Transcript Document

We will:
 Provide an overview of the revised guidance on
‘Choosing a Care Home on Discharge from Hospital’
 Explore roles and responsibilities using scenarios
from practice - including when an adult lacks capacity
 Consider how to handle choice issues sensitively with
patients, families and proxy decision makers
 Reflect on attitudes and behaviours that are unhelpful!
QUIZ
Hospitals have
plenty of beds for
me to stay in
“I don’t think I’ll
be able to
manage alone”
“I don’t know
what my
options are
after I leave
the hospital”
Hospital is the
safest place for
me to stay while
I recover
“I should remain
in hospital until I
am completely
well”
“I’m not sure
how to care for
myself after I am
discharged”
Research on patient experience of Delayed Discharge
University of Stirling
I came in with a fall and I
was walking with two sticks
and now…I can walk a wee
bit but not much. I’ve lost a
lot of weight. I caught a
bug, diarrhoea, sickness
then got another bug. Who
wants to be in hospital?
I used to like a laugh but it’s
wearing away. I thought I was never
getting out. There was no one to talk
to. It’s a lot better in the care home.
I’m still on my own but I’ve got a
TV, a DVD player. I can use the phone
whenever I want, my friends get up
and it’s quieter.
I am hardly getting any therapy now and that has been
the case for a number of weeks now…They say that
walking about is dangerous because of the obstacles.
You can imagine the day is long. I’m very angry that I
am not in control and I am liking it less and less.
Hazards of Hospitals …
“The effect in sickness of
colour is hardly at all
appreciated. I have seen in
fevers the most acute
suffering produced from the
patient not being able to see
out the window and the
knots in the wood being the
only view.”
21st Century Risks
Loss of physical and cognitive function from:
 Healthcare associated Infections
 Pressure sores
 Dehydration and malnutrition
 Sensory deprivation
 Accelerated bone loss
 Incontinence
 Isolation
 Delirium
50%
45%
40%
35%
30%
Series1
25%
20%
15%
10%
5%
0%
Hospital doctor
Wider family
GP
Hospital nurse
Partner/spouse
Friends
Social worker
•SCENARIO DISCUSSION
Discharge planning
The process should start on, or soon after admission
The consultant will:
 Provide an estimated discharge date
 Confirm when the patient is clinically ready for discharge
 Consider eligibility for NHS Continuing Healthcare, and clearly
document the decision
The MDT will:
 Explore the potential for rehab/reablement
 Consider all options for future care
 Fully involve the patient, family or proxy in the process
CEL 32 (2013)
GUIDANCE ON CHOOSING A CARE HOME ON DISCHARGE FROM
HOSPITAL
 The Cabinet Secretary for Health and Wellbeing has made it
clear that a patient does not have a right to ‘choose’ to stay in
hospital where this goes against best clinical practice.
 A person is not entitled to remain indefinitely in hospital once
they are ready for discharge.
 The NHS and local authorities will take robust action to ensure
that people are not inappropriately delayed in hospital if a
placement more appropriate to their needs is available
elsewhere.
Guiding principles
Patient can’t stay in hospital indefinitely – failure to engage with choice
process should not prevent discharge taking place
Decisions about long term care should not be made in acute setting
Start the process early
Full potential for rehab / reablement must be considered first
Patients will move to interim home where choice(s) are not available
What the Directions say
The authority must arrange for care in (the preferred)
accommodation, provided:
 The accommodation is suitable in relation to the individual’s
assessed needs
 To do so would not cost the authority more than it would
usually expect to pay for accommodation for someone with
the individual’s assessed needs
 The person in charge of the accommodation is willing to
provide accommodation subject to the authority’s usual
terms & conditions for such accommodation
 The accommodation will be available
What the Directions mean
suitable
•Care home is able to
meet the person’s
assessed needs, and
•is registered with the
Care Inspectorate and
is of an acceptable
standard
more than it would
usually expect to pay
•Local interpretation
required
Willing
available
•If the home is
unwilling or unable to
provide
accommodation the
patient should be
advised immediately
and helped to make
another choice
•One of the care
homes of choice has a
suitable vacancy, and
is prepared to allocate
that room in time to
facilitate discharge by
the agreed date of
discharge.
