Transfers of Care
Cardiff and Vale Health and
Social Care Community
Contact: Tanya Balch
Transfers of Care
• The transition between services should be
seamless for the person and this can only
happen where information is shared with the
accepting service (Exchange of information
between health and social care)
• Provision of dressing or other essential
equipment has been arranged and
documentation follows the person
• Information from discharging service to receiving
service.
Health
Local Authority
Specialist Training Available
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CHC Carol Preece
CPA
Lawrence Doyle
POVA Simon Williams
MCA Dorian Davies
FACS Dave McManus
e.learning DOH website discharge training
tool
• ‘Passing the Baton’ NLIAH website
Admission To A Service
Contact using the Enquiry
• In community
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GP
District nurses
Social workers
Community psychiatric nurses
• Admission to hospital
» Elective admissions
» Emergency admissions
» Ambulance staff
Simple /Complex
• 80% discharges are considered to be
simple
• A simple discharge is one where the
person is to return to their home or
previous residence with simple or no
ongoing health needs that can be met
without complex planning
•
Mr Lewis demographics
Simple or Complex Discharge
• Prior to the PDD it is essential to consider
all options regarding the discharge
destination
• Is the discharge simple? (may not require full unified
assessment)
» could be protocol led
» May require no follow up services
» May only need simple hospital discharge services
Baseline Assessment
• Baseline assessment is the initial picture of the person
• Requires a collection of information regarding the persons
presenting concerns and their ability to manage the activities of
living independently
-these may be health or social related
• Will identify areas where a more in depth assessment is required
prior to discharge
• Do their needs require the service that they have presented to? If
not then redirect appropriately
• If the person has been referred to the appropriate service then a
decision to admit needs to be made and the reason for admission
evident
Mr Miller baseline assessment
Treatment / Care
• Admission to a service implies that a need has been
identified and that there is a treatment plan or care plan
• All treatment or care plans have goals and with these in
mind it is possible to set predicted discharge dates
(PDD’s)
• A PDD is not a fixed date only a date which to goal plan
to, if needs change or treatment alters then the PDD can
be amended and will be a review date
Mr Miller discharge planning log1
Coffee
Mrs Orange Admitted With Confusion
• Cause of confusion is identified as UTI. A few days later
when treatment is under way Mrs Orange is mobile
around the ward and only needs some prompting to
carry out all her own care independently
• The medical team inform the staff that Mrs Orange can
go home, this is planned for the following day.
• That evening Mrs Orange daughter arrives on the ward
and when the nurse informs her that her mother is going
to home she is not very happy , she tells them that her
mother is not safe to be discharged as she lives alone
and is becoming increasingly confused
Risk Management
• There are risks in everything that we do
• All of us identify the risks around us an make choices
about what level of risk we are prepared to accept
• In assessing a persons needs we are required to identify
where a person has risks
• In the planning of their future needs we need to identify
how those risks will be managed
• A person with capacity has the right to make choices
about the level of risk they are prepared to accept
• Planning services for a person in hospital needs to
consider the circumstances and risks at home as well as
in the hospital intermediate car environment
Mental Capacity
• In planning an individuals treatment and care a person has a human
right to be informed and consented.
• The Mental Capacity Act means that we are no longer able to rely on
a single decision as to a persons capacity to make decisions.
• Each interaction should be considered as if the person was lucid
and understands what is said or happening to them.
• At each stage of care and with every decision made there should be
evidence to show efforts made to accommodate the persons
expressed wishes
• Only where another person has lasting power of attorney do they
have the right to make decisions on the persons behalf
Simple or Complex
Discharge
• Is the discharge planning complex?
