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Hampshire Hospitals NHS Foundation Trust. Managing Complex Discharge Policy – HH(1)/CL/729/16 Due for latest review August 2019. CHECK THE INTRANET FOR THE LATEST VERSION

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Managing Complex Discharge Policy – HH(1)/CL/729/16

Previous document(s) being replaced

Location Policy No Policy Name

HHFT HH(1)/CL/729/15 Choice on Discharge

Document Summary

This joint operational policy has been agreed by Southern Health NHS Trust and Hampshire County Council, and Hampshire Hospitals NHS Foundation Trust. The policy aims to support patients to transfer from the Trust at the appropriate time, and describes the process by which choice of discharge destination for an individual (and/or their representatives’) will be managed.

Ownership Author Alison Whitehorn

Job Title Discharge Improvement Lead

Document Type Level Level 1

Related Documents Document Details Complex Discharge policy

Relevant Standards CQC Outcome 1

Equality Analysis Completed by Sandra McArdle

Date Completed 16 November 2016

Final Document Approval Committee Policy Approval Group

Date Approved 21 November 2016

Specialist committee(s) recommending approval

Committee(s) N/A

Date Recommended

Final Document Ratification

Committee Executive Committee

Date Ratified 24 November 2016

Authorisation Authoriser Mary Edwards

Job Title Chief Executive

Signature

Date Authorised 1 December 2016

Dissemination Target Audience Clinical, Managerial and Administration staff who manage discharge planning on a day to day basis

Dissemination and Implementation Plan

Action Owner Due by

Publicise detail of new document via intranet and Midweek message

Communications Team Within 10 days of publication

Communication advising publication to all senior managers

Healthcare library, BNHH On publication

Publication of policy on intranet Healthcare library BNHH Within 10 days of publication

Review Expiry date 21 November 2019

Review date 21 August 2019


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Document Control – Document Amendments

Version No. Details Key amendments to note By whom Date

1.0 Align trust with national best practice

Based on partnership template policy to align with best practice

Gill Massey and Tracy Knatt

September 2016

V1.1 Updated to align with system wide approach (HIOW)

Rewritten to align with national guidelines

Alison Whitehorn

October 2016


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Template prepared by: Partnership of organisations listed in co‐branding with support from others from across the health and social care sector. First published: 23 March 2016


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SIGNED BY LEAD OFFICERS

Organisation Designation Signature

North Hampshire CCG representative

Chief Operating Officer

West Hampshire CCG representative (includes continuing healthcare)


Hampshire County Council Director Adult Services

Southern Health NHS Foundation Trust


Hampshire Hospitals NHS Foundation Trust



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Contents 1. Executive Summary ............................................................................................................ 6

2. Introduction ........................................................................................................................ 8

3. Purpose ............................................................................................................................... 8

4. Scope .................................................................................................................................. 9

5. Explanation of Terms ........................................................................................................ 10

6. Duties ................................................................................................................................ 11

7. Managing Complex Discharge .......................................................................................... 13

8. Managing the Discharge Plan – Choice, Availability and Interim Care ............................ 14

9. Principles of Discharge Management ............................................................................... 15

10. Detailed Guidance ............................................................................................................ 17

11. Stakeholders Engaged During Consultation ..................................................................... 24

12. Training ............................................................................................................................. 25

13. Consultation and Approval Process .................................................................................. 25

14. Monitoring Compliance and Effectiveness ....................................................................... 25

15. References ........................................................................................................................ 26

16. Associated Documentation .............................................................................................. 26

17. Contributors ...................................................................................................................... 26

Appendix A – Equality Analysis Form ....................................................................................... 27

Appendix B: Documentation to be issued (Factsheet A, Letters 1, 2, 3, 4 and Appendix 1 – Choice ) .................................................................................................................................... 29

Appendix C: Hospital Discharge and Mental Capacity Issues .................................................. 37

Appendix D: Summary of Legal Responsibilities and Rights .................................................... 39


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1. Executive Summary This policy defines the process that North and West Hampshire based NHS trusts and local authority adult social care departments will follow to manage complex discharge planning throughout a person’s inpatient stay, at the point they no longer require inpatient care. The overarching aim is to reduce delayed transfer of care through early engagement, support and the implementation of a fair and transparent escalation process. This policy is adapted from a national policy approach with page 3 indicating the organisations which have informed. The six stage complex discharge process is summarised below: Stages 1 to 3 apply to all patients to provide support and prevent the need for further escalation:

Stages Actions

Stage 1 Information provided on admission (Factsheet A)

Stage 2 Assess likely care needs on discharge (Letter 1)

Stage 3 Offering options and preparing for discharge (Letter 2)

Stages 4 to 6 represent the formal escalation process:

Stages Actions

Stage 4 Available care declined (Activate Stage 4 Choice on EPR)

Stage 5 Formal meeting and formal letter (Letter 3)

Stage 6 Legal process and formal letter ( Letter 4)

Final Stage Eviction from the Trust

Further detail is set out below.

Six Stage Complex Discharge Process and Actions When

Stage 1: Discuss discharge planning with individual and/or representative before or shortly after admission. Identify MDT member responsible for co‐ordinating discharge (named health or social care professional to contact about plans). Give standard information (Factsheet A) to individual and/or representative.

Stage 1: Information provided on admission (page 17)


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Print and complete choice audit tool (Appendix B) and keep within medical notes.

Stage 2: Refer individual to services as needed, e.g. another hospital, social services, or NHS Continuing Healthcare (CHC) when patient is ready to have needs assessed for discharge.

Give Letter 1 which explains the assessment and discharge process. Complete choice audit tool (within medical notes).

Stage 2: Assess likely care needs As soon as possible after admission (page 18)

Stage 3: Discuss discharge plans with individual and/or representative regularly. Ensure assessments of care needs are complete. Explain to individual and/or representative that they will need to accept an available discharge option, either as an interim or permanent plan. Ward Manager/Deputy and CHC or social care professional to jointly offer patient and/or representative at least one option.

Give Letter 2 which explains the offer of discharge option as they no longer need acute care. Complete choice audit tool (within medical notes).

Stage 3: Offering options and preparing for discharge Before EDD (page 20)

Stage 4: If individual and/or representative are reluctant to accept option/s offered, Ward Manager and CHC or social care professional discuss concerns and encourage them to reconsider. Confirm rationale for transfer to alternative or interim option if their preferred option is not available.

Activate the EPR‐review Stage 4 Choice. Escalate to Complex Discharge Team Lead and Ward Manager/Matron to agree urgent date (within 24 hours) for formal meeting if discharge plan still not agreed or concerns remain. Inform lead Consultant. Complete choice audit tool (within medical notes).

Stage 4: Available care declinedWithin 5 working days of EDD (page 21)

Stage 5: Continue to give information and encouragement to access support to individual and/or representative. Hold formal meeting with individual and/or representative supported by Complex Discharge Team Lead & Lead Clinician. This will be held even if declined by individual and/or representative.

Give Letter 3 describing what was discussed, follow‐up arrangements made, and the rationale for transfer to alternative or interim care. Complex discharge team Lead to notify Trust Legal team of Stage 5 situation. Complete choice audit tool (within medical notes).

Stage 5: Formal meeting and letter Hold formal meeting within 24 hours (page 22)

Stage 6: If transfer arrangements are not accepted, complex discharge team lead to escalate to OSM. They will meet the relevant Senior Manager from the agency leading discharge, and

Stage 6: Legal consult Five working


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consult Trust legal team regarding any legal proceedings concerned.

Give letter 4 to individual and/or representative to explain that discharge to the identified temporary alternative/interim option will go ahead in line with the policy, before instigating discharge.

days post the formal meeting (page 24)

Compulsory Discharge: If final discharge arrangements are not adhered to, Matron and Senior Operational Manager will escalated to Senior Clinicians and formal legal proceedings.

OSM supported by ADO to consult with Trust Solicitors to enact compulsory discharge.

