Document Details Title Approval process …

1 Document Details Title Transfer & Discharge of Clinical Care/Patient Policy Trust Ref No 1543- 35150 Local Ref (optional) Main points the Document covers The main aim of this policy is to ensure that all directorates have adequate arrangements to ensure effective handover of patients between clinical teams providing care for patients. Who is the Document aimed at? This policy applies to all service directorates who have a responsibility for direct patient care. Owner Narinder Kular Nurse Consultant Community Paediatrics Rachael Brown, Clinical Services Manager Approval process Approved by (Committee/Director) Steve Gregory Quality & Safety Committee Approval Date 05/12/2016 Initial Equality Impact Screening Yes Full Equality Impact Assessment No Lead Director Director of Nursing & Operations Category Clinical Sub Category All Clinical Services Review date 05/12/2019 Distribution Who the policy will be distributed to All Staff Method Electronically via Datix web safety alert to senior staff, all staff via the Trust website, Mandatory training Document Links Required by CQC Required by NHSLA This is a mandatory risk management policy for the NHSLA Risk Management Standards accreditation Other Amendments History No Date Amendment 1 New Policy 2 4 Reviewed up dated Clinical Policies incorporate SBAR tool V3 5 Transfer and discharge policy merged into one Document , amended and reviewed discharge policy.

2 2 Transfer of Clinical Care Policy Version V3 Datix Ref: 1543- Page 2 Index 1. Introduction 4 2. Purpose 4 3. Duties / Roles 4 Chief executive 4 Director Of Nursing & Medical Director 4 Service Managers 4 All Clinical Staff 4 4. Definitions 5 5. Guidance on Clinical Transfers of Care 7 6. Handover Requirements between all care settings to include both giving and receiving of information 8 How Handover is Recorded 8 SBAR Tool 9 What should an SBAR Communication convey? 9 Emergency Out of Hours Transfer 10 Single Point of Access 11 7. Key Principles for Discharge 11 Continuing Healthcare Needs 12 Transport 12 Delayed Transfers of Care 12 Self Discharge 12 Consent 13 Safeguarding 13 The Community Care (Delayed Discharge) Act 2003 13 Patients who Lack Capacity in Decision Making 13 Patient Self Discharge 14 8.

3 Discharge Information to be given to the receiving Healthcare Professional 14 9. Discharge Information to be provided to the Patient 14 10. Medicines Management on Patient Discharge (Inpatients) 15 11. The Discharge Summary 15 12. Dissemination & Implementation 16 13. Consultation 17 14. Monitoring Compliance 20 15. References 20 16. Associated Documents 21 17. Appendix 1 Transfer of Care Table Service Directories 22 Appendix 2 Form 1a Clinical Handover 28 3 Transfer of Clinical Care Policy Version V3 Datix Ref: 1543- Page 3 Appendix 2 Form 1B SCHT SBAR Handover Record 28 Appendix 3 Shropdoc Flagging Guidelines 28 Appendix 4 Single Point of Referral 29 4 Transfer and Discharge of Clinical Care Policy Dec16 Page 4 1. Introduction This Document sets out for staff across the Trust what is required to ensure effective transfer /discharge planning.

4 It includes an outline of the roles and responsibilities, the key principles fundamental to effective transfer /discharge, and the range of factors that need to be considered with patients and carers during their pathway. It outlines all matters pertaining to the process of patient transfer / discharge and follows guidance in Discharge from Hospital: Pathway, process and Practice Department of Health January 2003, Achieving Timely Simple Discharge from Hospital DH Aug 04 as well as key legislation including Community Care (Delayed Discharges etc) Act 2003 and the Mental Capacity Act 2005. The standards outlined in this policy should be adhered to regardless of the nature of the transfer / discharge being planned or time of day or the specific nature of the patient s requirements taking into account patient s wishes and right to self-discharge 2. Purpose This policy makes clear to staff what is required during the transfer/discharge process and the principles that need to underpin day to day practice.

5 It provides a reference for staff of all agencies so that they might understand both their individual and team s responsibilities. It will ensure that there is a clear and consistent process in place for dealing with discharge, thus ensuring a positive outcome for both patients and carers. Furthermore it will ensure that the Trust meets all its legal responsibilities and conforms to the relevant NHS LA Risk Management standards. 3. Duties/ Roles Chief executive The Chief executive has ultimate accountability for the strategic and operational management of the Trust, including ensuring there are effective and appropriate processes in place for the safe transfer / discharge of patients. Director of Nursing & Medical Director The Director of Nursing & Medical Director have responsibility for ensuring that appropriate transfer / discharge processes are in place and support patient safety at all times.

