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PAN WILTSHIRE CHOICE POLICY

On discharge from hospital/intermediate care or hospital transfer

Consultation Process

Links to each of

these

organisations are

to be added

Wiltshire managing Choice Policy created to meet Multiagency requirements by representatives from:

Wiltshire Council Adult Social Services

Salisbury Foundation Trust

Great Western Hospital

Royal United Hospital

Avon and Wiltshire Partnership

SEQOL

Sirona

Healthwatch Wiltshire

Healthwatch Somerset

Healthwatch Dorset

Healthwatch Hampshire

Healthwatch Swindon

Wiltshire Clinical Commissioning Group

Somerset Clinical Commissioning Group

Dorset Clinical Commissioning Group

Hampshire Clinical Commissioning Group

Swindon Clinical Commissioning Group

Wiltshire Council Legal – Adult Social Care

Wiltshire Clinical Commissioning Group Legal – Health

Version No: Wiltshire Choice Policy version 1

Date Approved:

Next Review Date:

Target Audience: Adult Health and Social Care staff involved in discharge plans of patients in Wiltshire inpatient NHS care

Approving Body/ Committee Chair:

Signed:

DOCUMENT HISTORY

Date of Issue Version No.

Next Review Date

Date Approved Director Responsible for

Change

Nature of Change

04/03/2015 1.0 March 2015 In principle 04/03/2015

DTOC Task & Finish Group

New Wiltshire Choice Policy.

15/05/2015 1.1 May 2015 Healthwatch Wiltshire

HWW provided advice around engagement process, feedback on literature/information, and liaison with other local HW.

20/05/2015 1.2 May 2015 Wiltshire Council Legal

Legal advice on legislation.

20/05/2015 1.3 June 2015 Multidisciplinary Professionals Workshop

Workshop to discuss progress and agree changes required within the Policy to ensure accuracy of information.

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27/07/2015 1.4 July 2015 Healthwatch Wiltshire and WCCG Comms

Patient letters where reviewed by both Healthwatch Wiltshire and WCCG Comms. Both organisations suggestions where taken on board and relevant changes made to the Patient Letters.

18/08/2015 1.5 August 2015 DAC Beachcroft LLP Solicitors

The Wiltshire Choice Policy was reviewed by WCCG Solicitors from the Health aspect of the Policy to ensure accuracy of information and all relevant changes made.

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TABLE OF CONTENT

WILTSHIRE CHOICE POLICY FOR MANAGING CHOICE ON HOSPITAL DISCHARGE

1 INTRODUTION ........................................................................................................... 4

2 SCOPE OF POLICY ................................................................................................... 4

3 PURPOSE ................................................................................................................... 4

4 DOCUMENT DEVELOPMENT .................................................................................... 5

5 GLOSSARY ................................................................................................................ 5

6 DEFINITION ................................................................................................................ 6

7 MANAGING CHOICE .................................................................................................. 6

8 CHOICE OF AVAILABLE OPTION/S AND INTERIM CARE ...................................... 8

9 MENTAL CAPACITY .................................................................................................. 9

10 DISCHARGE PLANNIG ............................................................................................ 11

11 ESCALATION PROCESS ......................................................................................... 11

12 CONSULTATION AND APPROVAL PROCESS ...................................................... 11

13 REVIEW, REVISION ................................................................................................. 12

14 MONITORING COMPLIANCE AND EFFECTIVENESS ............................................ 12 PROCESS FOR MANAGING CHOICE ON HOSPITAL DISCHARGE

1 STAGE 1 – GIVE STANDARD INFORMATION ......................................................... 13

2 STAGE 2 – REFER FOR SERVICES TO SUPPORT DISCHARGE ........................... 13

3 STAGE 3 – OFFER OPTION/S AND PREPARE FOR DISCHARGE ......................... 14

4 STAGE 4 – AVAILABLE CARE DECLINED .............................................................. 15

5 STAGE 5 – FORMAL MEETING AND FORMAL LETTER 1 ..................................... 15

6 STAGE 6 – LEGAL PROCESS AND FORMAL LETTER 2 ....................................... 16 APPENDICES

1 SUMMARY OF THE 6-STAGE MANAGING CHOICE PROCESS ............................ 17

2 MANAGING YOUR DISCHARGE; PATIENT INFORMATION .................................. 20

3 DISCHARGE PLANNING FACTSHEET 1 ................................................................ 23

4 DISCHARGE PLANNING FACTSHEET 2 ................................................................ 24

5 CHOICE LETTER 1A ................................................................................................ 25

6 CHOICE LETTER 1B ................................................................................................ 26

7 CHOICE LETTER 1C ................................................................................................ 27

8 CHOICE LETTER 1D ................................................................................................ 28

9 FORMAL LETTER 1 ................................................................................................. 28

10 FORMAL LETTER 2 ................................................................................................. 28

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INTRODUCTION

1.1 This policy defines how the Acute, Community Hospital or Intermediate Care Setting will

manage Choice throughout a patient's in-patient stay with regards to discharge

planning, particularly at the point when a patient is assessed as no longer requiring the

level of care provided by the Acute, Community Hospital or Intermediate Care Setting.

1.2 Patient participation, engagement and communication are central to the process for

managing Choice on discharge. The term "patient" is used here to describe an

individual who has been admitted for NHS in-patient services and not to define a

passive relationship. When verbal or written communication with the patient is referred

to, it applies equally or alternatively to communicating with the patient’s representative

as appropriate.

1.3 The overarching aim of the Wiltshire Choice Policy is to enable choice in the context of

reducing delays in the appropriate transfer of care or discharge of patients, through early

engagement and support, and the implementation of a fair and transparent escalation

process which all parties understand and can contribute to.

1.4 Please note the below clause referencing consideration/compliance with the Equality Act

and Human Rights Act:

“Under the Equality Act 2010”, in carrying out its functions an organisation has a duty to

avoid unlawful discrimination on the grounds of age, gender, disability, gender

reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or

belief or sexual orientation. It also has duties to have due regard to the need to

eliminate such discrimination and associated victimisation and harassment, and to

advance equality of opportunity and foster good relations between individuals with these

protected characteristics. In developing this policy the organisations which are

signatories to it have considered these duties and the way in which it might impact on

individuals with protected characteristics. It has concluded that there are no likely

adverse impacts on such individuals or other factors which require the policy to be

modified or additional steps to be taken in implementing the policy in order to ensure

compliance with the Equality Act duties.

The organisations are also satisfied that the Wiltshire Choice Policy is compliant with the

NHS Constitution and the Human Rights Act 1998.

1.5 Delays in discharge can have a negative effect on patient recovery and wellbeing and

stretch limited NHS resources.

2. SCOPE OF POLICY

2.1 This policy is relevant to all adult in-patients that are required to choose a destination

and/or Care provider on discharge from all beds across the system, (Acute/Community

Hospital and Intermediate Care Settings). The Policy applies equally to all adult patients

aged 18 and over, irrespective of their ongoing Health or Social Care and funding

arrangements for on-going care.

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3. PURPOSE

3.1 A Delayed Transfer of Care is experienced by an inpatient in a hospital, who is ready to

move on to the next stage of care but is prevented from doing so for one or more

reasons. Timely transfer and discharge arrangements are important in ensuring that the

NHS effectively manages emergency pressures. The arrangements for transfer to a

more appropriate care setting (either within the NHS or in discharge from NHS care) will

vary according to the needs of each patient but can be complex and sometimes lead to

delays. This Policy focuses solely on Delayed Transfer of Care due to Patient Choice.

3.2 The purpose of this policy is to ensure that Delayed Transfer of Care (DTOC) due to

Patient Choice is managed fairly throughout the discharge planning process. This

requires consistent and timely Multi-Disciplinary Team intervention across all bed-

based settings as set out in this policy.