Compulsory Discharge As soon as possible after stage 6

2. Introduction Reducing both individuals’ length of stay in hospital and delays in discharge results in improved health related outcomes and quality of care, and as such, is an important focus within the NHS nationally and also within the local health and social care system. Such improvement requires a close working partnership with other organisations, including primary care, hospital services, social services, voluntary services and the private sector. The purpose of a properly planned discharge from an acute hospital bed is to ensure that an individual can function as independently as possible in a safe and supported environment with no or minimal deterioration in quality of life. Appropriate alternative arrangements have to be made should the individual be unable or unwilling to return home. When a person is fit for discharge (as defined by the “Relevant Day” as per the Care Act 2014) and safe for transfer, they should have already considered (where appropriate) provision for their on‐going care needs. This relies on clear communication between the individual and their family or representatives, the ward and the multidisciplinary team. It is essential that individuals access alternative care and support services in a timely way to ensure the NHS can make acute hospital services available to those who require them. This policy has been produced to provide a clear process for offering choice within reasonable parameters in order that individuals do not remain in an acute hospital bed for inappropriate lengths of time whilst they are fit for discharge, at the detriment to themselves (such as exposure to unnecessary infection or loss of mobility/muscle use) and other individuals needing hospital beds. 3. Purpose The purpose of this policy is to ensure that complex discharge is managed fairly throughout the discharge planning process and that a clear escalation process is in place for when individuals remain in hospital longer than is clinically required, so there is a consistent approach across North and West Hampshire. This policy sets out a framework to support the following:


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NHS inpatient acute beds across North and West Hampshire will be used appropriately and efficiently for those people who require that service;

When individuals have completed their required assessment or treatment at their current acute inpatient setting they will not remain there due to lack of clarity about the need to accept an alternative care provider and/or location if their preferred option is unavailable;

Planning for effective transfer of care, will be in collaboration with the individual, their representatives and all MDT members and will be commenced at or before admission;

The process of sourcing a care provider and/or discharge destination will be followed in a fair and consistent way and there will be an audit trail of options offered to the individual and/or representative to confirm that the process has been followed;

The individual and/or their representatives will be provided with appropriate and timely information to enable them to gain ownership of their discharge and to be actively involved with planning their discharge;

Where an individual is unable to express a preference, an advocate will be consulted on their behalf. Where the patient lacks capacity to make decisions about discharge from hospital, then the application of the policy should be adapted as explained in Appendix C, following the Mental Capacity Act 2005.

4. Scope This policy applies to all directly and indirectly employed staff within West Hampshire CCG, North Hampshire CCG, Southern Health NHS Foundation Trust (SHFT) Hampshire Hospitals Foundation Trust (HHFT), and Hampshire County Council (HCC) staff directly involved in hospital discharge. From this point forward the generic term ‘organisation’ will be used to refer to the different organisations covered by this document. This policy applies to individuals (and their representatives) who have finished their treatment, are fit for discharge and are safe to transfer (as per the Care Act 2014 definition). Both the policy and the process of managing choice on discharge apply equally to all individuals, whether or not they need on‐going NHS or social care and whoever may be funding any such care. It does not apply if there is a dispute about whether treatment has been concluded by the Hospital. If there is a dispute, the onus is on Hospital staff to resolve this directly with the person in dispute before application of this policy. Any service subcontracted by providers in the system are expected to comply with this policy, either via contractual mechanism or by separate sign up. For example, this would include but not be exclusive to any virtual discharge pathways operated by the providers. It is not intended that this policy should apply where individual/ relatives/carers/advocates are challenging an eligibility decision with regards to NHS Continuing Healthcare. In these circumstances, please refer to the eligibility criteria for NHS Continuing Healthcare.


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5. Explanation of Terms Advocacy: a service to help people be involved in decisions, explore choices and options, defend their rights & responsibilities, and speak out about issues that matter to them CHC: NHS Continuing Healthcare is defined as a package of ongoing care for an individual aged 18 or over which is arranged and funded solely by the NHS where the individual has been found to have a ‘primary health need’. Deprivation of liberty: when an individual without mental capacity to consent is under continuous supervision and control and is not free to leave, and this is imputable to the state. See Appendix C. Discharge coordinator: the named individual responsible for coordinating a patient’s discharge. This could be a named nurse from the ward, a named social care professional from the local authority, an appropriate person from a voluntary sector organisation contracted to co‐ordinate statutory services and act as patient advocate, or a named CHC health professional. Independent Mental Capacity Advocate (IMCA): will represent patients assessed as lacking capacity under the Mental Capacity Act 2005 to make important decisions, such as change of accommodation, and who have no family and friends to consult. Interim care: A provisional placement that is suitable and able to meet the patient’s assessed needs whilst they wait for their preferred option. Intermediate care: Short‐term care provided free of charge by the NHS for people who no longer need to be in hospital but may need extra support to help them recover. It lasts for a maximum of six weeks and can be in the patient’s home or in a residential setting. MDT: Multidisciplinary team of health and social care professionals involved in the care and assessment of patients. Medically fit for discharge: Further inpatient medical care or treatment is no longer necessary, appropriate or offered. Any further care needs can more appropriately be met in other settings, without the need for an acute inpatient hospital bed. Mental capacity: Being able to make a specific decision at a specific time (see Appendix C). Patient: The individual receiving treatment in hospital. PDD: Predicted/Expected date of discharge. This means when the patient is clinically assessed as ready for discharge. This is initially based on average length‐of‐stay data and may change several times in response to the patient’s specific needs. Reablement: Reablement services are meant to help people adapt to a recent illness or disability by learning or relearning the skills necessary for independent daily living at


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home. Reablement should be provided free of charge by the local authority for up to six weeks. It can be extended at the local authority’s discretion. Self‐funder: A person who financially meets the full cost of their social care needs (apart from reablement care and the 12 week property disregard), because their financial capital exceeds the threshold for adult services funding, their level of need is not deemed to be high enough for local authority funding, or because they or a representative choose to pay for their care. 6. Duties 6.1 Post Holders with Duties Chief Executive – The Chief Executive has ultimate accountability for ensuring robust systems are in place to ensure that patients that the Trust acts within the requirements of the Adult Safeguarding policy. Directors and Boards Members – Directors and Boards Members have overall responsibility for ensuring that the Trust has effective systems and processes in place so as to ensure that the Trust meets the needs of adults at risk throughout the Trust. They must ensure that the Trust has the capacity and capability needed to ensure the safety of adults at risk who require any of the services that the Trust may offer and local population. Director of Nursing and Medical Director ‐ The Director of Nursing and Medical Director have a joint delegated Executive responsibility for ensuring that appropriate standards for patient transfers and discharges are followed. Director of Operations ‐ The Director of Operations is responsible for ensuring that senior clinical and operational managers take clinical ownership of the implementation of these guidelines. Responsible Consultant ‐ The Responsible Consultant has the primary responsibility for an individual’s care and discharge, although this may be delegated to appropriately trained staff. A decision regarding predicted date of discharge (PDD) should be made at the earliest opportunity following admission. Wherever possible this will be done at the first ward round or multidisciplinary team meeting following admission and documented in the individuals notes. Any changes made to PDD should be made in partnership with the multidisciplinary team, patient and carer/s. Any change in PDD should be clearly documents in the medical notes. Medical Teams ‐ The Medical Team are responsible for maintaining records of decisions made at multidisciplinary team meetings, supporting the requirement to meet with patient, family and MDT to advise that the patient no longer requires an acute care NHS bed and that alternative arrangements can be made.


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Clinical Matrons ‐ To manage the policy and their implementation within ward areas, ensuring all staff are fully conversant with them. To ensure adequate resources are in place to allow for the safe, effective implementation of the policy. To oversee the process, to appoint or confirm with appropriate agencies the discharge coordinator for each patient. To monitor the completion of audits associated with the monitoring of the policy and ensure the Choice Pathway audit trail is completed. To support staff with policy process, ensuring any corrective action or interventions relating to the policy is implemented. To ensure any staff training needs in relation to the policy and to managing patient choice on discharge is met. To ensure appropriate escalation process is undertaken when required. Discharge Healthcare or Social Care Professional ‐ Refers to the named individual responsible for coordinating a patient’s discharge – this could be a named nurse from the ward, a named social care professional from the local authority, an appropriate person from a voluntary sector organisation contracted to co‐ordinate statutory services and act as patient advocate, or a named CHC health professional. The coordinator will be responsible for undertaking a considerable number of actions listed throughout this policy and it will be their responsibly to explain the discharge planning process to the patient on admission and gain patient consent to be involved in discussions and decisions. They will ensure the patient is aware of this policy and of the circumstances in which an interim placement or package might be necessary. To ensure that any carer(s) of the patient are identified and supported through the discharge process. This includes providing information on Carer’s Assessments and support services and/or referrals to the relevant support services. Ensuring the carer has adequate support in place will reduce the risk of unnecessary readmission of the patient. To ensure all Letters are prepared and given to the patient, explain the process and ensure patient is aware of all timelines and steps. To advise patient and carers of assessments, availability of opportunities and processes and expected timescales. Ward Staff ‐ All ward staff are responsible for applying the principles of safe, effective and timely discharge planning, providing the current and correct advice and support to individuals, carers and families.


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To report to the ward manager/clinical matron any deficits in their knowledge, resources or processes in place to support this policy. To report any related issues to their line manager. To ensure any training required to implement this policy is undertaken. The Chief Executive has ultimate accountability for ensuring robust systems are in place to 7. Managing Complex Discharge Communication is central to the process of managing hospital discharge, beginning as early as possible, throughout the individuals stay and following discharge. When verbal or written communication with the individual is stated, this applies equally, or alternatively, to communicating with the individuals representative, as appropriate, and with consent. The acute hospital environment is not designed to meet the needs of people who are medically fit and safe for transfer and exposes individuals to increased likelihood of: • hospital‐acquired infection • functional decline with less likelihood of returning home • need of formal support and institutionalisation • hospital readmission • increased whole‐system pressure as individuals are unable to access the appropriate

environment of care in as timely a manner as possible. Decisions to accept care or support at home or to live in nursing or residential care are major, and often made during a time of considerable change in personal circumstances including adjustment to disability, increasing dependence and the potential erosion of social networks. Individuals and/or their representatives may find it difficult to choose a discharge destination or care provider for many reasons including: • Strong and sometimes unrealistic expectations of their ability to manage without

support; • Time needed to come to terms with change of circumstances; • Mental capacity issues; • Inconvenient location/uncertainty about the quality or cost of care; • Ethnic or religious beliefs that limit providing a certain type of service. Interactions with individuals and/or representatives will acknowledge and offer support with any concerns, whilst reinforcing the message that everyone will work towards the individuals discharge from hospital. By the time an individual is clinically ready for transfer of care they and/or their representative should understand that they cannot continue to occupy the inpatient bed and this will be achieved by ongoing dialogue within the ward setting supported by the MDT as appropriate. If the preferred location or care provider is not available the individual will be made aware that they will need to accept an available alternative, either as a permanent option or whilst they await availability of their preferred choice.


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Individuals who are funding their own care (‘self‐funding’) will be provided with the same advice, guidance and assistance on choice as those fully or partly funded by their LA/CCG. This will include the use of private companies commissioned by the organisations where appropriate and also signposting to social care information and websites. If these individuals choose not to take advice offered or decline guidance and assistance they must make their own arrangements for care on discharge from hospital. Any decision made on the individuals behalf by the MDT or a legal representative must be made in the individuals best interest, in line with the Mental Capacity Act 2005. A representative’s decision to decline support or guidance would need to be carefully considered. If an individual could continue their recovery in a more suitable setting, it is not appropriate that they remain in hospital after they are medically stable, ready for transfer and no longer requiring hospital treatment. 8. Managing the Discharge Plan – Choice, Availability and Interim Care The discharge plan should include choice wherever possible and recognise the individual’s autonomy to choose from available options. The MDT must be aware of the individuals housing and home situation (collateral history gathering) well ahead of their proposed discharge date in order to inform this choice. If more than one appropriate option is available when the individual is ready for transfer or discharge from acute hospital, the MDT will offer to support the individual and/or representative to choose. If appropriate and possible, the individual will be helped to return to their previous home, perhaps with care and support or following an interim period of rehabilitation. The individual and/or representative will be given information about what would be involved if the individual requires a domiciliary care package, care home placement, intermediate care or ‘step down’ care. Refusal to make a choice about available options or refusal to accept a single available temporary option must not lead to the individual remaining in the hospital indefinitely. If only one identified home or hospital can currently meet the individuals care needs, the process of searching for alternative options should not delay discharge. In this case a plan for transfer to the available option should be made alongside searching for alternatives, and if necessary the individual transferred on an interim bases and the search continued once the individual has been transferred. There may be occasions when an individual needs support from housing services in order to be discharged from hospital. In these circumstances early identification of any issues that may delay discharge is key, so that there is maximum opportunity to put in place any support required. This can include support from local authority housing services or other local community services. Individuals and/or representatives do not have the right to remain in hospital longer than required because they have not engaged with planning around housing issues. There may be occasions when an individual needs transfer to another hospital but the preferred hospital has no vacancies. Individuals and/or representatives do not have the


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right to remain in the current hospital longer than required because they do not wish to accept treatment at an available, more suitable alternative. If they choose to decline the offered transfer, discussions should start regarding discharge from NHS care. There may be occasions when an individual needs care at home or to move to a care home, and the preferred care provider or location is not available. This might be for many reasons, including that the individual’s own home might not be ready to support the discharge or the preferred care provider might have no vacancies. Individuals do not have the right to remain in hospital longer than required because they or their representative has refused or not reviewed available options. If available options are, or a single available option is rejected as a permanent move, it may be necessary for the hospital, in consultation with the local authority or CHC department to implement discharge to an alternative or interim location. If the individual is awaiting a care home, the local authority or CHC department will offer to keep the individual’s name on a waiting list for their preferred choice, subject to required quality and commissioning strategy. Unless circumstances determine otherwise, the local authority or CHC department will endeavour to ensure that individuals making an interim move should make only one such move before entering the care home of their choice. If an individual and/or representative indicate that they would prefer to stay in the interim care home permanently, either when offered a place in one of their original choices or during the waiting process, the local authority or CHC department will endeavour to negotiate this. Any waiting lists the individual is on will be amended accordingly if the individual is accepted on a permanent basis. If the individual is not accepted on a permanent basis, they will remain on the waiting lists as before. If considering implementing discharge against an individual’s wishes in line with this policy, the Trust legal team will be consulted (01256 314937). 9. Principles of Discharge Management 9.1 Supporting People to Make Decisions Patients should not be expected to make decisions about their long‐term future whilst in hospital, with home care, reablement or intermediate care or other supportive options being explored first, where that is appropriate to their needs. Where it is what the patient wants and where appropriate, all possible efforts should be made to support people to return to their homes instead of residential placements, with options around home care packages and housing adaptations explored and considered. People should be provided with high quality information, advice and support in a form that is accessible to them, and as early as possible before or on admission and throughout their stay, to enable effective participation in the discharge process and to support making an informed choice. Patients should be involved in all decisions about their care, as per the NHS Constitution, and should be provided with high quality


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support and information in order to participate, where possible. In the context of a discharge decision, the information relevant to the decision will include an understanding of their care needs on discharge, the process and outcome of the assessment of needs, offers of care and options available. Where it is identified that the patient requires a needs assessment under the Care Act 2014, but would have substantial difficulty in engaging in the assessment and care planning process, the local authority must consider whether there is anyone appropriate who can support the individual to be fully involved. If there is not then the local authority must arrange for an independent Care Act advocate.