Requiring a complete unified assessment
• A complex discharge is one where there may be
several agencies, family members involved in the
discharge plan and arrangements are complex
and inter dependant
• May require a series of goal / discharge planning
or review meetings
Continuum For Funding
Continuing Healthcare
NHS responsible for funding all care required
NHS funded nursing care
NHS via local health board fund nursing
element of care in a nursing home
Fair access to care criteria
Local authority have a responsibility for
funding care but this is means tested
Voluntary services
Comprehensive Assessments
• Where a persons needs are complex a full comprehensive
assessment will be required (completion of all domains of unified
assessment)
• The risks or likelihood of risks to the person or others in carrying out
-the activities of living must be identified
-harm to/from others
-Ability to make choice
-Ability to be involved with others
• Once completed the assessment should be signed and dated and it
will provide the evidence needed to determine eligibility for
– continuing health care
– Registered nursing care contribution
– local authority packages of care
Undertaking a comprehensive
assessment of need through
Unified Assessment
Carol Preece
Continuing Care Manager
Cardiff & Vale NHS Trust
Aims of the Session
• Increase knowledge and understanding of
Continuing NHS Health Care, NHS funded
Nursing Care and FACS through the use
of Unified assessment as a single tool.
• Understand to process to be followed
Current process
Patient information
Stored on Trust
Nursing Documentation,
medical Notes and
therapy records
Continuing NHS Health
Care
NHS Funded Nursing
Care
FACS
Continuing NHS Health Care
A situation where an individual has been
thoroughly assessed by a multidisciplinary team and judged to have
overall health needs that are so significant
that the NHS will manage and pay for all
the care they need.
When will an individual be eligible
for Continuing NHS Health Care
Following a comprehensive assessment
eligibility will depend upon the nature,
complexity, predictability and intensity of
an individuals health care need and health
input they require, regardless of diagnosis.
The Assessment Process
• At a minimum the MDT will consist of at a
minimum of a Consultant/GP, Nurse and Social
Worker
• An Appropriate validated assessment tool will be
used.
• Patients and their carers must be fully aware
and involved in the process.
• Family will be aware of who is co-ordinating the
assessment and this documented in the notes.
Cont.
• CHC information should be provided to facilitate
effective patient/carer involvement.
• It should be made clear that eligibility for CHC is
subject to reassessment, and an individual can
move in and out of eligibility
• It must be made clear that their changing
healthcare needs could impact on how their care
is funded.
Applying the Criteria
• The Matrix was developed by WAG to
facilitate the process
• This assessment tool is not prescriptive
but a guide to assist staff in relation to
individual eligibility for CHC.
• In all cases the overriding determination of
eligibility is an individuals Health care
needs. Not their illness or disability.
Recording the Decision
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Patient/Client records
Care plan
UA summary record
Formal record of the MDT
The Decision and the rationale on which the
decision is based should be clearly recorded
and signed.
• The patient will be informed of the decision and
reasoning verbally and in writing.
Service Provision in Cardiff & Vale
NHS Trust
General – West Wing
- St Davids Hospital
- Barry Hospital
Mental Health – St Davids Hospital
- Whitchurch Hospital
- Barry Hospital
Service Provision (cont.)
Community
24 hour District nursing Service
Up to a maximum of 5 visits in 24 hours
Night Sitting Service, twice weekly
Speciality
Neurosciences – Rookwood Hospital
Placement under CHC
• First instance access to in-patient bed
• Exceptional circumstance Nursing Home
• Nursing Home funding has to be provided
by LHB where individual resides
• CHC can be provided in the community
• Needs over and above core service has to
be costed and presented to LHB.
Reviewing Eligibility
• Policy suggests an initial review within three
months at a minimum six monthly, thereafter or
more regularly dependent on their assessed
needs.
• Review should follow the same process as
original assessment.
• Outcome to be clearly documenteddemonstrating what has changed since last
assessment.
Appeals
• The patient or their representative has the right
to ask for and independent review of the CHC
decision.
The purpose of the review is:
• Ensure that the proper procedure has been
followed in reaching a decision
• To ensure the eligibility criteria has properly and
consistently been applied.
The appeals procedure does not apply when
patients/families which to challenge
• The Content, rather than the application of the
Local Health Boards Eligibility criteria.
• The type and location of an offer of NHS funded
Continuing Care Service.
The NHS Trust must deal quickly (ideally within 2
weeks) with any verbal or written request to
reconsider decision about eligibility.
Stage 1 – Informal Resolution
• Undertaken by Continuing Care Manager
Trust/Case Manager
• This should provide individuals involved
with an opportunity to discuss their
concerns
• Ensure that the proper process has been
followed.
Stage 2 – Formal Review
• The Senior Nurse Assessor/Continuing Care
Manager in the LHB will co-ordinate the Review
process.