3.3 Effective use of this policy is dependent upon clear escalation processes being in

place when patients remain in an Acute/Community Hospital or Intermediate Care

Setting** [delete as appropriate] longer than is needed and where the patient and/or

their representative is unable or unwilling to accept discharge to an appropriate Care

Setting at the Estimated Date of Discharge or Actual Date of Discharge.

3.4 This operational policy sets out a framework to ensure that:

Acute/ Community Hospital or Intermediate Care Setting** [delete as appropriate] will

be used appropriately and efficiently for those requiring bed based care.

3.5 Planning for effective transfer of care, in collaboration with the patient and/or their

representative and a member of the Multi-Disciplinary Team will be commenced at or

before admission but no later than 4 hours after admission.

3.6 Where a patient is unable to express a preference, an advocate will be consulted on

their behalf.

4. DOCUMENT DEVELOPMENT

4.1 Guidance’s consulted includes;

Ministry of Justice. Mental Capacity Act 2005 and MCA Code of Practice, MCA

Deprivation of Liberty Safeguards(DOLs) and Guidance on DOLs.

The NHS Constitution for England

FS60 Choice of accommodation - care homes - Age UK

FS37 Hospital discharge arrangements - Age UK

In applying this policy, account will be taken of all related policy and guidance

documents issued by the Department of Health, including;

Care Act 2014 and NHS Act 2006 http://www.legislation.gov.uk/ukpga/2014/23

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Human Rights Act 1998 - Legislation.gov.uk

Equality Act 2010 - Legislation.gov.uk

2010. Ready to go? Planning the discharge and the transfer of patients from

hospital and intermediate care...

2010 Guidance on Eligibility Criteria for Adult Social Care ??????

2012 The National Framework for NHS Continuing Care and NHS-Funded Nursing

Care

The NHS continuing healthcare (responsibilities of social services authorities)

directions 2013

2013 Delayed discharges directions (continuing care) directions

Mental Capacity Act Code of Practice 2005

2014 Care and Support Statutory Guidance - Gov.UK

The NHS continuing healthcare (responsibilities of social services authorities)

directions 2013

The Care and Support (Discharge of Hospital Patients) Regulations www.legislation.gov.uk/uksi/2014/2823/.../uksi_20142823_en.pdf Mental Health Act 1983 and Code of Practice 2015 https://www.gov.uk/government/publications/code-of-practice-mental-health-act-1983

5. GLOSSARY

CHC: NHS Continuing Healthcare – I need to create a link to the CHC process as part

of Discharge Planning

Discharge process: Transition planning for the patient’s discharge from hospital to home

or other Care Setting and/or transfer to another hospital setting or to a specialist tertiary

care setting.

DTOC: A Delayed Transfer of Care is experienced by an inpatient in a hospital, who is

ready to move on to the next stage of care but is prevented from doing so for one or more

reasons. Timely transfer and discharge arrangements are important in ensuring that the

NHS effectively manages emergency pressures. The arrangements for transfer to a more

appropriate care setting (either within the NHS or in discharge from NHS care) will vary

according to the needs of each patient but can be complex and sometimes lead to

delays.

EDD: Estimated date of discharge. This is when a patient is ready and safe for

discharge. The EDD is initially based on average length-of-stay data and may change

several times in response to the patient’s specific needs.

In-patient Setting: This is any bed within an Acute, Community or Intermediate Care

Setting.

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Interim care: A provisional placement that is suitable and able to meet the patient’s

assessed needs whilst they wait for their preferred option.

IMCA: statutory Independent Mental Capacity Advocate, who will represent a patient

assessed as lacking capacity under the Mental Capacity Act 2005 to make important

decisions, such as change of accommodation, and who have no family or friends to

consult.

IMHA: statutory Independent Mental Health Advocate, who will support a patient who is

detained under the Mental Health Act 1983 to be involved in important decisions in

relation to their detention, such as change of accommodation.

Multi-Disciplinary Team or (MDT): Multi-Disciplinary Teams consist of staff from several

different professional backgrounds who have different areas of expertise. These teams

are able to respond to clients who require the help of more than one kind of professional.

Multi-Disciplinary Team can include: Senior Sister, who is in charge of the overall running

of the ward and nursing care. The Senior Sister has a dedicated team of junior sisters,

nurses, healthcare assistants, domestic staff and ward clerks. A dedicated discharge

coordinator assists with the discharge process, .A team of physiotherapists, occupational

therapists, speech and language therapists, Mental Health liaison officers and Social

workers also have input into patient care.

Discharge coordinator: Is a named person whose responsibility it is to help plan and

coordinate discharge planning communication.

Medically stable: This means:

The patient is safe to discharge and/or ready for safe transfer to another location.

Patient: In this Policy a Patient is an individual aged 18 and over and who is receiving

NHS Care.

Representative: A person nominated by the patient to be involved in discharge planning

or a family member, relative, person granted with a lasting power of attorney, court

deputy, friend or other advocate. It is good practice, unless there are clear reasons for

not doing so, to work with the carers, family and friends of an individual to help them to

get the care and support they need. Sharing information with these people should always

be with the consent of the individual. If the person lacks the mental capacity to make

a decisions about sharing information with key people, then the Mental Capacity Act

should be followed to ensure each decision to share information is in the person’s best

interests. Decisions and reasoning should always be recorded.

ADD: Actual Date of Discharge means when a patient is medically stable and safe for

discharge or transfer.

Self-funder: A person who financially meets the full cost of their Social Care needs,

whether because their financial capital exceeds the threshold for adult services funding or

because they or a representative choose to pay for their care.

Social Care assessment: The assessment of a person’s Social Care needs that all adult

patients are entitled to, regardless of financial status. A Social Care professional will help

identify suitable care and assist with discharge from hospital if asked.

Social Care professional: Social worker or Care manager allocated by Adult Services.

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6. DEFINITION

6.1 A delayed transfer of care (DTOC) occurs when a person is ready for discharge from an

Acute, Community Hospital or Intermediate Care Setting** [delete as appropriate] but is

still occupying a Bed designated for such care. A person is ready for Discharge and

safe transfer when;

A clinical decision has been made that the patient is ready for safe transfer;

The Multi-Disciplinary Team decision is the patient is ready for safe transfer;

The patient is safe to discharge and/or ready for safe transfer to another location.

7. MANAGING CHOICE

7.1 Reasons for delays (DTOCS) can be various but may include delay due to the patient

and/or their representative being unable or unwilling to support or arrange

discharge/transfer from hospital in a timely way. Communication is central to the process

of managing Choice on discharge. When verbal or written communication with the

patient and/or their representative is stated, this applies equally or alternatively, to

communicating with the patent’s representative, as appropriate and with consent.

7.2 The consequences of a patient who is ready for discharge or transfer remaining in an

in-patient setting can be:

Frustration and distress may be caused to patients and/or their relatives whilst

waiting for a preferred discharge destination to become available.

The needs of the person can be more appropriately met in a lower-acuity setting,

including a non-hospital environment

Decrease level of patient independence, as a bed based environment is not

designed to meet the needs of people who are medically stable

The patient is exposed to an unnecessary risk of hospital-acquired infection

The increased pressure within the Health care system, due to the inappropriate use

of inpatient beds.

Beds not being made available for those who really need it.

7.3 Patients may find it difficult to choose a discharge destination or Care provider for

many reasons, such as but not exclusively:

Anxiety at facing the major life transition of moving from hospital to a Care Home for

the first time, possibly for the rest of their life.

Fear about either the quality or the cost of care.

Reluctance to transfer to another inpatient setting that is not local to their home

because loved ones might find it difficult to visit.

Unwillingness to move into interim accommodation when their first choice is

unavailable.

7.4 The Acute, Community Hospital or Intermediate Care Setting** [delete as appropriate]

will acknowledge and offer support with any concerns, whether financial or otherwise,

whilst reinforcing the message that each member of the Multi-Disciplinary Team will

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work towards discharge, at the end of the period of care, to a safe destination. This

destination may not be the patient's preferred destination of choice.

7.5 At the point at which a patient is ready for discharge or transfer of care as decided

by the Multi-Disciplinary Team the patient does not have a choice of continuing to

occupy an Acute, Community Hospital or Intermediate Care Setting Bed** [delete

as appropriate].

7.6 If the patient's preferred Choice of accommodation is not available they will be required

to accept an alternative location or Care provider whilst they await the availability of their

preferred choice.

7.7 Patients who are self-funding their care will be provided with the same advice,

guidance and assistance on Choice as those fully or partly funded by the Local

Authority. If such patients decline to accept advice, guidance and assistance, a risk

assessment will be completed and arrangements will be made for their onward care

on discharge from in-patient setting. Once a patient is deemed ready and safe for

discharge or transfer to their usual place of residence or an alternative setting they will

be subject to the Wiltshire Choice Policy process.

7.8 If a patient can continue their recovery in a more suitable care setting, it is never

appropriate that they remain as an in-patient after they are ready and safe for discharge

or transfer and are no longer requiring An Acute, Community Hospital or Intermediate

Care Setting treatment.

8. CHOICE OF AVAILABLE OPTION/S AND INTERIM CARE

8.1 A discharge plan should include Patient Choice and recognise the patient’s autonomy to

choose from the option/s which are available. Where possible, patients will be offered a

choice but will only be offered accommodation which is available and meets their

assessed needs. On occasions there may only be one option for accommodation. If

more than one appropriate option is available when the patient is ready and safe for

discharge or transfer from an Acute/Community Hospital or Intermediate Care

Setting** [delete as appropriate] the Multi-Disciplinary Team will offer support to the

patient and/or their representative to choose an appropriate care setting.

8.2 Patients may be required to be transferred to an alternative in-patient setting or

discharged to a care setting other than the area the patient and/or their representative

has requested. The reasons for this will be explained. Patients and/or their

representatives need to understand that they do not have the right to remain in their

current in-patient setting longer than is required. If the patient and/or their representative

choose to decline the offer(s) made, discussions will commence on the options for the

patient/representative about their discharge from NHS care.

8.3 There may be occasions when a patient needs care at home or to move to a Residential/

Nursing home and the preferred Care provider or location is not available. This might be

for many reasons, including that the patient’s own home might not be ready to support

the discharge or the preferred Care provider might have no vacancies. Patients do not

have the right to remain in their current in-patient setting longer than required because

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their choice of accommodation is unavailable and they and/or their representative have

refused or not reviewed available option/s.

8.4 The patient and/or their representative will be given information about what would be

involved if the patient requires a domiciliary care package, Care Home placement or

Intermediate Care. Declining or refusal to make a choice about available option/s or

refusal to accept a single available temporary option/s must not lead to the patient

remaining in the hospital indefinitely.

8.5 If available option/s are, or a single available option is rejected as a permanent move,

it may be necessary for the Acute/Community Hospital or Intermediate Care

setting** [delete as appropriate] in consultation with the Local Authority to implement

discharge to an alternative or interim location. If the patient is awaiting a

Residential/Nursing Home, the Local Authority or Clinical Commissioning Group's CHC

department will offer to keep the patient’s name on a waiting list for their preferred

choice, subject to required quality and commissioning strategy. Unless circumstances

determine otherwise, the Local Authority or CHC department will ensure that patients

making an interim move will make only one such move before entering the

Residential/Nursing Home of their choice.

8.6 If a patient and/or their representative indicate that they would prefer to stay in the

interim Residential/Nursing Home permanently, either when offered a place in one of

their original choices or during the waiting process, the Local Authority or CHC

department will endeavour to negotiate this. Any waiting lists the patient is on will be

amended accordingly if the patient is accepted on a permanent basis. If the patient is

not accepted on a permanent basis, they will remain on the waiting lists as before.

The Checklist policy within Wiltshire for patients requiring CHC is that they are

discharged to their preferred place if there is availability and then they are assessed

within 3 months of admission or returning home if they are eligible from date of

discharge the CCG will reimburse agreed Care Home or appropriate Care Package

Costs.

8.8 If an Acute/Community Hospital or Intermediate Care Setting** [delete as appropriate] is

considering implementing discharge in line with the Wiltshire Choice Policy; Trust legal

advisers should be consulted.

9. MENTAL CAPACITY – ASSUMPTIONS OF CAPACITY

I need to insert here a link to each organisations own polices

9.1 A patient is assumed to have capacity to make their own decisions about discharge

arrangements and choice of care setting and a patient will be supported to make their

own decisions when they can. Where a patient is unable to make a decision then

decisions will be made in the patient's best interests in a way which is least restrictive of

the patient's rights and freedom of action.

9.2 Staff will be mindful of the obligation to seek the least restrictive option for the

patient’s discharge. Where the patient lacks capacity, staff should follow the

Trust/Organisational policies and procedures relating to Mental Capacity, Best Interest

and Deprivation of Liberty Safeguards.

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9.3 The safeguarding duties under the Care Act 2014 apply to an adult who:

has needs for care and support (whether or not the Local Authority is meeting any of

those needs) is experiencing, or at risk of, abuse or neglect as a result of those care and

support needs, is unable to protect themselves from either the risk of, or the experience

of, abuse or neglect. The guide under the Care Act 2014 has been created to provide

information on legal options for gaining access to people who fulfil the three criteria

above where access is restricted or denied. It is intended as a source of ready reference

in situations of uncertainty, rather than as a learning tool, laying out the potential routes

to resolution. It is important that social workers and their managers are as clear as

possible on which legal powers or options apply to which situations, and in cases of any

uncertainty that they consult their senior managers and/or the legal department of the

local authority.

9.4 If the patient is unable to make choices regarding discharge, there should be an

assessment of capacity in relation to the decision which the patient is being asked to

make. If the patient lacks capacity then the Multi-Disciplinary Team will make the ‘Best

Interests Decision’ as appropriate unless the decision is escalated in line with the Policy.

The Multi-Disciplinary Team will make the decision in consultation with the patient's

representative, Family, friends or an Independent Mental Capacity Advocate (IMCA, in

line with the Mental Capacity Act (2005) and Codes of Practice, In most cases the Multi-

Disciplinary Team will make the best interests decision as to where the patient will be

discharged or transferred, in consultation as above, but in some cases the decision will

be made by the placing organisation, which will be either the Local Authority or the

NHS Clinical Commissioning Group or both.

9.5 Independent Mental Health Advocacy (IMHA)

Independent Mental Health Advocacy is a statutory form of advocacy. Anyone who is

detained for treatment in a Mental Health setting, under the Act, is entitled to access

support from an Independent Mental Health Advocate (IMHA) in relation to their

detention. Other qualifying patients who qualify for IMHA advocacy support are:

detained or liable to be detained under the 1983 Act

subject to guardianship under the Act

community patients subject to community treatment orders

conditionally discharged

being considered for section 57 or 58A treatments but are not otherwise

subject to the Act (i.e. an ‘informal’ patient)

IMHA services provide an additional safeguard for patients who are subject to the Mental

Health Act, and are specialist advocates who are trained to work within the framework of

the Act. These services will not replace other advocacy services currently available to

patients, but are intended to operate in conjunction with them.

Independent Mental Capacity Advocate (IMCA)

IMCA is to help particularly vulnerable people who lack the capacity to make important

decisions about their Health and Social Welfare and who have no family or friends

with whom to consult about those decisions. The role of the IMCA is to work with and

support people who lack capacity.

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9.6 The Choice Policy applies to all patients 18 and over and being discharged or

transferred.

10. DISCHARGE PLANNING

10.1 Discharge planning starts for elective patients at pre-admission or within 4 hours for

non-elective admissions and recorded on hospital systems.

10.2 Estimated date of discharge, discharge letter and Factsheets and named

Multi-Disciplinary Team are all to be discussed with the patient and/or their

representative.

10.3 A member of the Multi-Disciplinary Team will assess the patient on a daily basis. When

the patient no longer requires the current in-patient setting and is safe for discharge or

transfer the patient will then be ready for discharge or transfer to an appropriate setting

to continue their treatment.

10.4 Whilst the patient still requires inpatient care, the patient representative will be involved

in discharge planning arrangements.

11. DISCHARGE PROCESS.

11.1 All staff are responsible for ensuring effective discharging planning is in place for every

patient from the point of admission until discharge.

11.2 Discharge planning starts for elective patients at pre-admission or within 4 hours for

non-elective admissions and recorded on hospital systems.

11.3 Each Acute/Community Hospital or Intermediate Care Setting is to follow its own Patient

Discharge Process. I need to insert a link here to each organisations Discharge Policy

11.4 Any concerns with discharge plans which may result in a delay are to be escalated in

line with the Wiltshire Choice Policy. Exercise of Discretion is to be used prior to

implementing the Wiltshire Choice Policy.

11.5 No discharge should be delayed if there is an available, appropriate option/s for

discharge or there is an interim option available. Remaining in an in-patient

setting when a patient has been declared as safe for discharge is not an option.

12. ESCALATION PROCESS:

12.1 An informal Mediation discussion is to take place if the Patient and/or their

representative disagree with leaving the Acute/Community Hospital or Intermediate Care

setting** [delete as appropriate]. This discussion can take place with or without the

attendance of the Multi-Disciplinary Team and Ward Matron.

12.2 If the patient and/or their representative are still not accepting the option/s offered to

them once the Mediation discussion has taken place then the Organisation is to initiate

the Wiltshire Choice Policy Process. The Multi-Disciplinary Teams are to discuss the

concerns/anxieties of the patient and/or their representative and encourage the patient

and/or their representative to reconsider. The Multi-Disciplinary Team are to clarify

rationally why safe transfer to an alternative or interim location is important if the

patients’ and/or representatives’ option/s is not available.

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12.3 If after the informal Mediation discussion the Patient and/or their representative agree to

the discharge/transfer then no further action is required.

12.4 If after the informal Mediation discussion the Patient and/or their representative still

disagree to the discharge/transfer then Formal Letter 1 is to be given to them.

12.5 The patient and/or their representative will be invited to a resolution discussion which will

be held even if the patient and/or their representative decide not to attend. At this

meeting the main objective is to give support and encouragement to reach a mutual

agreement with regards their discharge. A letter detailing the discussions held and any

advice or agreement met will be sent to the patient and/or their representative including

any follow up arrangements and again highlighting the rationale for transfer to an

alternative or interim care.

12.6 If discharge/transfer arrangements are still being disputed then consultation with each

organisation’s Legal Advisors is to take place before sending Formal Letter 2. To insert

here a link to each organisations escalation process. Once Legal Advisors confirm

the need to proceed then Formal Letter 2 is to be sent to the patient and/or their

representative. Formal Letter 2 is to be sent no later than 7 days after sending Formal

Letter 1. Formal Letter 2 will explain that discharge and/or safe transfer to an identified

alternative or interim location will go ahead in ???? days in line with the Wiltshire Choice

Policy.

12.7 Continuing disputes are to be referred to the Director of Nursing and the Chief

Executive, both of whom will ensure all related agencies are briefed and are aware of all

outcomes and discussions and of the legal process that will take place. External

messages are to be prepared by each organisations Comms and Legal departments.

12.8 I need to insert here the Wiltshire Clinical Commissioning Group and Wiltshire

Council escalation process document.

13. CONSULTATION AND APPROVAL PROCESS

13.1 The Wiltshire Choice Policy was developed in 2015 with Multi-Disciplinary

Professionals from across Health and Social Care in Wiltshire and through the

Delayed Transfer of Care (DToC) Task & Finish group meetings, Workshops and

individual meetings with various organisations.

13.2 Healthwatch Wiltshire provided advice around engagement process, feedback on

literature/information, and liaison with other Healthwatch’s.

13.3 The Wiltshire Choice Policy was reviewed in June 2015 by the Wiltshire Council Legal

Department to advice on Social Care aspects of the Policy.

13.4 Wiltshire Council Legal - Legal advice on Adult Social Care legislation.

13.5 Patient engagement was received via Healthwatch Wiltshire.

13.6 WCCG Legal – Legal advice on Health legislation

13.7 Upon approval by each organisation involved, the Wiltshire Choice Policy will then be

presented for final approval/sign off at the appropriate Boards.

THIS PART WILL CONTINUE AS THE POLICY DEVELOPS

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14. REVIEW AND REVISION

14.1 This policy will be reviewed annually.

15. MONITORING COMPLIANCE AND EFFECTIVENESS

15.1 Monitoring will take place by Acute Hospital staff, Community Hospital staff and

Intermediate Care Setting Staff with their teams and through other senior executive

groups.

Local monitoring will include an audit of;

Policy effectiveness.

Patient and/or their representative feedback and complaints.

SUMMARY OF THE 6 STAGES

STAGE 1 – GIVE STANDARD INFORMATION: During admission

1.1 The discharge coordinator supports the patient and/or their representative in liaison with

the Multi-Disciplinary Team currently involved in the patient’s care. They also ensure

that those who need to be involved after discharge are contacted at the earliest

opportunity to discuss the patient’s needs and that responsibilities are transferred on

discharge.

1.2 All parties will record plans, communication with the patient and/or representatives,

referrals and actions in the patient’s record.

1.3 If a discharge-planning information leaflet has been agreed locally (i.e. at the hospital),

the discharge coordinator or another member of the Multi-Disciplinary Team will give this

to all adult patients and/or their representatives on admission, and discuss the leaflet

content with them.

1.4 The discharge coordinator ensures that the patient and/or their representative are aware

of the Wiltshire Choice Policy and process for managing choice on hospital

discharge, and of the circumstances in which a move to alternative or interim

accommodation or care might be necessary. All communications reinforce the

expectation that patients will leave the hospital.

STAGE 2 – REFER TO SERVICES TO SUPPORT DISCHARGE: during admission

2.1 If the patient is likely to have ongoing Health or Social needs after discharge a member

of the Multi-Disciplinary Team will ensure timely referral to other services for assessment

as appropriate.

2.2 A member of the Multi-Disciplinary Team will explain expectations to the patient and/or

their representative and will re-offer factsheet 1 to minimise confusion (Appendix 3).

2.3 A patient can refuse NHS-funded care offered by their CHC but they would not then be

eligible for Local Authority funding and would need to self-fund their preferred option to

NHS care.

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2.4 In line with the Mental Capacity Act 2005, a person with a lasting power of attorney or

who is a court appointed Deputy can choose to self-fund their preferred option on behalf

of the patient but this decision would need to be made in the patient’s best interest.

STAGE 3 – OFFER OPTION/S AND PREPARE FOR DISCHARGE- before discharge

3.1 A member of the Multi-Disciplinary Team will advise the patient and/or their

representative about currently available Care providers that can meet their needs (which

may be only one option at that time).

3.2 If Social Services identify that the patient will ‘self-fund’ their care, the Social Care

professional will inform a member of the Multi-Disciplinary Team as to whether or not the

patient has care arranged. If not, they will offer to help the patient and/or their

representative find available option/s.

3.3 If there is currently one available option, the patient cannot remain in an in-patient

setting to wait for further choices and must accept one that is available on an interim

basis.

3.4 If the patient is being referred for inpatient rehabilitation they and/or their representative

will be made aware that a bed might not be available in the care setting close to their

home or, where there is a choice available, in their preferred care setting. The Multi-

Disciplinary Team will explain the benefits of safe transfer to an interim inpatient setting

and that the transfer will enable the patient to receive the correct treatment in an

appropriate setting and maximise their chance of swift recovery. The patient or their

representative cannot refuse to agree transfer from one NHS in patient setting to

another.

