Discharge planning and referral management

1. Discharge planning and referral management Sandra Petrie Clinical Screener Care Coordination

2. Aim: • To increase awareness of issues surrounding discharge to home-based health care services • Objective: • Refresh knowledge of discharge planning process • Increase knowledge of referral to home based health care services in Canterbury • Increase insight and understanding of the implication of poor discharge planning • What information do you need when a patient comes into your service? • When do you receive this information?

3. Care Coordination Centre (CCC) • In Canterbury, ALL referrals for nursing services including: hospital discharges for ACC District Nursing care; Rural DN; palliative care equipment; falls prevention … and non ACC short term (<8 wks) home based support services go through Canterbury CCC • Canterbury; Capital and Coast; Hutt Valley • Their work includes: • Clinical screening of referrals - meet criteria; • legibility; • all necessary information • Allocate client to provider

4. Home Based Service provided by Access, Healthcare NZ and Nurse Maude in Christchurch • Generalist care • •District nursing • • Catheter management • • Continence management • • Diabetes care • • Medication management • • Palliative care • • Wound care/compression • • ACC • Home based support: • Domestic assistance • If patient has a Community Services Card and no able bodied person at home, they may be eligible • Personal Assistance • Generally eligible for 3 showers per week up 45 minutes and will be reviewed after about 6 weeks. Aim to continue rehabilitation and reduce needs Early supported discharge/ Community Rehabilitation Enabled Support Team (CREST)

5. Specialist Community Services in Canterbury • Acute Demand • Cardio thoracic • Continence management and products • IV • Methadone • Paediatric outreach and Palliative care • Respiratory care • Specialist Palliative care • Stomaltherapy • Wound

6. Home based health care • Referral criteria • Requires a home visit by a nurse in order to maintain a state of wellbeing. • Is unable to access general practice or clinic for care due to mobility, finance, or transport barriers. • Has no suitable person (relative or friend) to administer care in the home. • Exclusions • In residential care. • If currently receiving CREST services any district nursing needs are referred to the CCCC by the CREST coordinator. Where possible, the CCCC ensures continuity of any previous district nursing provider. For other district nursing needs (outside of CREST) refer via CCCC. • The referral guidelines for Community nursing and Specialist nursing services are available on Health Pathways at • http://www.healthpathways.org.nz/

7. Discharge planning • When to start? • What can patient /family do for themselves? • Who is the best person to manage on-going care? • What fits with patients lifestyle? • What does the patient want? • Do they really need additional services – just in case? • What can be done prior to discharge?

8. What can be done before discharge? • Assessed for equipment • Many patients could manage without home based support i.e. showering if a shower stool is provided on discharge • If a patient needs pressure relieving equipment up to discharge- they will need it at home • Medications arranged • Up to 50% of patients discharged to community miss doses of medication immediately after discharge including warfarin, high dose steroids. • If a dose due within an hour of discharge, please administer before they leave • Providers can be contacted for case discussion • Send referral to CCC and request nurse contact the • Dept./ward, if complex case • What information do community providers need when a patient comes into their service? • When do they need to receive this information?

9. Include this information in your referral: • Date of referral and Name of referrer • Date when the service needs to start. • Patient condition and diagnosis • Reason for referral • Specific condition details, i.e. Catheter insertion date and details, wound treatment chart • Current Medications and the name of community pharmacy. Medication Chart if required • The patient's preferred provider: - specific provider may only be available for some conditions. - providers currently working with the patient e.g., home support service providers, CREST. • Information regarding barriers preventing the patient's accessing to other services e.g., general practice. • Known risks that the nurse may encounter when making a visit e.g., home detention, security while in ED or hospital, unsafe home environment, history of violence, undesirable associates • Discharge Summary

10. Generalpoints: • Send referral before the patient leaves the ward. • Referral can be sent several days before discharge- it is easier to cancel a visit that set up the service late in the day • If you send a referral late in the day to start that evening or early the following morning, especially for a large package of care - this may be declined • Ask if a patient has a current or preferred provider. • Ask if they want to change current provider if returning to service. • If a patient contacts ward after leaving saying they can’t manage- send urgent referral • Medication management: if supervision to ensure taking on time etc., … • No blister pack required • If need assistance taking medication: blister pack needed and yellow card • If prescribed medication , including cream, eye drops, etc., to be given : • Medication chart needed. • Be specific of reason for referral - “ just pop in” or “check following discharge” is not appropriate

12. Effects of discharge planning/referrals • Delayed discharge from hospital • Confusion • Deterioration in condition • Insufficient equipment- shower stool, pressure relieving equipment care = cannot be given • Insufficient information-patient has to repeat themselves; key information remains unknown by provider. • Readmission to hospital • Delayed visit-missed health care: meds, wound care; catheter care; • Disconnected care

20. Seamless care requires • Patient centred approach • Professional courtesy

21. I will ask you nicely … please fill in your referrals correctly or else: