Transfers of Care Cardiff and Vale Health and Social Care Community Contact: Tanya Balch

1. Transfers of Care Cardiff and Vale Health and Social Care CommunityContact: Tanya Balch

2. Transfers of Care • The transition between services should be seamless for the person and this can only happen where information is shared with the accepting service (Exchange of information between health and social care) • Provision of dressing or other essential equipment has been arranged and documentation follows the person • Information from discharging service to receiving service. Health Local Authority

3. Specialist Training Available • CHC - Carol Preece • CPA - Lawrence Doyle • POVA - Simon Williams • MCA - Dorian Davies • FACS - Dave McManus • e.learning DOH website discharge training tool • ‘Passing the Baton’ NLIAH website

4. Admission To A ServiceContact using the Enquiry • In community • GP • District nurses • Social workers • Community psychiatric nurses • Admission to hospital • Elective admissions • Emergency admissions • Ambulance staff

5. Simple /Complex • 80% discharges are considered to be simple • A simple discharge is one where the person is to return to their home or previous residence with simple or no ongoing health needs that can be met without complex planning • Mr Lewis demographics

6. Simpleor ComplexDischarge • Prior to the PDD it is essential to consider all options regarding the discharge destination • Is the discharge simple? (may not require full unified assessment) • could be protocol led • May require no follow up services • May only need simple hospital discharge services

7. Baseline Assessment • Baseline assessment is the initial picture of the person • Requires a collection of information regarding the persons presenting concerns and their ability to manage the activities of living independently -these may be health or social related • Will identify areas where a more in depth assessment is required prior to discharge • Do their needs require the service that they have presented to? If not then redirect appropriately • If the person has been referred to the appropriate service then a decision to admit needs to be made and the reason for admission evident Mr Miller baseline assessment

8. Treatment / Care • Admission to a service implies that a need has been identified and that there is a treatment plan or care plan • All treatment or care plans have goals and with these in mind it is possible to set predicted discharge dates (PDD’s) • A PDD is not a fixed date only a date which to goal plan to, if needs change or treatment alters then the PDD can be amended and will be a review date Mr Miller discharge planning log1

9. Coffee

10. Mrs Orange Admitted With Confusion • Cause of confusion is identified as UTI. A few days later when treatment is under way Mrs Orange is mobile around the ward and only needs some prompting to carry out all her own care independently • The medical team inform the staff that Mrs Orange can go home, this is planned for the following day. • That evening Mrs Orange daughter arrives on the ward and when the nurse informs her that her mother is going to home she is not very happy , she tells them that her mother is not safe to be discharged as she lives alone and is becoming increasingly confused

11. Risk Management • There are risks in everything that we do • All of us identify the risks around us an make choices about what level of risk we are prepared to accept • In assessing a persons needs we are required to identify where a person has risks • In the planning of their future needs we need to identify how those risks will be managed • A person with capacity has the right to make choices about the level of risk they are prepared to accept • Planning services for a person in hospital needs to consider the circumstances and risks at home as well as in the hospital intermediate car environment

12. Mental Capacity • In planning an individuals treatment and care a person has a human right to be informed and consented. • The Mental Capacity Act means that we are no longer able to rely on a single decision as to a persons capacity to make decisions. • Each interaction should be considered as if the person was lucid and understands what is said or happening to them. • At each stage of care and with every decision made there should be evidence to show efforts made to accommodate the persons expressed wishes • Only where another person has lasting power of attorney do they have the right to make decisions on the persons behalf

13. Simpleor ComplexDischarge • Is the discharge planning complex? Requiring a complete unified assessment • A complex discharge is one where there may be several agencies, family members involved in the discharge plan and arrangements are complex and inter dependant • May require a series of goal / discharge planning or review meetings

14. Continuum For Funding Continuing Healthcare NHS responsible for funding all care required NHS funded nursing care NHS via local health board fund nursing element of care in a nursing home Fair access to care criteria Local authority have a responsibility for funding care but this is means tested Voluntary services

15. Comprehensive Assessments • Where a persons needs are complex a full comprehensive assessment will be required (completion of all domains of unified assessment) • The risks or likelihood of risks to the person or others in carrying out -the activities of living must be identified -harm to/from others -Ability to make choice -Ability to be involved with others • Once completed the assessment should be signed and dated and it will provide the evidence needed to determine eligibility for • continuing health care • Registered nursing care contribution • local authority packages of care

16. Undertaking a comprehensive assessment of need through Unified Assessment Carol Preece Continuing Care Manager Cardiff & Vale NHS Trust

17. Aims of the Session • Increase knowledge and understanding of Continuing NHS Health Care, NHS funded Nursing Care and FACS through the use of Unified assessment as a single tool. • Understand to process to be followed

18. Current process

19. Continuing NHS Health Care A situation where an individual has been thoroughly assessed by a multi-disciplinary team and judged to have overall health needs that are so significant that the NHS will manage and pay for all the care they need.

20. When will an individual be eligible for Continuing NHS Health Care Following a comprehensive assessment eligibility will depend upon the nature, complexity, predictability and intensity of an individuals health care need and health input they require, regardless of diagnosis.

21. The Assessment Process • At a minimum the MDT will consist of at a minimum of a Consultant/GP, Nurse and Social Worker • An Appropriate validated assessment tool will be used. • Patients and their carers must be fully aware and involved in the process. • Family will be aware of who is co-ordinating the assessment and this documented in the notes.

22. Cont. • CHC information should be provided to facilitate effective patient/carer involvement. • It should be made clear that eligibility for CHC is subject to reassessment, and an individual can move in and out of eligibility • It must be made clear that their changing healthcare needs could impact on how their care is funded.

23. Applying the Criteria • The Matrix was developed by WAG to facilitate the process • This assessment tool is not prescriptive but a guide to assist staff in relation to individual eligibility for CHC. • In all cases the overriding determination of eligibility is an individuals Health care needs. Not their illness or disability.

24. Recording the Decision • Patient/Client records • Care plan • UA summary record • Formal record of the MDT • The Decision and the rationale on which the decision is based should be clearly recorded and signed. • The patient will be informed of the decision and reasoning verbally and in writing.

25. Service Provision in Cardiff & Vale NHS Trust General – West Wing - St Davids Hospital - Barry Hospital Mental Health – St Davids Hospital - Whitchurch Hospital - Barry Hospital

26. Service Provision (cont.) Community 24 hour District nursing Service Up to a maximum of 5 visits in 24 hours Night Sitting Service, twice weekly Speciality Neurosciences – Rookwood Hospital

27. Placement under CHC • First instance access to in-patient bed • Exceptional circumstance Nursing Home • Nursing Home funding has to be provided by LHB where individual resides • CHC can be provided in the community • Needs over and above core service has to be costed and presented to LHB.

28. Reviewing Eligibility • Policy suggests an initial review within three months at a minimum six monthly, thereafter or more regularly dependent on their assessed needs. • Review should follow the same process as original assessment. • Outcome to be clearly documented- demonstrating what has changed since last assessment.

29. Appeals • The patient or their representative has the right to ask for and independent review of the CHC decision. The purpose of the review is: • Ensure that the proper procedure has been followed in reaching a decision • To ensure the eligibility criteria has properly and consistently been applied.

30. The appeals procedure does not apply when patients/families which to challenge • The Content, rather than the application of the Local Health Boards Eligibility criteria. • The type and location of an offer of NHS funded Continuing Care Service. The NHS Trust must deal quickly (ideally within 2 weeks) with any verbal or written request to reconsider decision about eligibility.

31. Stage 1 – Informal Resolution • Undertaken by Continuing Care Manager Trust/Case Manager • This should provide individuals involved with an opportunity to discuss their concerns • Ensure that the proper process has been followed.

32. Stage 2 – Formal Review • The Senior Nurse Assessor/Continuing Care Manager in the LHB will co-ordinate the Review process. • Writen Consent (5 Days) • LHB orward request to the chairperson of Independent Reivew Panel • Chairperson will decide on convening a panel • Outcome (within 2 weeks).