Many patients will want to involve others to support them, such as family or friends, carers or others. Where the patient has capacity to make their own decisions about confidentiality and information sharing, confidential information about the patient should only be shared with those others with the patient’s consent. Where the patient has been assessed as lacking capacity in this respect, information may be shared in his or her best interests in accordance with requirements set out in the Mental Capacity Act 2005 Code of Practice and Appendix C of this document. Where a person is providing care or considering providing care post‐discharge, and acting as an unpaid carer, they must be informed and invited to be involved in the discharge process and informed about their rights and sources of support. People have a choice about whether or not to provide care for other adults and people must be informed about their choices when establishing whether they are willing and able to provide care. Carers must be offered the information, training and support they need to provide care following discharge, including a carer’s assessment. The process of offering choice of care provider and/or discharge destination will be followed in a fair and consistent way and there will be an audit trail of choices offered to people. Interactions with patients will acknowledge and offer support to address any concerns. If a patient is not willing to accept any of the available, appropriate alternatives, then it may be that they are discharged, after having had appropriate warning of the risks and consequences of doing so. This option would only be pursued following the offer and rejection of available, appropriate options of care and appropriate safeguards and risk assessments. For patients who may lack capacity to make their own discharge decisions, see Appendix C.

9.2 Timely discharge from acute care If a patient is medically fit for discharge, it is not suitable that they remain in hospital due to the negative impact this can have on their health outcomes. Patients do not have the right to remain in hospital longer than required. Except where a patient with the relevant capacity has made an informed decision to discharge himself/herself against the advice of health or social care professionals, the


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discharge process must not put the patient or their carers at risk of harm or that could breach their right to respect for private life. It should not create a situation whereby the independence of the carer or the sustainability of their caring role is jeopardised. Planning for effective transfer of care, in collaboration with the patient and/or representatives and all Multi‐Disciplinary Team (MDT) members, should be commenced at or before admission, or as soon as possible after an emergency admission. The SAFER patient flow bundle should be applied to support timely discharge. The process and timelines within this policy should be clearly communicated to the patient so that by the time a patient is medically fit for discharge they are aware of and understand the discharge process, the decisions and actions that they may need to undertake and the support they will receive. If a patient’s preferred care placement or package on discharge is not available when they become medically fit for discharge, an available alternative which is appropriate to their health and care needs will be offered on an interim basis, whilst they await availability of their preferred choice.

9.3 Funding arrangements This policy applies equally to people regardless of the funding arrangements and the nature of their ongoing care. Those self‐funding care will be offered the same level of advice, guidance and assistance regarding choice as those fully or partly funded by their local authority or NHS Continuing Healthcare (CHC), although it is likely that some of the content will need to differ. A full assessment for NHS CHC should only be undertaken where the longer‐term needs of the individual are clear. In the majority of cases, these assessments should be conducted outside of hospital within a reasonable time frame and should not be a reason for delaying discharge to care outside of hospital. However, if (and only if) the individual has a ‘rapidly deteriorating condition which may be entering a terminal phase’ the NHS CHC Fast Track Pathway should be considered.

10. Detailed Guidance Stages 1 to 3 apply to all patients to provide support and prevent the need for further escalation:

Stages Detailed Guidance

Stage 1 Information provided on admission

The discharge planning process will be led at ward level by the MDT responsible for the individual’s care, with one named member taking overall responsibility for each individual, hereafter referred to as the responsible MDT member;

This may be a discharge facilitator, case manager or another health or social care professional as appropriate. The responsible MDT member supports the individual and/or representative in liaison with all currently involved in the individual’s care. They also ensure that those who need to be involved after discharge are contacted at the earliest


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opportunity to discuss the individual’s needs and that responsibilities are transferred on discharge;

All parties will record plans, communication with the individual and/or representatives, referrals and actions in the individual’s record including the Choice Pathway (Choice Audit) document (Appendix B)

The discharge‐planning information leaflet (Factsheet A can be found at Appendix B) will be given to the individual and/or their representatives as soon as possible after admission, and the content discussed with them.

Staff on the ward should take note of relevant information about the individuals housing and home circumstances as soon as possible after admission, and record this information in the appropriate records. This should enable early identification of any issues that may have contributed to the admission and any issues that need to be rectified in order to facilitate return home. If the patient is identified as homeless refer to the complex discharge team immediately;

The individual’s state of mental capacity to choose their discharge destination should also be established clearly, as early as possible in the admission. This may include establishing if anyone has powers to make a decision on the individual’s behalf, for example under a Lasting Power of Attorney agreement or under deputyship .It is advisable to seek further advice from Trust legal team on the application of this policy in cases where an individual lacks capacity (refer to Appendix C)

If there are safeguarding concerns that may impede discharge, these should also be flagged to the appropriate team early on in line with organisational policies on safeguarding. The responsible MDT member should ensure that the individual and/or representative are aware of the Managing Complex Discharge policy and process, and of the circumstances in which a move to alternative or interim accommodation or care might be necessary; The discharge coordinator will ensure that the patient is aware of this policy and of the circumstances in which an interim placement or package might be necessary. All communication will clearly set out the process that the hospital will follow in order to work towards the patient’s safe and timely discharge when their need for inpatient treatment ends. It should be made clear that they will receive advice and support in making a decision.

All communications should reinforce the expectation that individuals will leave the hospital as soon as their need for inpatient treatment ends with the PDD clearly defined and communicated.

Stage 2

Assess likely care needs on discharge

As soon as the individual’s likely needs on discharge can be appropriately gauged and are stable, a baseline assessment should be


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undertaken to determine whether the individual or carer is likely to need new or different services on discharge and the appropriate notifications, assessments and referrals to other services made;

The responsible MDT member should discuss expectations with the individual and/or their representative, and use Letter 1 (Appendix B, to reinforce this;

If no new needs are anticipated then it may be possible for previously arranged care (if any) to be restarted in the individuals usual place of residence (home or care/nursing home) without the need for further assessments – this may be arranged by the responsible MDT member in the case of private care arrangements, or a staff member acting as a trusted professional on behalf of the local authority;

If the individual requires support from housing services to enable discharge from hospital, relevant information on services available should be provided;

All relevant assessments should be completed by the MDT and appropriate arrangements put in place for discharge as soon as possible, and before the PDD;

Assessments at this stage should include consideration of interim arrangements if the individual’s first choice of care provider is not available;

The outcomes of the MDT assessments should be recorded in the individual’s records and the individual and their representatives informed that the assessment process has confirmed the recommended level of ongoing care and support required. Once the level of ongoing care and support is confirmed, the MDT will confirm the EDD and communicate this to the individual and their carer / and or representative;

If the individual is found eligible for care funded by CHC or their local authority, a representative of the relevant organisation (or the delegated service) will identify and arrange appropriate, available services. They will give consideration to all assessments and involve individuals and/or representatives in decisions as appropriate, whilst taking account of quality, safety and financial sustainability. The organisation arranging care ensures the individual and/or their representative and the discharge coordinator are informed of all currently available options;

In certain circumstances, a third party may choose to ‘top‐up’ social services funding to pay for a more expensive care option. This can be discussed with the social services representative

An individual or representative cannot ‘top‐up’ CHC payments to fund a more expensive care option and if a person is eligible for CHC, the local authority is prevented in law from funding care.

However, the individual’s CCG will offer the option of a personal health budget, which can give more flexibility and choice of care.

An individual can refuse NHS‐funded care offered by their CHC department but they would not then be eligible for local authority


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funding and would need to self‐fund their care;

In line with the Mental Capacity Act 2005, a person with power of attorney or who is a court appointed guardian can choose to self‐fund their preferred option on behalf of the individual but this decision would need to be in the individual’s best interest. Support is offered to relatives or friends making decisions of this nature, which may be life‐changing for the individual;

In line with the Mental Capacity Act 2005, a person with power of attorney or who is a court appointed guardian can choose to self‐fund their preferred option on behalf of the individual but this decision would need to be in the individual’s best interest. Support is offered to relatives or friends making decisions of this nature, which may be life‐changing for the individual.