• Writen Consent (5 Days)
• LHB orward request to the chairperson of
Independent Reivew Panel
• Chairperson will decide on convening a panel
• Outcome (within 2 weeks).
Problems
• Lack of understanding about the process
and information required.
• Time
• Poor quality data in care
plans/documentation
• Lack of individual/family involvement
• ombudsman
Funded Nursing Care
• Nursing homes registration etc
Funded Nursing Care
Your Involvement
What do we require ?
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Baseline
Unified Assessment
All pages signed and dated as usually faxed through to us
Consideration of Continuing Healthcare
Proforma from Social Worker
Identification of funding i.e. LA/Self funded
Nursing Home placement identified
Nurse Assessor Role
• Agreement of FNC for Nursing Homes prior to
placement
• 3 monthly assessment post placement
• Yearly reviews
• Continuing Healthcare assessments for any
Service Users identified as having triggers.
• Advice to Residential but mainly Nursing Homes
Links with Homes
• Providing link nurse advice and support to
care homes in the Vale of Glamorgan area
• Training as required i.e. Nutrition or
identified training needs in the Care Home
• Involvement with Carvale (Cardiff and Vale
Matrons Forum)
POVA
• Reporting any concerns to Vulnerable
Adult team via VA1 form
• Ensuring that care being provided in the
care homes is to a standard expected by
the LHB commissioning team
• Reporting any concerns to line
management
Protection Of Vulnerable Adults
• Whatever plans are put in place for a service user we
have a duty to identify those at risk and to not put them
at further risk by acts of neglect or omission
• Where we have knowledge of any POVA issues they
should be discussed with the POVA team
• Where the POVA team are involved with an investigation
this is confidential, however they will inform the MDT of
any decisions that will affect care or discharge planning
• Involvement of the POVA team should not stop the
patients pathway and discharge
FACING FACS
FAIR ACCESS TO CARE SERVICES
ELIGIBILITY FOR ADULT SOCIAL CARE
David McManus
Service Manager, Cardiff Council
What is Fair Access to Care
Services?
Every local council in the UK uses a national framework from the
Department of Health to decide eligibility criteria for the adult social
care services it provides.
The aim is to have greater consistency across the country on how
decisions are made about whether people have services or not.
What is the framework?
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Nationally and locally the evidence is that people’s highest priority is
keeping their independence. Government guidance puts the risks to
independence, if needs are not met, in four bands - critical, substantial,
moderate, low.
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Councils are allowed to decide whether they have enough resources to
provide help for people in all four of the bands, or just for some of them.
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In Cardiff, and the Vale, we provide services to people in the critical and
substantial bands. We call these two bands our “eligibility criteria”.
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People in the moderate and low bands do not meet our eligibility criteria
and so will not get a service. We will still provide information and advice on
other sources of help.
What is the framework?
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Judging whether someone is eligible or not is a risk assessment.
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Assessing an individual’s circumstances, strengths and abilities, problems,
and related risks, are the basis for determining an individual’s eligibility.
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It is only when someone’s circumstances impacts negatively upon their
independence, within the eligible banding, will it result in the person
receiving help.
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It is the effect of a condition or circumstances upon independence, not
simply the presence of it.
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What is needed to remove, or help manage the risk, will define eligible
need.
Four Categories of
Independence
• Autonomy – ability to make own choices and take own decisions.
• Health and Safety – freedom from harm, abuse and neglect and
taking wider issues of housing and community safety into account.
• Daily Living – ability to manage personal and other daily routines.
• Involvement – ability to participate in social, family
leisure, work, educational, life
FACS ELIGIBILITY CATEGORIES
OF RISK
LOW RISK – where there is a need for minimal help including the
provision of information.
MODERATE RISK – someone beginning to struggle to meet need, and
may require some help, or manages but with difficulty.
---------------------------------------------------------SUBSTANTIAL RISK– someone who is not able to be manage a need
without assistance
CRITICAL RISK– someone for whom there would be extremely serious
consequences if a need was not met
The Matrix
FAIR ACCESS TO CARE
SERVICES
Severity
Likelihood
Negligible
Unlikely
Medium
Severe
Extreme
L
L
M
M
L
L
S
S
Likely
L
M
S
C
Highly Likely
L
M
S
C
Quite unlikely
L = Low M = Moderate S = Substantial C + Critical
The thinking process
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What is the issue or difficulty? (e.g. unable to remember to take medication)
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What will happen if the issue is not addressed? (Risk)
(symptom control fails – health deteriorates rapidly)
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How likely is it that this will happen?
