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Managing hospital admissions and transfer between places of care
Hospital admissions
When a care home resident goes to hospital it is important to make sure that hospital staff are given all the information they need to support and care for that person. Care homes can help with this by ensuring that when a resident goes to hospital important documents relating to their care should go with them to hospital. This ensures continuity of care for the resident.
What information do I need to send?
Care homes need to look at sending the following information:
- Any DNAR (Do Not Attempt Resuscitation) / ReSPECT forms
- Any Advanced Care Plan
- MAR (Medication Administration Record) sheets
-
Know who I am/ This is me / One page profile. If you don't already use one of these then Alzheimer's Society have a template available for this. This is me template This Is Me Booklet
- Any information/care plans that may help hospital staff in relation to behaviour that may challenge as information here may help staff de-escalate or distract patients who become agitated or distressed
Care Homes may also send SBAR (Situation Background Assessment Recommendation) information. Not all care homes use this documentation so don't panic if you don't use this.
What if the resident returns without their documentation?
If any resident returns to the care home from hospital without the documentation that was sent with them, then please fill the following Operational discharge form
This can then be emailed to stephanieturner4@nhs.net . Please also send a copy to carequality@leeds.gov.uk as we regularly meet with the Integrated Care Board.
Care Home Trusted Assessors
Challenges have been identified in relation to hospital discharges into care homes. Specifically, delays have been linked with a wait for assessments to be completed to understand if a patient is appropriate for the particular home and whether they are able to meet the identified needs. Due to pressures faced within the care home at any given time, it can take up to a week, in some cases, to undertake an initial assessment. This causes the patient, who is medically fit for discharge, unnecessary and extended time in hospital as well as putting increased pressures on the hospital.
In order to overcome this challenge and to develop relationships with care homes, the Care Home Trusted Assessor(CHTA) role has been introduced to provide support to both care homes and the hospital, around discharges.
The CHTA provides a comprehensive assessment which enables an informed decision to be made by the home manager, regarding suitability for the service. Managers can still visit the ward and meet the patient after the CHTA assessment if it is felt that needs can be met, alternatively, discharge can be coordinated if it is felt an appropriate placement. It is important to note that if you as the manager, do not feel able to support the needs of an individual based upon the CHTA assessment, you are not obliged to admit. Discharges must be safe.
The CHTA can also review an existing resident who is in hospital where a home may be concerned that needs may have changed. We commit to undertaking as assessment for a returning resident within 2 hours, time of referral dependent, in order to try and facilitate a timely discharge home.
The CHTA is not assessing the needs of the patient and is not involved in the decision-making process regarding home selection. Home managers maintain the regulatory responsibility for admissions and ongoing care planning.
To make a referral, arrange a joint assessment or a visit and for any further information contact:
julia.taylor@leeds.gov.uk 07595210217
helen.rayworth2@leeds.gov.uk 07712215156
For more information click here - Trusted Assessor Role .
Get Me Better Champions - resources for learning disability providers
Leeds and York Partnership NHS Foundation Trust have a range of resources for individuals with a learning disability.
All of these resources can be found here:-
https://www.yourhealthmatters-leeds.nhs.uk/get-me-better-resources/
Hospital Passport
Individuals with a learning disability should be supported to complete this and a copy should be taken with them to the hospital for planned or emergency admissions or treatment.
About the end of my life
This is a document that can be completed with individuals with a learning disability to plan for the end of their life.
If you support someone with a learning disability and/or autism, and they have a planned hospital admission or have been admitted in an emergency, please contact the following team who can offer support around meeting reasonable adjustments:
Alison Conyers or Barbara Ball
Email - Leedsth-tr.ldautism@nhs.net
Tel - 0113 2066836
Mob -07899988703
Palliative Care - https://www.yourhealthmatters-leeds.nhs.uk/get-me-better-palliative-care/.
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