Stage 3

Offering options and preparing for Discharge

The social care or CHC professional (or delegated service) and a member of the MDT will jointly advise the individual and/or their representative about currently available care providers that can meet their needs (which might be only one option at that time) and any potential cost or contribution at the earliest appropriate stage. The individual and/or their representative should be advised on likely availability and waiting times, costs, and on their right to seek inspection reports from the CQC;

If social services identify that the individual will ‘self‐fund’ their care, the social care professional will inform the responsible MDT member whether or not the individual has care arranged. If not, they will offer to help the individual and/or representative find available option/s;

A lack of vacancies can result in long waiting lists for some of the more popular care homes. If there is currently at least one available option, the individual cannot remain in hospital to wait for further choices and will need to either accept one that is available or make alternative interim arrangements, at least on a temporary basis;

The person offering care will endeavour to meet the individuals and/or representative’s wishes regarding specific concerns about the appropriateness of a temporary arrangement if concerns are brought to their attention. The options chosen may be ranked in order of preference but all choices should be pursued simultaneously. The person offering care will also offer advice on the practical and financial implications of each option;

If the individual has been referred for inpatient rehabilitation they and/or their representative will be made aware that a bed might not be available at the community hospital closest to their home. The MDT will explain that transfer to an alternative hospital will enable the individual to receive required services in an appropriate setting and maximise their chance of swift recovery;

The responsible MDT member should clarify expectations and may use


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Letter 2 (Appendix B), if appropriate to minimise confusion later on;

If post hospital options are severely restricted or the individual is on a waiting list for a specific location, the individual and/or representative will need to either accept transfer to somewhere that is not their first preference on a short‐term basis, or make alternative interim arrangements. They will not have the option of remaining in hospital to wait for their preferred option to be available;

In cases where the individual requires a package of care, they and /or their representative will be advised of available care options that can temporarily meet their care needs while they wait for a more favoured option;

When an individual transfers temporarily to a care arrangement that is not their preferred choice, a representative from the relevant organisation will continue to discuss permanent options with the individual and/or representative;

In cases where available options are declining to accept the individual into their care, this is outside the remit of this policy– in these cases there may be no options to choose from and so alternative means of meeting the individual’s needs should be discussed with the CCG and Social Care and will need to be managed outside of this policy;

When an individual is assessed as needing to transfer to another hospital, the MDT will explain the benefits of transferring to a different hospital if their preferred choice is full. If an identified community hospital can meet the individuals care needs and is the only currently available appropriate option, transfer to that hospital will not be able to be rejected by the family and/or representative.

Tailored information should be provided to the patient about the care options available to them, including details of costs. The conditions of funding for interim, intermediate and reablement places, (and the 12 week property disregard of fees for the circumstances when the patient transfers directly to a care home) should be made clear.

Arrangements for discharge should be put in place to coincide with the individuals PDD.

Stage 4

Available Care Declined‐ Activate the EPR‐REVIEW Stage 4 CHOICE ( this then alerts the complex discharge team who will provide support/advice and guidance of these patients to the ward team

In all cases, if the individual is assessed as having capacity and does not agree with the recommended level of ongoing care and support they require, their wishes must be respected and discharge home arranged;

If an individual and/or their representative is not happy with the proposed arrangements for discharge, MDT members will explain clearly that refusal to choose an available care provider or location will not prevent the discharge process proceeding;

At this stage, the responsible MDT member should encourage resolution of any potential barrier to discharge and seek support from


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MDT members involved. The individual and/or representative is provided details by the ward or directed to the patient advice and liaison service (PALS) for advice and information regarding advocacy if required;

The hospital and MDT, in consultation with the individual and/or representative, should agree what the individual needs on discharge and what constitutes a suitable and appropriate option. At this stage the MDT needs to ensure:

that the individual (and/or their representative) has had clear explanation verbally and in writing of discharge and on‐going care arrangements & that all relevant information is available to enable an informed decision to be made;

assistance to find alternative places of safety has been offered;

Once this stage is reached, the Matron will conduct a review of the Choice Audit Trail Document, and commence if it not initiated to ensure the policy has been adhered to robustly. If the discharge arrangements are not agreed in time for the EDD, the responsible MDT member should escalate to the ward Manager for support. The ward manager will consult any specialist staff involved and notify the Operational Service Manager (OSM). All parties should continue to encourage individuals and/ or their representatives to make their own choices throughout this process. The ward manager will start the formal process and arrange a meeting to discuss discharge within five working days of the EDD, documenting this and discussions with the individual and/ or their representatives in the notes. The following people should be invited to the meeting:

Individual and/or representatives

Ward manager/deputy

Complex discharge lead manager

Relevant manager from agency leading discharge

The individual’s consultant may also wish to attend the meeting

OSM

Stage 5

Formal Meeting and Issue of Letter 3

At the point of arranging a formal meeting, it would be appropriate to notify the Trust Legal Team (01256 314937) and provide a summary of the situation to date using the choice audit documentation to support (this will be done by the complex discharge team lead). The purpose of this is to ensure that, should it be necessary to use stage 6 of the policy, that there is minimal delay in progression of final stage;

Consideration should be given to having an appropriate note taker present, to record the key decisions made and actions agreed during the meeting. Copies of this record should be placed within the patients notes;


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If the individual and/or their representative/s do not engage with discharge planning or are unable to attend a reasonable request for a formal meeting this should go ahead without them and a follow‐up letter should be sent afterwards summarising discussion and plans;

Continue to give information and encouragement to access support to individual and/or representative. Hold formal meeting with individual and/or representative supported by Complex Discharge Team member and Lead Clinician. This will be held even if declined by individual and/or representative

The formal meeting enables all parties to discuss transfer to the most appropriate available care provider at least as an interim option. The ward manager will consult specialist staff/OSM involved for guidance if needed and, if it appears that there will be further delay escalate as required. A plan for discharge within five working days must be made at this meeting;

If an MDT decision is made at this point that the individual or their representatives are not acting in the individual’s best interests, a referral to the Court of Protection may be made. This statement only applies to individuals who are assessed as not having capacity under the Mental Capacity Act 2005 – please seek support from the Complex Discharge Team lead if this occurs;

The ward manager or deputy should give or send letter 3 (Appendix B), which should be adapted as required, within 24 hours of the meeting. The letter should be copied to all parties present at the meeting and a copy placed in the individual healthcare records. Complex discharge team to notify Trust Legal team of Stage 5 situation. Complete choice audit tool (within medical notes).

Social services, CHC and ward staff should continue to support the individual and/or representative where possible to finalise plans for discharge. If required, the social care or CHC professional continues to search for available care options;

The MDT will continue to work with the individual and/or representative to arrange an appropriate means of meeting the individual’s care needs at the point of discharge. The allocated social care or CHC professional should lead the process of making arrangements for an individual to transfer to an identified care provider or location on the agreed date.

Interim placements will be funded by the relevant CCG for a maximum of three weeks and this timescale will be clearly communicated to the patient from the outset.

Discussions regarding permanent options will continue throughout the interim placement with a designated person from the relevant organisation.

Self‐funders will be required to fund their care in the interim package / placement beyond the three weeks maximum period, if a permanent decision has not yet been made or if the chosen package / placement is not yet available. The exception to this is where the 12 week


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property disregard applies.

Where the need for a NHS CHC assessment has been identified on hospital discharge the individual should not be charged for their care during the period it takes to complete the NHS CHC assessment.

The relevant statutory organisation is responsible for funding the interim placement beyond the three week period if the ongoing placement/package is not yet available.

A conference call (or face to face meeting) will be initiated at Stage 5, to brief the OSM and legal team representative. The OSM will then brief the Deputy Ops Director. This call (or meeting) will be led by the Complex Discharge Team lead who will use the audit log and any other relevant information and keep a record of notes and actions agreed. The Deputy OD will inform the Clinical Operations Director and the CD.

Stage 6

Legal Process and Issue of Letter 4

If there has been no agreement reached in relation to discharge arrangements after stages 1 to 5 and subsequent transfer arrangements are challenged or not adhered to by the individual and/or representative, the Matron/Complex Discharge Lead Manager will also inform the Lead Clinician and OSM. This OSM should contact the appropriate senior manager from the agency leading the discharge to urgently meet and discuss plans for transfer to an interim location or alternative care provider.