3.5 A member of the Multi-Disciplinary Team will clarify expectations and will give factsheet

2 (Appendix 4) to minimise confusion later on.

3.6 When a patient is assessed as ready for discharge to a Care Home, they and/or their

representative will be encouraged by a member of the Multi-Disciplinary Team to

consider the available option/s and to choose one without delay so that discharge can be

arranged on the EDD.

STAGE 4 – AVAILABLE OPTION/S DECLINED- informal process

4.1 The Multi-Disciplinary Team, in consultation with the patient and/or their representative

will agree, where possible, what the patient's needs are upon discharge and what

constitutes a suitable and appropriate option for discharge and discharge letters

(Appendix 5) explaining your discharge and/or safe transfer.

4.2 If the patient and/or their representative is not happy with the proposed arrangements to

facilitate discharge, a member of the Multi-Disciplinary Team will explain clearly that

refusal to choose an available Care provider or inpatient setting will not delay the

discharge process from proceeding.

4.3 At this stage, a member of the Multi-Disciplinary Team will encourage resolution of any

potential barrier to discharge and seek support from the Mediation Team.

4.4 The patient and/or their representative have the right to be provided details of the Patient

Advice and Liaison Service (PALS) for advice and information regarding advocacy if

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required. The Patient Advice and Liaison Service (PALS) offer confidential advice,

support and information on health-related matters. They provide a point of contact for

patients, their representatives, their families and their carers. You can find officers from

PALS in your local hospital. find your nearest PALS office . To be inserted here a link

to each organisations Complaints Procedures.

4.5 If discharge arrangements are still not agreed, then Formal Letter 1 (Appendix 6) will be

given to the patient and/or their representative.

4.6 The patient and/or their representative will be invited to a resolution meeting, which is

held even if the patient and/or their representative do not attend. The aim of the meeting

is to resolve any of the patient's anxieties or concerns. Clarification on why it is in the

patient's best interests to accept safe transfer will be explained. A letter of the

discussions in the meeting are to be sent to the patient and/or their representative where

possible within 24 hours with the follow-up arrangements that are agreed and the

rationale as to why discharge or transfer to an alternative or interim care setting is in the

best interests of the patient.

4.7 The resolution meeting enables all parties to discuss and agree discharge or transfer to

the most appropriate available setting, even if this is as an interim option.

STAGE 5 – LETTER 2 – (Appendix 6) formal process

5.1 If the patient and/or their representative are still disputing with the discharge planning,

then organisations should seek their own advice according to their own discharge

policies. The Policy recommends that Legal Advisors are to be consulted prior to Formal

Letter 2 (Appendix 7) being sent to the patient and/or their representative. Once the

Legal Advisors confirm the Wiltshire Choice Process is still to be implemented then

Formal Letter 2, explaining that discharge to the identified alternative or interim inpatient

setting will go ahead with a planned EDD which should be set wherever possible, which

will be sent no later than 7 days from the decision to implement Formal Letter 2.

5.2 The Multi-Disciplinary Team will continue to work with the patient and/or their

representative to try and resolve the situation and agree discharge or transfer.

STAGE 6 – LEGAL PROCESS

6.1 If no agreement has been reached regarding discharge arrangements after Stages 1 – 5

and transfer arrangements are challenged by the patient and/or their representative,

then these disputes will be referred initially to the Director of Nursing and the Chief

Executive of the organisation where the patient is accommodated, both of whom will

ensure all related agencies are briefed and are aware of all outcomes and discussions

and of the legal process that will take place. Escalation to organisational leads in line

with each organisation’s Discharge Policy. As stated earlier in the Policy to have a

link inserted here to the relevant Discharge Policy Document

6.2 The Director of Nursing and the Chief Executive will consult with their Legal advisors

regarding legal proceedings to ensure safe discharge from hospital, in order to

safeguard the health and wellbeing of this and other patients.

6.3 Prepare external message/lines to take with Comms/Legal.

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6.4 Where the Local Authority or the NHS Wiltshire Clinical Commissioning Group is placing

the patient and the dispute cannot be resolved at organisational level, the dispute should

be escalated to the placing authority (either the Local Authority or NHS WCCG or both),

so that further legal advice can be sought by the placing organisation. To insert here

the escalation process for WCCG and LA

6.5 Wherever possible disputes about placement should be resolved informally and by

mediation. To achieve a safe discharge where necessary, legal advice will be sought as

to the appropriate option/s available. To insert a link here for each organisation’s

escalation process

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(Appendix 1)

SUMMARY OF THE 6 STAGES – To be given to the patient and/or their representative

Stage 1: STANDARD INFORMATION TO BE GIVEN TO THE PATIENT AND/OR THEIR REPRESENTATIVE

Summary of the 6 Stages (Appendix 1) and Managing your discharge – patient information letter – (Appendix 2) are to be given during the discussions that are to start with the patient and/or their representative within 4 hours of admission with regards to their discharge planning.

Explain the process for reviewing Estimated Date of Discharge (EDD).

The discharge coordinator supports the patient and/or their representative in liaison with the Multi-Disciplinary Team currently involved in the patient’s care. They also ensure that those who need to be involved after discharge are contacted at the earliest opportunity to discuss the patient’s needs and that responsibilities are transferred on discharge.

All parties will record plans, communication with the patient and/or representatives, referrals and actions in the patient’s record.

If a discharge-planning information leaflet has been agreed locally (i.e. at the hospital), the discharge coordinator or another member of the Multi-Disciplinary Team will give this to all adult patients and/or their representatives on admission, and discuss the leaflet content with them.

The discharge coordinator ensures that the patient and/or their representative are aware of the Wiltshire Choice Policy and process for managing choice on hospital discharge, and of the circumstances in which a move to alternative or interim accommodation or care might be necessary. All communications reinforce the expectation that patients will leave the hospital.

Stage 2: REFER TO SERVICES TO SUPPORT DISCHARGE

If the patient is likely to have ongoing Health or Social needs after discharge a member of the Multi-Disciplinary Team will ensure timely referral to other services for assessment as appropriate.

A member of the Multi-Disciplinary Team will explain expectations to the patient and/or their representative and will re-offer Factsheet 1 to minimise confusion (Appendix 3).

A patient can refuse NHS-funded care offered by their CHC but they would not then be eligible for Local Authority funding and would need to self-fund their preferred option to NHS care.

In line with the Mental Capacity Act 2005, a person with a lasting power of attorney or who is a court appointed Deputy can choose to self-fund their preferred option on behalf of the patient but this decision would need to be made in the patient’s best interest.

Stage 3: OFFER AND PREPARE FOR DISCHARGE

A member of the Multi-Disciplinary Team will advise the patient and/or their representative about currently available Care providers that can meet their needs (which may be only one option at that time).

If Social Services identify that the patient will ‘self-fund’ their care, the Social Care professional will inform a member of the Multi-Disciplinary Team as to whether or not the patient has care arranged. If not, they will offer to help the patient and/or their representative find available option/s.

If there is currently one available option, the patient cannot remain in an in-patient setting to wait for further choices and must accept one that is available on an interim basis.

If the patient is being referred for inpatient rehabilitation they and/or their representative will be made aware that a bed might not be available in the care setting close to their home or, where there is a choice available, in their preferred care setting. The Multi-Disciplinary Team will explain the benefits of safe transfer to an interim inpatient setting and that the transfer will enable

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the patient to receive the correct treatment in an appropriate setting and maximise their chance of swift recovery. The patient or their representative cannot refuse to agree transfer from one NHS in patient setting to another.

A member of the Multi-Disciplinary Team will clarify expectations and will give factsheet 2 (Appendix 4) to minimise confusion later on.

When a patient is assessed as ready for discharge to a Care Home, they and/or their representative will be encouraged by a member of the Multi-Disciplinary Team to consider the available option/s and to choose one without delay so that discharge can be arranged on the EDD.

