker, community care manager and team manager should be present at the case conference. If any key professional is unable to attend, a verbal report should be obtained before the meeting. Ultimately, the decision to discharge rests with the doctor in charge of the patient's care. Discharge may legally be refused if the vulnerable adult lacks the mental capacity to make their own decisions regarding future care, and vulnerable adults may be retained in hospital under a duty of care (the common law doctrine of necessity).
Issues to consider when planning discharge for vulnerable adults
Concerns over mental capacity
If the vulnerable adult has the mental capacity to discharge themselves then discharge cannot be prevented. Every effort should be made—with partner agencies—to ensure appropriate service support and monitoring, to maximize the potential for a safe and successful discharge.
If the vulnerable adult lacks the mental capacity to make their own informed decision regarding discharge, the decision may need to be made on his/her behalf, and in consideration of what future care placement would be in his or her best interests.
If there is any doubt over mental capacity, a test of mental capacity should be undertaken by the healthcare professional in charge of the current episode of care, with a second opinion from a relevant specialist if necessary, to inform decision-making. (See Chapter 16 ‘Mental health’ for more information on capacity and consent.)
Alcohol and drugs
If the vulnerable adult is under the influence of alcohol or drugs, then the relevant person from the Drug or Alcohol Liaison Team (either community or hospital based) should be invited and involved in the case conference.
Mental Health Act
If the vulnerable adult is mentally ill and their current mental health symptoms are a cause for concern in relation to safe discharge, use of the Mental Health Act 1983 may need to be considered. This can prevent discharge, ensure that mental health needs are assessed, and that appropriate treatment is given. If the vulnerable adult is believed to be mentally ill, but has not yet had a psychiatric assessment, an urgent referral to a psychiatrist should be made. If discharge needs to be prevented to save life, an emergency referral to the psychiatrist on-call should be made without delay.
Nursing or medical needs
The nursing and medical needs of vulnerable adults will need to be reassessed when considering whether they could be met at home or in a care home, and what service inputs would be required to adequately meet them.
Appropriate clinical specialists/therapists should be involved in the assessments as appropriate, especially for high-risk areas, such as nutrition, medication, and mobility needs.
Family's capability or willingness to provide care
If the vulnerable adult is returning home to the care of a family member, then their capability to provide adequate care and their willingness to take on the role of care-giver should be considered. This should be established in a separate interview held before the case conference.
Any previous history of neglect or abuse by family members, or others in the home situation or within the care home needs to be considered. The opinions of professionals previously involved in care management should be sought before the case conference to inform decision-making. It is essential that the relevant Community Care Manager is present at the meeting.
The wishes of the vulnerable adult about their future care should be sought and considered. Any fears or concerns regarding discharge should be heard within the context of the case conference.
Ideally, an interview with the vulnerable adult should be held beforehand and fed back at the conference. Any disclosures the vulnerable adult makes regarding previous abuse should be referred under the Protection of Vulnerable Adults Policy, via the Divisional Manager for Clinical Throughput.
The case conference may also be used to discuss possible alternative placements to meet the vulnerable adult's identified needs. Any instances of alleged or suspected care home neglect or abuse should be referred under the Protection of Vulnerable Adults Policy, as above, via the Divisional Manager for Clinical Throughput to the Care Standards Inspectorate.
If the case conference cannot reach a unanimous decision, the following may be useful in obtaining further information:
• Home visit: this is usually done by an occupational therapist to assess the home environment and the risks that may be present; it should involve other clinical specialists or therapists as appropriate for identified risks. The visit may need to take place with a male escort, or a double-handed female visit may suffice, with mobile phone reporting in and out to base, according to the lone worker policy
• Shared care: carers and family could be invited into the care setting to assist or take over aspects of personal care under the supervision of appropriate members of the multi-disciplinary team
• Overnight stay or trial period: this could occur with intensive monitoring and reassessment, before final discharge is agreed.
No secrets: Guidance on developing and implementing. multi-agency policies and procedures to protect. vulnerable adults from abuse. Available at: www.dh.gov.uk
Further considerations for the safe discharge of vulnerable adults
The opinions of the professionals present at the case management meeting, and the decisions or agreements made should be carefully recorded in the case notes. Minutes of the meeting should be taken and held in the patient's record. Full documentation is crucial, and may be protective against litigation.
Informing the family
A decision not to discharge should be conveyed in writing to the family by the consultant in charge of the vulnerable adult's care. The carers should be given a formal opportunity to discuss the decision in a carer or family meeting.
The letter should state that any appeal regarding the decision should be addressed to the consultant, not the nursing staff or other professionals. The family or carers should be informed in the letter of their right to complain about the decision or about broader care issues.
The trust's complaints procedure should be followed.