The Matron will then use template letter 4 (Appendix B) to notify the individual and/or representative of their planned transfer/discharge arrangements, and should these be refused that legal advice will be sought and discharge instigated to the named interim option (see Appendix 6);

The complex discharge team lead should ensure a summary is prepared of any outstanding issues yet to be resolved, and consult Trust legal department regarding any legal proceedings concerned. Compulsory Discharge from the Trust If the final stage of the escalation process does not result in discharge from the Trust, the Medical Director (or Clinical Director for the relevant Division) in the Trust will be informed by the Operations Director without delay. The Operations Director would have been informed by the Complex Discharge Team Lead. The Medical Director/Clinical Director and Operations Director will discuss compulsory discharge from the Trust with the Trust solicitors, and a plan made to enact this.

11. Stakeholders Engaged During Consultation

Stakeholder Date of


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Consultation

Consultant Body (FCSS, Medical & Surgical) October 2016

Matrons (FCSS, Medical & Surgical) October 2016

Safeguarding (Trust Safeguarding Lead) October 2016

Legal Department October 2016

Divisional Directors (FCSS, Medical & Surgical) October 2016

Divisional Governance Leads (FCSS, Medical & Surgical) October 2016

Infection Prevention and Control (Lead Infection Prevention & Control Nurse)

November 2016

Health and Safety (Health and Safety Advisor) November 2016

Information Governance (Information Governance Manager) November 2016

Risk and Compliance (Risk and Compliance Manager) November 2016

12. Training All relevant staff will be given opportunity to familiarise themselves with the policy. This will be enabled by training to a variety of staff who manage patient care within bedded areas on a day to day operational basis, including Matrons, Ward Managers, Flow Co‐coordinators, Ward Clerks, OSMs and Deputy Ops Directors. A training pack will be produced and as part of the roll out of the policy a dedicated page will be created on the intranet with FAQs as the roll out progresses. Ongoing training will be provided by the Complex Discharge Team. Annual training will be delivered as outlined in the Trust training needs analysis and will be conducting in line with the Trust Learning and Development Policy. 13. Consultation and Approval Process This policy was developed nationally by a collaboration of partners with input from people working across the system, both locally and nationally. This policy will be signed off by each division, before being reviewed by HHFT policy approval group. Once approved, final ratification will be via Executive Committee. 14. Monitoring Compliance and Effectiveness Monitoring will take place by quarterly audit through HHFT’s Complex Discharge Lead Manager, reporting to HHFT’s Governance Board as part of performance monitoring. Monitoring in each hospital will be undertaken on a biannual basis, facilitated by the local manager or lead nurse for discharge services. Local monitoring will include an audit of:

Staff training to check that training courses are relevant to the policy and ensure training is undertaken;

Policy effectiveness;

Review of when choice information is provided;

Patient and/or representative feedback and complaints;


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Number and Length of Delayed Transfers of Care;

Equality monitoring

Minimum requirements

Requirement Reviewed by

Method of Monitoring Frequency of Review

Monitoring Committee

A. Review of items described above in local monitoring

Integrated Discharge Manager

Review of items described above in local monitoring

Bi‐annual HHFT Medicine Division Governance Board

15. References Policy adapted from: SUPPORTING PATIENTS’ CHOICES TO AVOID DELAYED DISCHARGE Version number: 1.0 First published: 23 March 2016 and prepared by a partnership of organisations listed in co‐branding with support from others from across the health and social care sector. Equality Act 2010 and Human Rights Act 1998, regarding disability and heritage languages; Accessible Information Standard to be introduced in July 2016 Mental Capacity Act 2005 Code of Practice available at: https://www.gov.uk/government/publications/mental‐capacity‐act‐code‐of‐practice Care Act 2014 Barnet PCT v X [2006] EWHC 787. A patient has no right to demand / the NHS has no obligation to provide something not clinically indicated, (R (Burke) v GMC [2005] EWCA Civ 1003), including provision of an inpatient bed and a patient who lacks mental capacity for the relevant decisions has no greater right to demand this (Aintree University Hospitals NHS Foundation Trust vJames [2013] UKSC 67). http://www.fabnhsstuff.net/2015/08/26/the‐safer‐patient‐flow‐bundle 16. Associated Documentation

Discharge Planning Policy

Complaints Processes 17. Contributors

Contributor Job Title Contributor Name

Complex Discharge Leads Gill Massey, Tracey Knatt

Discharge Improvement Lead Alison Whitehorn


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Appendix A – Equality Analysis Form To be completed by the Policy Author at the development stage of the policy and before consultation. Part 1 should be forwarded to an Equality Analysis Lead (list available on the Document Control Trust Intranet page) for sign off and any comments from them considered and addressed before seeking final approval of the policy.

Document Name:

Part 1 – Policy Author to complete and forward on to an EA Lead for sign off

1. Could the application of this document have a detrimental equality impact on individuals with any of the following protected characteristics? (See Note 1)

Yes/No/NA

Summarise the equality and diversity related elements within the policy

a Age No

b Disability No

c Gender reassignment No

d Race No

e Religion or belief No

f Sex No

g Sexual orientation No

h Marriage & civil partnership No

i Pregnancy and maternity No

2. If ‘Yes’ to question 1, do you consider the detrimental impact to be valid, justifiable and lawful? If so, please explain your reasoning.

N/A

3. Specify with which, if any, individuals and groups you have consulted in reaching your decision.

Part 2 – Equality Analysis Lead to complete and forward back to the Policy Author

Provide a brief summary of the potential impact of the policy and whether sufficient consideration has been given to the Equality Duty.

1. Is this document recommended for publication? If ‘yes’ go to question 3 if ‘No’ complete number 2 below.

2. This document is not recommended for publication because:

a Amendments are suggested as follows:

b A more detailed equality analysis should be undertaken as follows:

c Other (please specify)

3. Specify with which, if any, individuals and groups you have consulted in reaching your decision.

Name: Sandra McArdle Job Title: Associate Director of Governance


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Date: 16 November 2016

Part 3 – Policy Author to complete on receipt of part 2 and before forwarding for final policy approval

1. I have reviewed the Part 2 assessment and have made the necessary amendments to the policy. If you have answered ‘no’, please explain why not

Name: Alsion Whitehorn Job Title: Discharge Improvement Lead Date: 16 November 2016

Note 1 Under the terms of the Equality Act 2010 public sector Equality Duty, the Trust has a legal responsibility to think about the following three aims of the Equality Duty as part of our decision making and policy development.

Eliminate unlawful discrimination, harassment and victimisation;

Advance equality of opportunity between people who share a protected characteristic and people who do not share it; and

Foster good relations between people who share a protected characteristic and people who do not share it.


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Appendix B: Documentation to be issued (Factsheet A, Letters 1, 2, 3, 4 and Appendix 1 – Choice )

Factsheet A: standard information on admission

Dear Sir or Madam, Welcome to [Enter Hospital Name and Location here]. We wish to make your stay with us as pleasant as possible, and return you home as soon as you become well enough. The information in this letter is designed to let you know what you can expect during your time with us, and what we expect from you in return. We will start to plan for your discharge from hospital as soon as possible after you are admitted, so that your stay is only as long as is necessary. We want to involve you actively in this planning so that there are no surprises and we come up with a plan which is tailored to you. What to expect:

The nurse in charge of your ward and your named consultant will be responsible for your day to day care.

The ward team looking after you will discuss with you the date they expect you will be able to return home – this is called an estimated date of discharge – and will keep you informed should this date need to change.

We will assess the things you may need upon discharge as soon as possible after you are admitted, to put them in place with minimal delay. If you need some extra support, the teams will meet with you to talk about what options are available and make a plan that will best meet your needs. We do expect you and your family and/or representatives to work with us to ensure you are able to be discharged on the date planned.