Stage 4: AVAILABLE OPTION/S DECLINED

The Multi-Disciplinary Team, in consultation with the patient and/or their representative will agree, where possible, what the patient's needs are upon discharge and what constitutes a suitable and appropriate option for discharge and discharge letters (Appendix 5) explaining your discharge and/or safe transfer.

If the patient and/or their representative is not happy with the proposed arrangements to facilitate discharge, a member of the Multi-Disciplinary Team will explain clearly that refusal to choose an available Care provider or inpatient setting will not delay the discharge process from proceeding.

At this stage, a member of the Multi-Disciplinary Team will encourage resolution of any potential barrier to discharge and seek support from the Mediation Team.

The patient and/or their representative have the right to be provided details of the Patient Advice and Liaison Service (PALS) for advice and information regarding advocacy if required. The Patient Advice and Liaison Service (PALS) offer confidential advice, support and information on health-related matters. They provide a point of contact for patients, their representatives, their families and their carers. You can find officers from PALS in your local hospital. find your nearest PALS office . To be inserted here a link to each organisations Complaints Procedures.

If discharge arrangements are still not agreed, then Formal Letter 1 (Appendix 6) will be given to the patient and/or their representative.

The patient and/or their representative will be invited to a resolution meeting, which is held even if the patient and/or their representative do not attend. The aim of the meeting is to resolve any of the patient's anxieties or concerns. Clarification on why it is in the patient's best interests to accept safe transfer will be explained. A letter of the discussions in the meeting are to be sent to the patient and/or their representative where possible within 24 hours with the follow-up arrangements that are agreed and the rationale as to why discharge or transfer to an alternative or interim care setting is in the best interests of the patient.

The resolution meeting enables all parties to discuss and agree discharge or transfer to the most appropriate available setting, even if this is as an interim option.

5: FORMAL LETTER 2 (APPENDIX 7)

If the patient and/or their representative are still disputing with the discharge planning, then organisations should seek their own advice according to their own discharge policies. The Policy recommends that Legal Advisors are to be consulted prior to Formal Letter 2 (Appendix 7) being sent to the patient and/or their representative. Once the Legal Advisors confirm the Wiltshire Choice Process is still to be implemented then Formal Letter 2, explaining that discharge to the identified alternative or interim inpatient setting will go ahead with a planned EDD which should be set wherever possible, which will be sent no later than 7 days from the decision to implement Formal Letter 2.

The Multi-Disciplinary Team will continuously work with the patient and/or their representative to try and resolve the situation and agree discharge or transfer.

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6: LEGAL PROCESS

If no agreement has been reached regarding discharge arrangements after Stages 1 – 5 and transfer arrangements are challenged by the patient and/or their representative, then these disputes will be referred initially to the Director of Nursing and the Chief Executive of the organisation where the patient is accommodated, both of whom will ensure all related agencies are briefed and are aware of all outcomes and discussions and of the legal process that will take place. Escalation to organisational leads in line with each organisation’s Discharge Policy. As stated earlier in the Policy to have a link inserted here to the relevant Discharge Policy Document

The Director of Nursing and the Chief Executive will consult with their Legal advisors regarding legal proceedings to ensure safe discharge from hospital, in order to safeguard the health and wellbeing of this and other patients.

Prepare external message/lines to take with Comms/Legal.

Where the Local Authority or the NHS Wiltshire Clinical Commissioning Group is placing the patient and the dispute cannot be resolved at organisational level, the dispute should be escalated to the placing authority (either the Local Authority or NHS WCCG or both), so that further legal advice can be sought by the placing organisation. To insert here the escalation process for WCCG and LA

Wherever possible disputes about placement should be resolved informally and by mediation. To achieve a safe discharge where necessary, legal advice will be sought as to the appropriate option/s available. To insert a link here for each organisation’s escalation process

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MANAGING YOUR DISCHARGE; PATIENT INFORMATION (Appendix 2)

Date

Dear

It is time for you to Leave this Acute/ Community Hospital or Intermediate Care Setting**

[delete as appropriate]

We are pleased you are feeling better and that you are now ready to leave. During your time in

this Acute/Community Hospital or Intermediate Care Setting** [delete as appropriate] your Multi-

Disciplinary Team have made regular assessments of your abilities and needs. It is now

confirmed you are save for transfer and therefore ready for discharge.

An assessment has been made of the help and support you need next, to help you to stay well

and supported, and a decision has been made for you to be discharged to your home with

Care/a Residential Home/a Care Home/a Community Hospital or an Intermediate Care Bed**

[delete as appropriate].

Now you are ready to be discharged there are good reasons why you should not stay in

hospital:

A hospital ward is not the best place to continue your recovery once your Acute Hospital

illness is over

Staying in hospital longer than necessary will impact on your recovery

Staying in hospital may increase your risk of acquiring infection

The benefits of effective discharge planning for you are:

Your needs are met

You are able to maximise independence

You will feel part of the care process, an active partner and not disempowered

So that you are able to be discharged as smoothly as possible, it is essential to have an

effective plan in place.

What happens next?

A member of your Multi-Disciplinary Team will work with you and/or your representative to find

an appropriate Care Package/ Residential Home/ Care Home/ Community Hospital,

Intermediate Care Setting** [delete as appropriate] that has capacity. An assessment will be

used to make this decision and your Multi-Disciplinary Team will help to find the relevant care

that meets your assessed needs.

Throughout this process every effort will be made to ensure your needs are met. If you find a

Residential or Care Home ** [delete as appropriate] which does not currently have a vacancy,

you will be moved to an alternative Residential or Care Home** [delete as appropriate] which

does meet your assessed needs, until the original vacancy becomes available. If you need a

Community Hospital or Intermediate Care Setting** [delete as appropriate], we will transfer you

to the first available bed in any of those available across Wiltshire. This is in order to maximise

your therapy and rehabilitation opportunities.

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Timescales

Once you have been declared safe for transfer and have been offered alternative care, you

need to leave hospital by your Actual Date of Discharge which has been confirmed with you

and/or your representative. We will do everything we can during this period to assist you to find

the care that meets your needs.

The Wiltshire Choice Policy Process comprises of six stages. (Please see attached

sheet) Please note the Wiltshire Choice Policy will come into effect at Stage 4.

Stages 1 to 3 apply to EVERY patient in order to provide support in a safe and timely

way:

Stage 1 – Information to be given to the patient and/or their representative

Stage 2 – Referred for service support to enable discharge

Stage 3 – Available care offered and patient is discharged

Stages 4 to 6 represent the formal escalation process:

Stage 4 – Available option/s declined – Wiltshire Choice Policy comes into effect

Stage 5 – Formal meeting held to agree an interim plan and patient receives a Formal Letter (1)

Stage 6 – Legal process begins and patient receives a second Formal Letter (2)

Social Care Payments

If the place you are moving to needs to be funded and you need financial assistance to help you

do this a Social Worker can assist you with this process. You will be asked to provide the

relevant information needed to complete a financial assessment – you will need to return this

information within 5 working days.

Overview of the process to be followed if offer of onward care is refused

A discharge plan will include ‘patient choice’ where possible, and recognise your autonomy to

choose from the option/s available according to your assessed needs. If more than one

appropriate option is available, your Multi-Disciplinary Team will offer to support you and/or your

representative to choose your preferred option once you are ready for safe transfer or

discharge.

If only one identified option can currently meet your care needs, transfer to this single currently

available option is not to be rejected by you and/or your representative.

There may be occasions when a patient needs to be transferred to another hospital but the

preferred hospital has no vacancies. Patients and/or their representatives will be offered an

alternative option where there is availability, and patients and/or their representatives do not

have the right to remain in the current hospital simply because they do not wish to accept

treatment at the alternative available option. If they choose to decline the alternative offered

transfer, discussions should start regarding discharge from NHS care.