33. Problems • Lack of understanding about the process and information required. • Time • Poor quality data in care plans/documentation • Lack of individual/family involvement • ombudsman

34. Funded Nursing Care • Nursing homes registration etc

35. Funded Nursing Care Your Involvement

36. What do we require ? • Baseline • Unified Assessment • All pages signed and dated as usually faxed through to us • Consideration of Continuing Healthcare • Proforma from Social Worker • Identification of funding i.e. LA/Self funded • Nursing Home placement identified

37. Nurse Assessor Role • Agreement of FNC for Nursing Homes prior to placement • 3 monthly assessment post placement • Yearly reviews • Continuing Healthcare assessments for any Service Users identified as having triggers. • Advice to Residential but mainly Nursing Homes

38. Links with Homes • Providing link nurse advice and support to care homes in the Vale of Glamorgan area • Training as required i.e. Nutrition or identified training needs in the Care Home • Involvement with Carvale (Cardiff and Vale Matrons Forum)

39. POVA • Reporting any concerns to Vulnerable Adult team via VA1 form • Ensuring that care being provided in the care homes is to a standard expected by the LHB commissioning team • Reporting any concerns to line management

40. Protection Of Vulnerable Adults • Whatever plans are put in place for a service user we have a duty to identify those at risk and to not put them at further risk by acts of neglect or omission • Where we have knowledge of any POVA issues they should be discussed with the POVA team • Where the POVA team are involved with an investigation this is confidential, however they will inform the MDT of any decisions that will affect care or discharge planning • Involvement of the POVA team should not stop the patients pathway and discharge

41. FACING FACS FAIR ACCESS TO CARE SERVICES ELIGIBILITY FOR ADULT SOCIAL CARE David McManus Service Manager, Cardiff Council

42. What is Fair Access to Care Services? Every local council in the UK uses a national framework from the Department of Health to decide eligibility criteria for the adult social care services it provides. The aim is to have greater consistency across the country on how decisions are made about whether people have services or not.

43. What is the framework? • Nationally and locally the evidence is that people’s highest priority is keeping their independence. Government guidance puts the risks to independence, if needs are not met, in four bands - critical, substantial, moderate,low. • Councils are allowed to decide whether they have enough resources to provide help for people in all four of the bands, or just for some of them. • In Cardiff, and the Vale, we provide services to people in the critical and substantial bands. We call these two bands our “eligibility criteria”. • People in the moderate and low bands do not meet our eligibility criteria and so will not get a service. We will still provide information and advice on other sources of help.

44. What is the framework? • Judging whether someone is eligible or not is a risk assessment. • Assessing an individual’s circumstances, strengths and abilities, problems, and related risks, are the basis for determining an individual’s eligibility. • It is only when someone’s circumstances impacts negatively upon their independence, within the eligible banding, will it result in the person receiving help. • It is the effect of a condition or circumstances upon independence, not simply the presence of it. • What is needed to remove, or help manage the risk, will define eligible need.

45. Four Categories of Independence • Autonomy – ability to make own choices and take own decisions. • Health and Safety – freedom from harm, abuse and neglect and taking wider issues of housing and community safety into account. • Daily Living – ability to manage personal and other daily routines. • Involvement – ability to participate in social, family leisure, work, educational, life

46. FACS ELIGIBILITY CATEGORIES OF RISK LOW RISK – where there is a need for minimal help including the provision of information. MODERATE RISK – someone beginning to struggle to meet need, and may require some help, or manages but with difficulty. ---------------------------------------------------------- SUBSTANTIAL RISK– someone who is not able to be manage a need without assistance CRITICAL RISK– someone for whom there would be extremely serious consequences if a need was not met

47. The Matrix

48. The thinking process • What is the issue or difficulty? (e.g. unable to remember to take medication) • What will happen if the issue is not addressed? (Risk) (symptom control fails – health deteriorates rapidly) • How likely is it that this will happen? (every day – highly likely within a few days) • What will be the severity if it does happen? (will need medical attention, could precipitate hospital admission – extreme) • How far does that impact upon independence? Impacts upon all four aspects. Using the matrix, highly likely and extreme = CRITICAL FACS Critical Risk = Life is or could be threatened

49. Recording • Information written in Domains should follow the ‘thinking process’. Information needed by social care is not just a description, but an evaluation of what the issue or difficulty is, what risk this presents, and likelihood and severity.

50. Goal Planning and Reviews • Achievement of goals means the person needs a review and may no longer need the service • If goal planning has been effective the review date will coincide with the date the person is fit for transfer of their care • A person completing treatment with one service may just be starting it with another • e.g. when discharged from hospital to home.