6 Service Managers Service Managers are responsible for the day to day operational management of transfer / discharge processes in line with the policy and ensuring their teams are aware of the requirements of this policy. All Clinical Staff Clinical staff are key essential members of the Multi-disciplinary team (MDT) in ensuring that safe and timely transfer / discharge takes place, and have the central role in co-ordinating the patient s transfer / discharge in the clinical environment. All clinical staff are required to comply with this policy and to report any transfer/discharge related issues to their line manager and to complete a 5 Transfer and Discharge of Clinical Care Policy Dec16 Page 5 Datix incident report in line with the Trust s Incident reporting policy. This policy refers to transfers and discharges to, from and between all the following Trust services: Community Hospitals Wards Community Beds Community Integrated Community Services / Interdisciplinary Team Specialist Services & teams (Children and Adolescence Mental Health Service, Prison Healthcare, Preventative services, Diagnostics, access to assessment, rehabilitation & treatment (DAART), Shropshire Enablement Team, Substance Misuse, Advanced Primary Care Services, Diabetes Nursing service, Continence Service, Podiatry, Minor Injuries Unit, Therapy ) Children s Services Dental 4.

7 Definitions AMHS Adult Mental Health Service AHPs Allied Health Care Professionals APCS Advanced Primary Care Service CAMHS Children Adolescents Mental Health Services Carer The term carer is used as the generic term for relatives/friends/neighbours that are providing unpaid care to the patient. They may not necessarily be living in the same household as the person they are caring for. CCNT Community Children s Nursing Team CMHT Community Mental Health Team CNR Community Neuro Rehabilitation Team CSMT Community Substance Misuse Team DAART Diagnostic Assessment and Access to Referral and Treatment DNACPR Do not attempt cardio pulmonary resuscitation EIP Early Intervention Programme EG Latin expression Exempli Gratia EWS Early Warning Score GP General Practitioner Handover Will involve minimal disturbance to the patient s activities of daily living. Does not prevent or hamper a return to their usual place of residence.

8 Will not require a significant change in support offered to the patient or their carer in the community. 6 Transfer and Discharge of Clinical Care Policy Dec16 Page 6 ICS / IDT Integrated Community Services / Interdisciplinary Team MIUs Minor Injury Units Multi-Disciplinary Team (MDT) The team of staff who contributes to the patient s care and/or discharge. EG Doctors, Nurses, AHP s, Health Care Assistants, Therapy assistants, Psychologist, Liaison Nurse., Social worker. NHS National Health Service NPSA National Patient Safety Agency OoH Out of Hours [time period 18:30pm-08:00am] Out of Hours Handover A handover of information that takes place at night or weekends. [18:30-08:00 hours] Patient The People receiving clinical services from the Trust are referred to as patients. SaTH Shrewsbury and Telford Hospitals SBAR S = Situation B = Background A = Assessment R = Recommendation SBAR is an easy to remember mechanism that can be used to frame communications or conversations.

9 It is a structured way of communicating information that requires a response from receiver. SCHT Shropshire Community Health (NHS)Trust SPR Single Point of Referral Shropdoc GP OoH Provider in Shropshire & Telford Shrop Shropshire Transfer of Care The transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis NPSA Discharge Discharge is used generically to describe the formal release of a patient from the Trusts clinical services at the conclusion of a hospital stay or series of treatments. This may incorporate the transfer of care to another provider. Patient The People receiving clinical services from the Trust are referred to as patients. The term Patients is used as a broad term and includes services where specifically the term service-user is used.

10 7 Transfer and Discharge of Clinical Care Policy Dec16 Page 7 Carer The term carer is used as the generic term for relatives/friends/neighbours who are providing unpaid care to the patient. They may not necessarily be living in the same household as the person they are caring for. Simple discharge Will involve minimal disturbance to the patient s activities of daily living. Does not prevent or hamper a return to their usual place of residence. Will not require a significant change in support offered to the patient or their carer in the community. Complex discharge A discharge process that requires complex coordination of services to enable safe discharge Expected discharge date A target discharge date to which all agencies can work whilst recognizing that the date may change according to the patients needs. This is set at the first available MDT Self discharge Related to patients wishing to self-discharge against medical advice To Take Out Medicines (TTOs) Medicines which the patients take away when they leave hospital Multi-Disciplinary Team (MDT) The team of staff who contributes to the patient s care and/or discharge.