There may be occasions when a patient needs to have care provided at home or to move to a

Care Home, and the preferred Care provider or location is not available. This could be for many

reasons, including that the patient’s own home might not be ready to support the discharge or

the preferred Care provider might have no vacancies. Patients do not have the right to remain

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in hospital longer than required because they and/or their representative have refused, or have

not reviewed the available alternative option/s.

If appropriate and possible, the patient will be helped to return to their own home, perhaps with

care and support or following an interim period of rehabilitation.

The patient and/or their representative will be given information about what would be involved if

the patient requires a Domiciliary Care package, Care Home placement or Intermediate Care.

Refusal to make a choice about available option/s or refusal to accept a single available

temporary option must not lead to the patient remaining in the hospital indefinitely.

If available option/s are, or a single available option is rejected as a permanent move, it may be

necessary for the Acute/ Community Hospital or Intermediate Care Setting** [delete as

appropriate] in consultation with the Local Authority or NHS Continuing Healthcare (CHC)

department to implement discharge to an alternative or interim location. If the patient is awaiting

a Care Home, the Local Authority or CHC department will offer to keep the patient’s name on a

waiting list for their preferred choice, subject to required quality and commissioning strategy.

Unless circumstances determine otherwise, the Local Authority or CHC department will ensure

that patients making an interim move should make only one such move before entering the

Care Home of their choice.

If a patient and/or their representative indicate they would prefer to stay in the interim Care

Home permanently, either when offered a place in one of their original choices or during the

waiting process, the Local Authority or CHC department will endeavour to negotiate this. Any

waiting lists the patient is on will be amended accordingly should the patient be accepted on a

permanent basis. If the patient is not accepted on a permanent basis, they will remain on the

waiting lists as before.

If the Acute/Community Hospital or Intermediate Care Setting** [delete as appropriate] is

considering implementing discharge in line with this policy, Trust legal advisers will be

consulted.

If the patient has not left hospital by their Actual Date of Discharge [insert date] then legal action

will be taken by the [???] to allow the patient to be discharged to a place meeting their needs. A

patient and/or their representative will be advised of the legal action being initiated by receipt of

a legal letter.

There is support available throughout the discharge process and staff members will speak to

your Care team if you have any questions or concerns. Patients will only be moved once it has

been agreed by their Multi-Disciplinary Team that they are safe for discharge. Very rarely there

can be disagreements about the timing or the Care required which can be difficult to negotiate

and we will work with you and/or your representative to resolve these situations.

We recognise that discharge from hospital can be a difficult and stressful time for patients, their

families and carers, but please remember, we are here to help.

If you have any queries during the process then please do not hesitate to contact us at any

time.

Yours sincerely

[INSERT SIGNATURE BLOCK OF AUTHORISED SIGNATORY]

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DISCHARGE PLANNING FACTSHEET 1 (Appendix 3)

Dear Sir/Madam

During your stay in hospital, Health and Social Care services are here to help you so that you

are able to leave hospital as quickly and easily as possible, and to help you understand what

the next steps will be regarding your future care. Health and Social Care Services are required

to follow national legislation on the way that your discharge from hospital is planned.

This letter explains the policy that has been agreed by ??????

From the day of your admission into this Acute/Community Hospital or Intermediate Care

Setting** [delete as appropriate] we will discuss with you and/or your representative about your

needs in order to support a safe discharge. When your consultant confirms you are safe for

discharge and therefore no longer need the health care you are receiving, we will aim to move

you as soon as possible. This could be to your own home or somewhere such as rehabilitation

or a short stay unit in a Community Hospital or Intermediate Care Setting ** [delete as

appropriate].

Most patients will be discharged straight home. Sometimes an immediate return home is not

possible and you may need extra support. In these situations the Multi-Disciplinary Team will

arrange a referral to Social Services. The Social worker will work with you and/or your

representative and the rest of the Multi-Disciplinary Team to identify your needs and arrange the

most appropriate help.

If the assessment shows that you need Residential or Nursing Home care to meet your long

term needs, you and/or your representative will be given option/s to choose from of the home

you would like to live in. If your first choice home does not immediately have a vacancy, and you

choose to wait for a place to become available there, you will be supported to move to an

interim place elsewhere which Social Services will help to arrange, until your first choice is

available.

Should you choose not to be referred to Social Services, or if you intend to fund your own care,

you will be responsible for ensuring you have made appropriate arrangements once you have

been declared safe for transfer.

If your assessment shows you require Intermediate Care, you will be advised of the services

available to you. It is not possible to refuse an Intermediate Care Setting based on the location

of the placement and, whilst every effort will be made to find you a bed as near to your home as

possible, remaining in an Acute/Community Hospital Bed is not an option when an Intermediate

Care Setting is available.

If you have concerns about how you will manage after you are discharged, please speak with

the Ward Sister or Nurse-in-Charge.

This factsheet does not have to be used but can be photocopied and given to inpatients and/or their

representatives. When a patient has been assessed under the Mental Capacity Act 2005 as not having

capacity to make decisions about their discharge, this factsheet can be given to a representative, such as

their next of kin.

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DISCHARGE PLANNING FACTSHEET 2 (Appendix 4)

ACCEPTING AN AVAILABLE OPTION

Dear Sir or Madam

Following your admission to this hospital we want to help you with your arrangements to make

sure you have the right level of care now that you are safe to be discharged from hospital.

Your recent assessment shows that you will need ongoing care or reablement/rehabilitation

outside of this hospital. A member of your Multi-Disciplinary Team who has been caring for you

will advise you of the current available option/s. You will need to choose one of the option/s

available to you at this time. If you have not had this information yet, please let us know.

If your first choice has no vacancies now, you will be asked to move to a temporary option which

is available whilst you wait for your preferred choice to be ready. This is so you receive the

treatment you need as soon as possible in the appropriate Care setting. If you would like a

copy of this factsheet to be given to someone else who cares for you, or you have any

questions, please speak to one of the nurses on your ward or to any member of the Multi-

Disciplinary Team caring for you.

Please do not hesitate to ask if you have any questions.

Best wishes for your continued recovery.

Yours sincerely

This factsheet does not have to be used but can be photocopied and given to inpatients and/or their

representatives. When a patient has been assessed under the Mental Capacity Act 2005 as not having

capacity to make decisions about their discharge, this factsheet can be given to a representative, such as

their next of kin.

LOGO’S

Our reference: (Appendix 5)

To:

Date:

Dear Sir or Madam

CHOICE LETTER 1A

Notification of plan to transfer to another hospital

The members of your Multi-disciplinary Team caring for you at this Acute/Community Hospital,

Intermediate Care Setting** [delete as appropriate] have assessed that you need to transfer to

another hospital to continue your treatment or rehabilitation. We understand that you may

prefer not to move to a different hospital but your condition has improved which means you no

longer need the level of care provided at this Acute/Community Hospital.

As you are unable to return home safely yet we will do everything we can to help you to move

onto the next step of your treatment in another Care setting with as little anxiety to you and/or

your representative.

To make sure that you continue to get well as quickly as possible, it is important that we help

you to receive the next level of treatment without delay.

Please be aware that the hospital you prefer to go to next may not have beds available at the

time of your safe transfer from this hospital. If you would like, we can ask that your name

remains on the waiting list for an alternative hospital to the one you have chosen for the next

step of your recovery. Of course this also means that you may become well enough to return

home from the alternative hospital very quickly.

Please discuss transfer plans with the nurse in charge of your ward or the person below. We

will make arrangements for safe transfer to the most appropriate hospital to further your

treatment and which is able to offer you a bed.

If you would like a copy of this letter to be given to someone else or you have any questions

please speak to the person below or any member of the Multi-Disciplinary Team caring for you.

Please do not hesitate to ask if you have any questions.

Ward contact name and phone number: ………………………………………………………

Best wishes for your continued recovery.