If family members arrive in the care setting demanding to discharge their relative against medical advice, they should be asked to leave, and be advised to address their complaint or concerns to the consultant in charge of care.
If they refuse to leave the care setting or if they attempt to abduct their relative, security and the police should be called to remove them, or to retrieve the vulnerable adult. The protection of adults' policy should be automatically invoked following abduction and a strategy meeting involving the police should be held at the earliest possible convenience. Such an event should also be clearly documented and a critical incident form completed in the usual manner.
If family members become vexatious and disrupt the vulnerable adult or other patients, restricted visiting may become necessary. This should be contracted with the family, and the timing, frequency, and location of supervised visits agreed. Requests for restricted visiting should be addressed to the relevant manager. The next of kin/carers should be informed in writing of any decision to restrict visiting.
Trust legal department
In complex cases, for example, where a complaint or litigation exists, or is anticipated, it may be useful to obtain the support of the trust's legal department regarding actions taken and decisions made. They can also refer the situation to the trust's solicitors if necessary.
NHS continuing care criteria
Where the vulnerable adult has been retained in hospital under a duty of care, but does not meet NHS continuing care criteria, an alternative placement may need to be found using appropriate legal powers. If voluntary placement is not possible, legal advice should be sought and a separate meeting held.
Accident and emergency unit
If a vulnerable adult is treated in an accident and emergency unit, and there are significant concerns regarding safe discharge planning, the person should not be discharged until further investigations occur.
The vulnerable adult should be admitted to a place of safety, such as a hospital, nursing, or residential home, according to their medical or social care needs. Discharge would be negligent if serious concerns are present.
If the decision is made to go ahead with discharge against advice, e.g. if the vulnerable adult is assessed as having capacity to make an informed decision and wants to leave, but concerns are still present, key professionals should be alerted to the planned date of discharge as soon as possible, so that effective strategies can be put in place. The involvement of the Community Care Manager from the outset is crucial in follow-up monitoring and in planning community services care.
Multidisciplinary team meetings (MDT)
It is the responsibility of the ward manager or nurse to ensure that the following arrangements are in place when MDT meetings occur:
• The time, duration, venue, chair, method of recording, and list of participants is agreed and recorded
• Arrangements for absences through representation or report are agreed and recorded
• Arrangements are made with professional groups who may not be able to participate on every occasion, such as therapists, to ensure that their contribution is assured.
The role of the MDT meeting
The MDT meeting aims to:
• Consider the situation of each patient on the ward at the time
• Consider for those patients who are subject to a section 2 notification, whether the notification should continue or be withdrawn
• Discuss the actions and tasks needed to progress the patient through their care/treatment/discharge or transfer process, and allocate responsibility with agreed timescales
• Problem solve and provide solutions, anticipating the variety of issues and difficulties that may be involved in complex discharges, and involve patient and carers
• Take account of the timescales involved in providing social care, to anticipate events in the discharge process
• Review the estimated date of discharge
• Ensure that all professionals involved in the care of an individual patient agree to their discharge in writing
• Ensure that the patient is fully involved in their assessments and discharge
• Agree the timing of the completion of notification form section 5 to social services, when the patient is medically fit and systems are in place for a safe discharge.
The issue of section 5 is a team decision.
• Assessment notification before 2 p.m.: starts minimum 3-day period from the same day
• Assessment notification after 2 p.m.: starts minimum 3-day period from the next day
• Discharge notification after 5 p.m.: treated as having been given the following day
• Pre-11 a.m. discharge of patient: equivalent to the previous day.
Legislation requires that the local authority will be liable to make delayed discharge payments if:
It has not been possible to discharge the patient because and only because, the local authority has not made available for the patient a community care service
The local authority has a responsibility to carry out an assessment of need with a view to identifying any community care service needed to facilitate a safe discharge.
The act of carrying out an assessment does not place a duty on the local authority to meet every assessed need. It will make a judgement as to which needs it considers essential, and which are required to minimize risk to the person and will meet these needs. These judgments will inform the final support plan.
Continuing care means care provided over an extended period of time to a person aged 18 or over, to meet physical or mental health needs that have arisen as the result of disability, accident, or illness.
NHS Continuing Healthcare means a package of continuing care arranged and funded solely by the NHS. The actual services provided as part of this package should be seen in the wider context of best practice and service development for each client group.
A person who needs continuing care may require services from NHS bodies and/or from local authorities. Both have responsibilities to ensure that the assessment of eligibility for and the provision of continuing care takes place in a timely and consistent fashion.
If a person does not qualify for NHS continuing healthcare, the NHS may still have a responsibility to contribute to that person's health needs. This is sometimes known as a joint package of continuing care. The most obvious way in which this is provided is by means of the Registered Nursing Care Contribution, in a care home setting, but there are many other models.