The hospital is designed to meet your needs while you are acutely unwell, and staying in hospital past this point can be detrimental to your health and the health of other people requiring hospital services. Some important things to consider:

Staying in hospital longer than necessary is not good for you – it can put you at greater risk of hospital‐acquired infection, and decrease your ability to function independently.

It is also not good for the NHS – other people who are acutely unwell, or who are waiting for surgery will need to be admitted to hospital. If the hospital does not have space to do this, this puts us under pressure and we may have to keep people waiting for long periods of time in the emergency department or cancel surgery.

These things result in a poor experience for everyone involved.


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As such, it is very important that we are efficient in getting you better, and that we work together in planning for your return home. Before you leave hospital we will ensure that you have the medications and information you need and that there is a plan to transport you home. We will provide you with a paper summary of your admission and update your GP.

If you are unsure at any time what is happening with your care or what is happening in relation to your discharge, please speak to the nurse in charge of your ward who will be happy to help you.

With best wishes for a speedy recovery.

The team caring for you at this hospital.

On behalf of NHS healthcare and local authority services in North & West Hampshire

When a patient has been assessed under the Mental Capacity Act 2005 as not having capacity to make decisions about their discharge, letters may be given in their best interest to their representative, such as their next of kin (delete this section prior to letter issue).


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STAGE 2 – LETTER 1

Date

Dear (name)

This letter is to explain the assessment and discharge process. With your permission, we will request an assessment to find out what services you might need to be safely discharged from hospital. A health or social care professional will discuss your needs with you, with your family or with any others you would like involved. We want to find out whether, with the right help and support you can return home from this hospital or whether care elsewhere might be needed.

Of course you may not require any support to be able to return home, in which case we will work with you to make sure you are discharged as soon as you are ready to leave hospital.

If you do need care at home, if you need to stay in a care home or if you need to transfer to another hospital, the team looking after you at this hospital can help arrange this. We will do all that we can to help you and to give you the information you need to make a decision.

If your preferred choice is not immediately available when you are ready to leave hospital, it is not possible for you to stay in this hospital waiting. You would need to accept an alternative option temporarily. Discharge from hospital is not a good time to consider long‐term care but we know that it can take time to make even temporary arrangements. We will do our best to help you make arrangements as quickly as possible.

If you would like a copy of this letter to be given to someone else or you have any questions please speak to one of the nurses on your ward or any member of the team caring for you. Please do not hesitate to ask if you have any questions.

With best wishes for a speedy recovery

The team caring for you at this hospital

On behalf of NHS healthcare and local authority services in North and West Hampshire



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STAGE 3‐Letter 2

Date

Dear (name) Following your admission to this hospital, we would like to support you with arrangements for safe discharge with the right level of care. Your recent assessment shows that you will need support or treatment elsewhere. It has been recommended by the team involved in your assessment, in consultation with you, that your care and support needs can be met by enter proposed care and support arrangement here (e.g. returning home with a care package with the support comprising [x & y times a day] for [x period of time] and your community health service <OR> moving into a reablement service prior to a care home/nursing home) A member of the team caring for you will advise you of currently available options and you will need to choose one of these or to arrange an alternative option that is available at this time. If you have not had this information yet, please let us know. If your first choice has no current vacancies, you will be asked to move to a temporary option that is available whilst you wait for your preferred choice to be ready. If you need treatment at another hospital but your preferred hospital is full, you will have to transfer to a hospital that can offer you a bed. It is not possible for you to remain at this hospital when you are ready for discharge or transfer. This would increase your risk of catching a hospital acquired infection and of becoming increasingly less independent. The team caring for you at this hospital will help make arrangements for your discharge as soon as a suitable option is available. If you have any queries, or concerns, please do not hesitate to ask a member of the team involved in your care.

With best wishes

The team caring for you at this hospital

On behalf of NHS healthcare and local authority services in North and West Hampshire



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STAGE 5‐ LETTER 3 ( tailor as needed)

Date Dear (name) The purpose of the meeting today was to discuss the need for you/person’s name to be discharged now that inpatient hospital care is no longer required. I am sorry you were unable to attend ( use if not present). All required assessments of [your/person’s name] needs are now complete and you/he/she is ready for discharge. In discussion with the consultant and the clinical team it has been recommended that your/person’s name needs would be met by enter proposed care and support arrangement here. (Only for patients with capacity) However, if you wish to return home without the recommended care and / or support in place, this is your decision to make. We do not wish to cause you or your family anxiety but you will not be able to stay at this hospital whilst you wait for your ongoing care arrangements to start. AND We will have to transfer you to a suitable hospital that can offer the treatment you need without delay. If you would like, we will ask that your name remains on the waiting list for a different hospital, which may be able to offer you a bed after a few days. However, please be aware that your preferred hospital may remain full and you may become well enough to return home from the alternative hospital very quickly. OR We will find a care home that can offer a temporary room. You will need to stay there until transfer to a preferred home can be arranged. If you have not yet found a long‐term care home you like, the care manager responsible for your case will help you. They will offer to help make arrangements for your move to the temporary care home. When a date has been agreed for you to transfer to your preferred care home, they will help make arrangements for that move too. OR We will find a care home that can offer a temporary room. You will only need to stay there until your return home with care can be arranged. The care manager responsible for your case will make arrangements for your move to the temporary care home and continue to help you arrange care at home. When the care at home is ready to start, your care manager will also help make arrangements for your return home.


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OR We will ask a housing manager to find a temporary place for you to stay until your return home can be arranged. Your care or housing manager will make arrangements for your move to the temporary place and when your home is ready, they will also help with making arrangements for your transfer home. Please finalise and discuss discharge plans with the nurse in charge of your ward within 5 working days of this letter. Failing this, you will have to either transfer to a temporary arrangement identified by us or inform us of an alternative arrangement to leave the hospital without further delay. If we do not hear from you we will make arrangements for transfer to the temporary care arrangement as soon as possible. If you would like a copy of this letter to be given to someone else or you have any questions please speak to one of the people below or any member of the team caring for you. Please do not hesitate to ask if you have any questions. Yours sincerely, Ward Matron [Trust Name] Tel: direct line On behalf of NHS and local authority services in North and West Hampshire When a patient has been assessed under the Mental Capacity Act 2005 as not having capacity to make decisions about their discharge, letters may be given in their best interest to their representative, such as their next of kin (delete this section prior to letter issue).


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STAGE 6‐LETTER 4

Date Dear Person/representative’s name FINAL NOTIFICATION OF TRANSFER TO ALTERNATIVE CARE I am writing further to the letter dated [date] sent to you by name, job role. You/person’s name needs to be discharged from [ward name] now that you/they no longer require hospital care. This hospital has offered you support and guidance to enable your safe and appropriate discharge. You have been informed of your responsibility to finalise other arrangements if you would prefer not to accept what has been proposed. As outlined in the previous letter, we will now instigate safe transfer to the location below, which has been assessed as suitable to meet your needs. Should this transfer be refused, the Trust will facilitate discharge. Your will be told if you are responsible for paying care fees. If you are appealing a local authority or NHS decision regarding funding, the fees you pay may be reimbursed if your appeal is upheld. If you would like further information or support regarding discharge arrangements please speak to the ward manager. If we do not hear from you, we will assume that you are in agreement with the content of this letter and that we continue to arrange transfer without your involvement. Please do not hesitate to ask if you have any questions. Discharge destination: Address: Tel number: Date of transfer/discharge: Care coordinator name & contact number: Yours sincerely Matron [Trust Name] Tel: direct line On behalf of NHS and local authority services in North and West Hampshire When a patient has been assessed under the Mental Capacity Act 2005 as not having capacity to make decisions about their discharge, letters may be given in their best interest to their representative, such as their next of kin (delete this section prior to letter issue)


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APPENDIX 1‐CHOICE PATHWAY (choice Audit trail)

Individuals name ………………………… Hospital number ……………..…..……… Hospital …………………………………… MDT representative...……………………

Action Date Signed

STAGE 1 – INFORMATION PROVIDED ON ADMISSION

Discharge planning patient info leaflet given.

