DISTRICT NURSE LIAISON

1. DISTRICT NURSE LIAISON DEPARTMENT RLI

2. Learning Outcomes • Focus on discharging planning • An overview of our role • Discharge process at the RLI • Increased knowledge of the journey of Section 2 • The assessment process • An overview of continuing care process and the Decision Support Tool

3. Who are we? • Employed by NHS North Lancashire (was NLtPCT) • 2 WTE (0.6 WTE seconded from RLI) to cover the entire RLI site • District Nurse Liaison team tel: 01524 583600 Fax: 01524 516307

4. Discharge planning • Planned • Individualised - Patients wishes • Needs identified - health and social • Safe • Supported • Communication • Accurate updated information

5. Planned • Maybe use a checklist • Avoid Friday pm discharges • Timescales: • Integrated palliative care scheme IPCS (pilot Lancaster locality) refer DN team • Fast track refer to DNLO and DN team • Routine DN team

6. Needs identified • Refer to MDT • Assessment • Equipment • Care package • Advice and support

7. Safe • Patient fit to travel • Environment assessed as appropriate • Access to home clarified • Consider Piperline/Telecare

8. Supported • Who – family or friends • Need for care and or support from professionals or voluntary agencies -refer DN or community matrons

9. Communication: Information: • Accurate and updated including demographics • Use section 2 not the old single page referral • Written and verbal • Pick up the phone

10. Role of the District Nurse Liaison Department • To help facilitate a seamless patient journey • To undertake holistic assessments of patients with complex health needs • A member of the MDT involved around decision making regarding placement on discharge • Facilate working relationships between primary and secondary care

11. Role of the District Nurse Liaison Department – Cont’d • Provide nursing assessments for Social Services • To screen and assess for consideration for NHS funded Continuing Healthcare • Endeavour to provide on-going education and advice to other health professionals

12. How we work • Reactive service – via section 2 referrals • Routine MDTs/panel meetings each week

13. What else do we do: Assess for and order nursing equipment Beds/ pressure relieving equipment Attend: • Weekly MDTs ward 50, oncology and MU2 wards • Daily allocation meetings with hospital SW team • Weekly Panel meeting with Social Services

14. Cont. • Attend case conferences • General Liaison with other MDT members • Continuing Health Care advice to all • Telephone advice about the assessment process, including with patients families • Sign posting and information • Service development and management • Education

15. We do not: • Organise home oxygen • Organise TNP (topical negative pressure) • Fax referrals to DN teams in this locality • Complete assessments for incontinence products

16. Section 2 journey: (the process for complex discharge) • Wards send updated Section 2 – discharge team - DNLO – discharge team – SW/MDT • DNLO screen referral (section 2) Possible outcomes: • Assessment with ward staff and patient arranged • Deferred if patient not medically fit for assessment • Refer back to discharge team

17. The Assessment Process Prior to assessment: • Ward staff to advise patient of referral • If possible ward staff to ascertain patient and family’s wishes Nurse Assessor (DNLO) attend ward to: • Gain consent, completes NHS continuing healthcare needs checklist if no referral for full consideration required → • Continues to complete Assessment

18. The Assessment Process – Cont’d • Discuss with patient and ward staff/MDT outcome and recommendation of level of care and potential placement • Document recommendation and outcome of NHS needs checklist in discharge pathway/discharge communication

19. cont. Information gained from: • Patient and carers • Ward staff and the MDT including District Nurses • Hospital Notes Copy of nursing assessment given to discharge team

20. Referral for NHS Continuing Healthcare (non fast track) Identified by needs checklist: • MDT organised by ward staff to include patient and/or family • MDT led by health lead (usually nurse assessors) • Ascertain needs and whether choice of discharge is safe and appropriate • Review of needs – if still triggers • MDT complete DST (Decision Support Tool) and health lead submit to NHS North Lancashire Commissioning Department with recommendation • Panel meet every 2 weeks (if potentially LCC funding patient cannot be discharged until outcome of panel)

21. Continuing Healthcare Fast track • Ascertain discharge appropriate and timely • DNLO and DN team involved asap • Ascertain patient’s needs and wishes • DNLO complete checklist and Fast track form completed (faxed to NHS North Lancashire) • Discharge planned • Pt discharged

22. What to do at the weekend • Phone DN teams to liaise • Fax to DN teams comprehensive section 2 and phone to confirm • ? Eligible for ICPS Consider that Community core services are skeleton services

23. Referal (Section 2) to District Nurses (Ward to fax directly to DN Teams using referral pack). Please ensure information is: • Accurate • Adequate • Updated and needs identified Please be aware District Nurses: • Usually work alone • Cannot commit to time or length of visit • Do not carry a supply of dressings/catheters or medication DNLO will endeavour to keep the pack with up to date contact details

24. Useful Website 2009 revised Continuing Healthcare tools and information www.dh.gov.uk/.../SocialCare/Deliveringadultsocialcare/Continuingcare/index.htm -

25. Learning Outcomes • Focus on discharge planning • An overview of our role • Increased knowledge of the journey of Section 2 • The assessment process • An overview of continuing care process and the Decision Support Tool • Information to take forward into practice

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