(every day – highly likely within a few days)
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What will be the severity if it does happen?
(will need medical attention, could precipitate hospital admission – extreme)
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How far does that impact upon independence?
Impacts upon all four aspects.
Using the matrix, highly likely and extreme = CRITICAL
FACS Critical Risk = Life is or could be threatened
Recording
• Information written in Domains should
follow the ‘thinking process’. Information
needed by social care is not just a
description, but an evaluation of what the
issue or difficulty is, what risk this
presents, and likelihood and severity.
Goal Planning and Reviews
• Achievement of goals means the person needs
a review and may no longer need the service
• If goal planning has been effective the review
date will coincide with the date the person is fit
for transfer of their care
• A person completing treatment with one service
may just be starting it with another
» e.g. when discharged from hospital to home.
Discharge/ Review
• A discharge planning meeting,
documented on discharge planning Log 2
should be held with MDT and patient
/family to confirm discharge date and that
all aspects of future care are in place to
make a smooth transition of care
• A transfer/discharge letter should be
forwarded to all that will be involved in
future care provision
Lunch
Multi Disciplinary Teams
Responsibilities
• A well functioning multi disciplinary team will ensure that
it clearly identifies what is required and by whom in the
discharge plan
• Timescales can be set by the multi disciplinary team
dependant on realistic goals and clearly documented
• Patient and family members also have responsibilities in
achieving the discharge plan (choice protocol)
• The multi disciplinary team should recognise and advise
on the need for independent Advocacy to support service
users
• A care coordinator should be identified
Discharge Liaison Nurse
The discharge liaison nurses role is to
facilitate the safe and timely discharge of
patients
• By having expert knowledge of process
and documentation
• By being able to support and educate staff
to provide effective discharge planning
• In case management and coordination of
specific individual cases
Case study Lucy Davey
• Mrs Davey is due to be discharged but then extends her stroke 2 days
before discharge. the doctors advise her daughter that next few days are
critical and she may not survive.
• 2 weeks later Mrs Davey is still with us physically she is immobile, doubly
incontinent she requires assistance of 2 to provide any care, move her in
bed or transfer her to chair although this has been avoided as there is a high
risk of falls. Mrs Davey cannot communicate very well she ties to speak but
cannot make herself understood most of the time and this seems to lead to
frustration and resistance to care but is variable according to which nurses
are looking after her. Mrs Davey was stopped from eating a drinking for a
week as her swallowing was compromised however she is now eating a
pureed diet and has had no difficulties but does require feeding by staff or
her daughter
• As Mrs Davey is now stable she no longer needs to be in hospital and a
discharge plan is required. An MDT decision making meeting is arranged for
2 weeks time
What information you will require to ensure the meeting is able to make
decisions about Mrs Davey’s future care.
Hold a meeting and make a decision as to Mrs Davey’s eligibility for CHC,
where suitable discharge may be to and what actions will be required to
enable this transfer of care
Delayed Transfers of Care
June 2008
Cardiff 82
Vale 30
Out of Area 9
Delays are categorised and
need to be supported by
documented evidence
Social care
Health
Dispute
Choice
Delays reported
Cardiff and Vale
NHS Trust
2005
206
2006
174
2007
160
2008
121
Flowchart
1.Admission (enquiry)
2. Referral/ request for involvement
3. Commencement of Unified Assessment by Domains
ESCALATION MAY BE REQUIRED BETWEEN THESE TWO STAGES
4. Discharge Planning Meeting
5. 48hrs prior to discharge
6. DISCHARGE
Effective Discharge Planning
Can;
• Reduce length of stay
• Increase patient satisfaction
• Reduce delayed transfers of care
Resources To Support
Hospital discharge service (Age Concern)
Advocacy-Good neighbour scheme - welfare rights
Care and repair - Placement advisers
District Nurses
Joint Equipment Store
Reablement Teams
Cardiff Local Authority Resource Index
Cardiff And Vale Acute Response Team
Community Palliative Care Team