NHS continuing healthcare may be provided by PCT's in any setting including, but not limited to, a care home, hospice or the person's own home. Eligibility for NHS continuing healthcare is not determined or influenced either by the setting where the care is provided, or by the characteristics of the person who delivers the care. It is determined by the person's need.
The decision-making rationale should not marginalize a need because it is successfully managed: well-managed needs are still needs. Only where the successful management of a healthcare need has permanently reduced or removed an ongoing need, will this have a bearing on NHS continuing healthcare eligibility.
Nurse-led or nurse-initiated discharge
There are no legal or professional reasons why nurses or allied health professionals (AHP) cannot take on more responsibility for the discharge process, including the decision to discharge. They can assess the patient, liaise with the multidisciplinary team, and plan a timely discharge based on the agreed clinical management plan. They can also write discharge letters, make follow up calls, and give advice to patients, carers, and other health and social care professionals involved in the person's care.
The Department of Health workbook Discharge Planning: pathway, process and practice was revised and reissued in 2003. It is aimed particularly at people with complex needs, where ward based staff will need extra help in discharge planning.
The discharge decision: questions to ask
• Has a date of discharge been estimated and documented?
• Has the patient been involved or informed?
• Is the patient clinically stable and fit for discharge?
• Have transport arrangements been made?
• Are there clothes for discharge and keys on the ward?
• Have the relevant tablets been dispensed, and their purpose and regime explained to the patient?
• Has the GP, district nurses, and carers been involved/informed?
• Has an outpatient appointment been made and given to the patient?
• Is the transfer time to the discharge lounge agreed?
• Has the patient been given information about self-care and do they know who to contact if the symptoms return?
• Has the patient been given a hospital sick certificate if required?
Professional and legal implications for nurses and allied health professionals (AHP) initiating discharge
Overall legal responsibility for a patient's care remains with the named consultant during admission, stay, and discharge. However, the consultant can delegate responsibility to an appropriately qualified health professional.
When a task is delegated, the consultant/lead clinician assumes responsibility for delegating appropriately. The person to whom the responsibility is delegated takes on the commitment, and the responsibility for carrying out the task in a responsible, accountable, reasonable, and logical manner in keeping with their own professional code of conduct.
The consultant/lead clinician should always make sure that the person taking on the responsibility has the appropriate knowledge and skills. Where nurses and allied health professionals are taking on this responsibility, clear competencies and training should be developed (see list below).
The person to whom responsibility is delegated should be aware that they are accountable for all their actions. There should be clear lines of communication between the consultant/lead clinician and the health professional discharging the patient, so that they are accessible for advice when necessary.
It is recommended that the parameters of clinical/medical stability for each individual patient are agreed with the consultant or lead clinician, and recorded on a locally developed form or documented in the patient's healthcare record. This form should be completed on admission or as soon as is reasonably practical (written reasons should be given for any delay), and be subject to ongoing review. Each review should also be documented on the form within the patient's notes. The patient should be told about the content of this form, and kept up-to-date, in line with the principles of informed consent.
The nurse or AHP initiated discharge should begin only when the person responsible for discharge is confident that the patient's condition falls within the agreed parameters (see above). There should be provision on the form for confirmation that the parameters have been met. It is vital that each step of the process is documented fully and precisely. Every decision must be capable of scrutiny. Everyone involved in the discharge process must be prepared to provide a rationale for their actions.
Competencies should include (but not be limited to) knowledge of:
• The principles of informed consent
• The Human Rights Act
• The Data Protection Act
• The Community Care Act
• Professional codes of conduct.
What is intermediate care?
Intermediate care is a setting that provides a safe environment in which the patient can recover and/or participate in an individualized rehabilitation programme, to ensure a safe discharge home.
Intermediate care may be considered once a patient's treatment in hospital is complete and the clinical team feels that they are medically stable, but not quite ready to go home. Such patients may require further time to recover or may need to participate in a rehabilitation programme.
Who needs intermediate care?
• Patients who have problems with reduced mobility, following injury or illness, and who require therapy and/or confidence building to support their return home
• Patients who need to recover following illness or an operation, but who do not require an acute setting (this may also include people living in the community).
Further considerations for effective discharge
• The home loans service provides a wide range of specialist equipment to people in their own homes. Early referral prevents delay
• Eligibility for specialist equipment is based on needs as assessed by an appropriate therapist or clinician
• Specialist equipment is usually provided for a period of less than 6 months. If it is needed for more than 6 months application can be made to the continuing NHS health care facilitator.
The ward staff are responsible for ensuring that referrals to the appropriate agencies are made as early as possible. Consider the following issues for your patients when there are no identified nursing needs:
• No fixed abode
• Housing or environmental issues
• Patients or carers refusing discharge
• Decreased functional ability
• Mental health needs that may affect the potential for independent living
• Abuse of self or others
• Respite care
• Not registered with a GP.