•If it is unlikely that a
preferred home will
be available by the
agreed DofD then the
patient will be asked
to make interim
arrangements that will
facilitate discharge
within that period
Roles and Responsibilities
Patients, family & proxy
All staff
The Medical Director
The Clinician
Nursing & ward staff
Social care staff
•Fully engage in the assessment and choice process
•Proxies should act in the best interests of their charge when making any decisions
•Be clear, open and sensitive
•All staff should give a consistent message that staying in hospital once RFD isn’t an
option
•Should be informed of reluctant discharges when appropriate
•Responsible for sending the escalation letter to patients, family or carer where they
refuse to engage with the choice process
•Assess when patient is clinically ready for discharge (as part of MDT process)
•Support the MDT decisions about the next stage of care (but it is not the role of the
clinician alone to make these decisions)
•Ensure effective and inclusive communication with the patient, family and proxy
throughout the discharge process.
•Senior Charge nurse will develop staff expertise in discharge planning
•Senior charge nurse will escalate reluctant discharges to the Medical Director
•Lead responsibility for assessment, and provision of community care services
•Ensure discharge planning starts as early as possible in the patient journey
•Carry out financial assessments
•Help patients and families through the choice process.
The Adults with Incapacity (Scotland) Act 2000 provides a
framework for safeguarding the welfare and managing
the finances of adults (people aged 16 or over) who lack
capacity due to mental illness, learning disability or a
related condition, or an inability to communicate.
SOME MORE QUESTIONS
Within the AWI Act “incapable” means incapable of:
Acting on decisions, or
Making decisions, or
Communicating decisions, or
Understanding decisions, or
Retaining the memory of decisions.
But, a diagnosis of Dementia does not automatically
mean the person lacks capacity!
Person’s
wishes
Benefit
Least
restrictive
Encourage
Consult
 Establish if a Power of Attorney, Guardian or
Intervention Order is in place
 Consider using the provisions of S13za of the Social
Work (Scotland) Act 1968 to discharge.
 Discuss with family/carers the need to apply for
Guardianship
 Consider applying for Guardianship
Proxy’s
should
Proxy’s
should not:
Follow the principles
of the AWI Act
Insist the patient
stays in hospital once
clinically ready for
discharge
Actively engage in the
choice process and
act in the best
interests of the
patient at all times.
Unnecessarily delay
Guardianship
applications – where
this happens the LA
should take over
Take account of the
relevant guidance
and codes of practice
for proxy’s
Remember!
Always
check the
proxy
powers!
 Communicate!
 Remind them of their duties under the Act
 Escalate the case to the Medical Director, same as for
a capable patient.
 Apply to the Sheriff for Direction
 Consult your legal advisors
 Enforce discharge through Courts
 An incapable adult can be discharged, without a proxy in
place IF:
 Everyone agrees
 There’s no Guardian or Welfare attorney (with appropriate
powers) already in place
 No intervention order has been granted
 There are no applications pending for an intervention or
guardianship order
 There will be no deprivation of liberty under Article 5, ECHR.
Deciding what amounts to 'deprivation of liberty' will
depend on the circumstances of each individual case.
Such decisions may involve a fine balancing of elements
and in such cases practitioners might want to consider
taking advice from their own legal departments.
SOME FURTHER DISCUSSION
But I know
best
We have a
target we have
to achieve
We need the bed
Only following
Government
instructions
Success Factors
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Early dialogue
Sensitive and supportive approach
Pleasant but firm attitude
Consistent messages
Helpful information
Strong leadership
Clear policy and escalation process
Final thoughts…
“A patient is the most
important person in our
hospital. He is not an
interruption; he is the
purpose of it.”
Bombay Hospital
Other Challenges
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Access - geography and transport
Ethnicity, cultural and faith issues
Costs
Capacity
Quality
And finally…….
THANK YOU
CEL 32 (2013)
 GUIDANCE ON CHOOSING A CARE HOME ON DISCHARGE FROM
HOSPITAL
 Enquiries to:
Isla Bisset
St Andrew’s House
Regent Road
Edinburgh EH1 3DG
Tel: 0131-244 3748
[email protected]
http://www.scotland.gov.uk