Patient informed of EDD and told when it is revised

Patient/representative informed of named responsible MDT member.

Locally agreed discharge planning tool or paperwork started

STAGE 2 – ASSESS LIKELY CARE NEEDS ON DISCHARGE

Patient referred to community services if required

Letter 1 given to patient/representative if wished

Expectation managed regarding availability of preferred option

STAGE 3 – OFFERING OPTIONS AND PREPARING FOR DISCHARGE

Letter 2 given to patient/representative if wished

STAGE 4 – AVAILABLE CARE DECLINED Care declined by (name, relationship): Date: Reason given:

STAGE 5 – FORMAL MEETING AND LETTER 3Date: Invited attendees: Individual / representative attendees: Template letter 3 given by ward manager:

STAGE 6 – LEGAL PROCESS AND LETTER 4 Alternative or interim discharge location sourced: Letter 4 given to patient/representative from matron.

Legal advice sought

END: Reason process terminated (start new form if process re‐started):

File in patient notes and copy to appropriate teams as requested. To be used in Stage 5 briefing meeting with OSM


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Appendix C: Hospital Discharge and Mental Capacity Issues

All staff must follow the five guiding principles of the Mental Capacity Act 2005 (“MCA”). This means:

Presume that adults from 16 are mentally capable of making their own decisions;

Do not determine the person lacks capacity until all practicable steps to support them have been taken without success;

Do not consider someone to lack capacity because they make a decision we consider to be unwise;

When the patient is assessed to lack capacity we must act in their best interests;

Before taking any action or decision on their behalf we must consider if it can be achieved in a less restrictive way.

Capacity is specific to the decision that must be made, at the relevant time, and so it is possible that a patient who has been assessed as having capacity to consent to or refuse the treatment they have had as an inpatient may lack capacity to make decisions around discharge and care planning (and vice versa). Where there is a reason to doubt capacity for a particular decision, it must be specifically assessed, in accordance with the MCA, the MCA Code of Practice and relevant case law and documented appropriately.

All practicable steps must be taken to support the patient to make the decision before concluding that they are unable to make it themselves. This might involve taking a number of steps such as a providing information in a different format or breaking information down into smaller chunks.

If a person is assessed to lack capacity this means that staff have tested whether they can:

Understand the information relevant to the decision,

Retain the information long enough to make a decision,

Use and weigh the information as part of the decision making process and

Communicate the decision they want to make.

In the context of a discharge decision, the information relevant to the decision will include an understanding of their care needs on discharge, the process and outcome of the assessment of needs, offers of care and options available, with the person being given concrete information to consider, not starting with a blank sheet approach.

Options which are not available (e.g. placements which are not available, care which is not considered clinically appropriate, or care which will not be funded) should not be considered in either capacity assessments or in best interest decision‐making. A patient with capacity cannot insist on staying in hospital after they are medically fit for discharge and so neither is it an option for a patient who lacks capacity for the discharge decision.

Where a patient, despite all reasonable efforts to support them, lacks capacity for discharge decisions, the decision must be made in their best interests (see MCA s4).

It is important to identify who the decision maker is as it could be a number of different people. The decision maker may be an attorney (if a health and welfare Lasting Power of Attorney has been granted, and is valid, applicable and registered) or a Deputy (if a health and welfare Deputy has been appointed by the Court). If neither of these is appointed then it will be the health or care professional who needs to make the decision in question. The wishes and feelings of the patient are paramount,


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but this does not mean they will always get what they want, any more than a patient with capacity would.

“Best interests” is interpreted widely, and goes beyond medical risk and benefit to include social, psychological and emotional factors. Before making a best interest decision, it should be tested by asking whether the patient’s best interests can be achieved in a way which is less restrictive of their rights and freedoms.

A patient is entitled to an Independent Mental Capacity Advocate (IMCA) where it is proposed that an NHS body or a local authority provides accommodation in a care home for 8 weeks or longer unless there is someone to consult about their best interests other than a paid professional (MCA s38‐39).

If the proposed placement or care package on discharge puts a patient without capacity to consent to it at risk of being deprived of liberty (Article 5, European Convention of Human Rights), currently as interpreted by the Supreme Court in Cheshire West [2014] UKSC 19 to mean “under continuous supervision and control and not free to leave” then additional safeguards are required to ensure that the deprivation is lawful.

Where the proposed deprivation of liberty is in a hospital or a registered care home, a referral must be made for a standard authorisation under the Deprivation of Liberty Safeguards (DoLS). However, DoLS do not extend to other placements, such as supported living or domiciliary care and so any proposed deprivation of liberty there can only be authorised by the Court of Protection. [In either case, case law has found that it is preferable for any proposed deprivation of liberty to be authorised in advance by a prior referral to DoLS or Court application – see for example Re AJ ( DoLS) [2015] EWCOP 5, or Re AG [2015] EWCOP 78]

[It may be appropriate to seek legal advice on cases where deprivation of liberty after discharge appears to be an issue.]


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Appendix D: Summary of Legal Responsibilities and Rights This appendix includes a brief summary of selected key legal responsibilities held by participating organisations and the rights that patients have in relation to the specific topic of this policy, with references to specific legislation and case law. This list does not cover all of the legal complexities in relation to this issue – it is only provided as a guide to the people reading this policy and should not be used in place of legal advice.

Responsibility or right in relation to choice at

discharge Relevant legislation / case law

Hospital (NHS Trust)

No clinician or Trust is obliged to offer anything which is not clinically indicated. This includes provision of an acute inpatient bed.

R (Burke) v GMC [2005] EWCA Civ 1003; Aintree University Hospitals NHS FT v James [2013] UKSC 67

A Trust is obliged to carry out its functions “effectively, efficiently and economically”, which is not consistent with prolonged occupation of inpatient beds by patients who are medically fit for discharge

In some cases, where the patient’s refusal to leave hospital when medically fit for discharge constitutes a nuisance or disturbance, an offence may be committed and there is a power to remove the patient

Alternatively, other remedies may be available to Trusts under property law

Where appropriate, where the Trust considers it will not be safe to discharge a patient unless arrangements for care and support are in place it must give notice to local authority, including provision in some circumstances for a financial remedy against the local authority where discharge is delayed as a result of failure to meet needs

Responsibility to seek authorisation for any deprivation of liberty occurring in the hospital

NHS Act 2006 (as amended) s26, 63

Criminal Justice and Immigration Act 2008, ss119‐121 [and see NHS Protect guidance]

Barnet PCT v X [2006] EWHC 787

Care Act 2014, Schedule 3, Care and Support (Discharge of Hospital Patients) Regulations 2012, and Delayed Discharge (Continuing Healthcare) Directions 2013

MCA Schedule A1, paras 1‐3 24 and 76

Local Authority Responsibility to assess a patient’s needs for care and support where it appears to the local authority that the patient may have such needs

Responsibility to assess a carer’s needs for support and choice about caring

Care Act 2014 s9

Care Act 2014 s10


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Responsibility to provide patient’s choice of accommodation in care home / shared lives / supported living, where this is to be arranged by the local authority, in some circumstances

Responsibility to provide information and support on choices

Responsibility to offer choices / involve the patient in preparation of a care and support plan

Responsibility to provide a Care Act advocate if a patient would experience substantial difficulty in participating in the assessment of need or care planning process unless there is another (unpaid) appropriate person to fill this role

Responsibility to authorise deprivation of liberty in care homes and hospitals

Care Act 2014 s30, Care and Support and After‐care (Choice of Accommodation) Regulations 2014

Care Act 2014 s4

Care Act 2014 s25

Care Act 2014, s67

MCA Schedule A1 paras 21, 50

Clinical Commissioning Group [and NHS England]

Responsibility to ensure an assessment for eligibility for NHS funded Continuing Healthcare where it appears that there may be a need for such care. [This is the responsibility for NHS England for military personnel and prisoners]

NHS Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012, reg 21