Yours sincerely

LOGO’S

Our reference: (Appendix 5)

To:

Date:

Dear Sir or Madam

CHOICE LETTER 1B Leaving hospital and moving to a Residential or Nursing home

You will soon be ready to leave this Acute/Community Hospital, Intermediate Care Setting**

[delete as appropriate] and the members of your Multi-Disciplinary Team who have been looking

after you will have discussed and agreed with you what your needs will be when you are

discharged. The members of the Multi-Disciplinary Team who understand your needs have

recommended that at the current time, the best place your needs can be met are in a

Residential/Nursing home and we will be doing all we can to support you to move to a home

that meets your needs.

The Acute/Community Hospital, Intermediate Care Setting** [delete as appropriate] has decided

that you no longer require treatment and care in this environment and will therefore wish to

ensure you leave this Acute/Community Hospital, Intermediate Care Setting** [delete as

appropriate] at the earliest possible time so that you can start to receive care which is more

appropriate for you. This is best for you and your health, and it means that the hospital is able

to treat patients who need a bed in acute care as quickly as possible. Our Adult Care

Team/Care Home Selection will advise you about your choice of care / nursing home, including

some guidance on the average costs which the Council will pay for care / nursing home beds.

We believe this will help you and your family to make the best decision in your choice of care /

nursing home. We will also advice you whether you should be looking for a Residential or

Nursing home, as the services and costs differ between these, and some services won’t be

relevant to the sort of care you need now. Although you are entirely self-funding at the moment,

it might be likely that the Council will take over your funding responsibility in the future, so you

may wish to choose a home which provides services at the cost which the Council usually pays.

Finally, it’s important that this hospital treats the people who need the level of care and support

as soon as they require our help. We are sure that you and/or your representative will

understand this and help us to ensure we are able to use our resources for as many people as

possible who need that level of support. We urge you and/or your representative to consider

your future residence as soon as you have been given an Estimated Date of Discharge.

Please contact the Wiltshire Social Care Team if you have any concerns or if you need advice

at any time. You and/or your representative will have been given a leaflet with the contact

details of the team, (I need to understand who this is) or you can speak to a member of the

Multi-disciplinary Team or member of the hospital Ward staff and they will be able to give you

the telephone number.

Best wishes for your continued recovery.

Yours sincerely

LOGO’S

Our reference: (Appendix 5)

To:

Date:

Dear Sir or Madam

CHOICE LETTER 1C

Notification of plan to transfer from the Acute Hospital to Intermediate Care (interim care)

whilst waiting for a Care Package.

We understand that you are ready to leave this Acute/Community Hospital, Intermediate Care

Setting** [delete as appropriate] so that you can receive care at home, but it has not yet been

possible to find a Care Package suitable to your needs, and at present you are not yet safe at

home without care.

It is important for your continued recovery that you start to receive the right kind of care as soon

as possible. This means that this hospital is no longer the right place for you to receive your

treatment. A Care manager has been asked to find you a place in a Care Home where you can

begin to receive the level of care you need on a temporary basis, until we have been able to

secure the Care Package you will receive at your own home. As soon as this is the case, you

will be able to go home. The Care manager can make arrangements for your move to the

temporary Care Home and will continue to help you arrange care at home and to help you make

the arrangements to get you home. Please discuss discharge plans with the nurse in charge of

your ward. You might have organised your own alternative arrangements to allow you to leave

hospital. Please let us know, if we do not hear from you or your Care manager we will make

arrangements for transfer to a temporary Care Home as soon as possible.

If you would like a copy of this letter to be given to someone else or you have any questions

please speak to one of the people below or any member of the Multi-Disciplinary Team caring

for you.

Please do not hesitate to ask if you have any questions.

Ward contact name and phone number: ………………………………………………

Care manager name and phone number: …………………………………………............

Best wishes for your continued recovery.

Yours sincerely

LOGO’S

Our reference: (Appendix 5)

To:

Date:

Dear Sir or Madam

CHOICE LETTER 1D

Notification of plan to transfer to a temporary location until housing is ready – This

would only be if the patients’ needs met Social Care criteria.

We understand that you are ready to leave this Acute/Community Hospital, Intermediate Care

Setting** [delete as appropriate] but that your home will need cleaning or adaptation before you

can return there. You might also need a new home to be found for you which is more suitable

for you.

It is important for your continued recovery that you start to receive the right kind of care as soon

as possible. This means that this hospital is no longer the right place for you to receive your

treatment. A Care or Housing manager has been asked to find you a temporary place in a Care

Home, until you are able to return to your own, or your new home. Your Care or Housing

manager will make arrangements for your move to the temporary place and when your home is

ready, they can also help with making arrangements for your transfer home.

Please discuss discharge plans with the nurse in charge of your ward. You may have arranged

your own alternative plans. If you do not wish to transfer to the temporary location found by

your Care or Housing manager you will need to inform us, so that you can leave the hospital

without further delay. Otherwise, we will make arrangements for transfer to the temporary

location as soon as possible.

If you would like a copy of this letter to be given to someone else or you have any questions

please speak to one of the people below or any member of the Multi-Disciplinary Team caring

for you. Please do not hesitate to ask if you have any questions.

Ward contact name: ………………………………………………………………………

Ward contact phone number: ……………………………………………………………

Care or Housing manager name: …………………………………………………………

Care or Housing manager phone number: …………………………………………...........

Best wishes for your continued recovery.

Yours sincerely

LOGO’S

Our reference: (Appendix 6)

To:

Date:

Dear Sir or Madam FORMAL LETTER 1

YOUR DISCHARGE FROM HOSPITAL

As we said in our previous letter dated (date), we are pleased that you are well enough to leave

this Acute/Community Hospital Intermediate Care Setting.

We do not wish to cause you or your family undue anxiety or distress, but you will be aware that

there are many people needing hospital care and we need to be able to offer treatment to

others requiring care at the earliest opportunity and we would like to complete your safe transfer

as smoothly as possible.

It is important you leave this Acute/Community Hospital Intermediate Care Setting so you can

be provided with the level of care and support that you currently require. The Trust will,

therefore, formally discharge you to one of the option/s given to you.

All members of the Multi-Disciplinary Team will assist you with the transfer and answer any

questions you may have about your care. Alternatively, if you or your representative would like

to discuss this decision with a Senior Trust Manager then please do not hesitate to contact me

at the above number.

If you are still dissatisfied, you are entitled to have your complaint investigated under the NHS

Complaints Procedure (PALS). Please contact your Ward Manager if you wish to obtain further

details of this procedure.

I would like to take this opportunity to offer you my best wishes for the future and to thank you

for your co-operation.

Yours sincerely

LOGO’S

Our reference: (Appendix 7)

To:

Date:

Dear Sir or Madam

FORMAL LETTER 2

FINAL NOTIFICATION – DATE OF TRANSFER TO ALTERNATIVE CARE

I am writing further to the letter you were recently sent, informing you of proposed arrangements

for your discharge. This Acute/Community Hospital or Intermediate Care Setting** [delete as

appropriate] has offered you all the necessary support and guidance to enable your safe and

appropriate discharge. You have been informed of your responsibility to finalise other

arrangements if you would prefer not to accept what has been proposed.

As outlined in the notification letter, we will now instigate safe transfer to the location below,

which has been assessed as suitable to meet your needs. Should this transfer be refused, this

Acute/Community Hospital or Intermediate Care Setting** [delete as appropriate] will be

required to take legal advice to facilitate discharge.

You will be informed if you are responsible for paying care fees. If you are appealing a Local

Authority or NHS decision regarding funding, the fees you pay may be reimbursed if your

appeal is upheld.

If you would like further information or support regarding discharge arrangements please speak

to a member of your Multi-Disciplinary Team caring for you. If we do not hear from you, we will

assume that you are happy with the content of this letter and that we continue to arrange safe

transfer without your involvement.

Please do not hesitate to ask if you have any questions.

Discharge destination:

Address:

Tel number: Date of transfer/discharge:

Yours sincerely