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Sunday 23 November 2008
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Policy on the Direction on Choice of Accommodation and managing reluctant discharge from hospital for NHS and Local Authority organisations within South West Peninsula
Contents
1. Introduction
2. Maintaining Independence
3. Summary of the Choice of Accommodation Directions
4. Technical Details
5. Roles and Responsibilities for Direction on Choice of Accommodation
6. Process for Implementing the Choice of Accommodation Directions
7. Reluctant Discharge from An NHS Bed
8. Monitoring and Evaluation
1.1 This policy has been produced by the SHA, in collaboration with, NHS Trusts and Social Services Departments in the South West Peninsula. It is intended to set a framework for developing local agreements between NHS Trusts and Social Services Departments within the Peninsula.
1.2 The objective of the policy is to ensure consistency in the outcomes service users and patients can expect irrespective of where they live within the peninsula and the organisation with which they come in contact. However, the process through which the policy is implemented will vary according to local arrangements.
1.3 This policy has been developed in collaboration with the Peninsula Reimbursement Project Board on behalf of individual NHS Trusts, PCT’s and Social Services Authorities. The principles that underpin the Joint Policy on Reimbursement apply in full to this guidance. This document should be read alongside:
1.4 The aim of this policy is to assist local health and social care communities to review current procedures and practice in relation to the “Choice of Accommodations Directions” and processes for managing reluctant discharges.
1.5 The DoH has issued new draft guidance to update existing guidance in light of the Community Care (Delayed Discharges) Act 2003[2]. This guidance clarifies a number of issues and elaborates on the use of alternative forms of care. It does not change the underlying position therefore local systems should not delay the review and further development of their local arrangements in anticipation of the final version.
1.6 This document has been issued to support the development of local protocols to address the issues which may arise when people need to move from NHS hospital care to a care home once the Multi Disciplinary Team (MDT) assess that hospital care is no longer required. However, the principles set out here will apply equally to moves from any one form of care to another (e.g. Community Hospital to Continuing NHS care, Intermediate care to long term care).
2.1 Most people return home after a period of acute care, some after a period of intermediate care. Local policies and procedures and service provision should support maximum opportunity for rehabilitation and continued independence as close to home as possible.
2.2 Ability to return home is often proscribed because of the lack of available support services. It is not in the best interest of an individual who was admitted to an acute hospital from home, to be discharged to a long term residential or nursing home placement. There may be exceptions to this, in which case there should be full agreement between all members of the MDT, the individual and where appropriate their family/carers. Therefore, all health and social care systems should aim to have in place services so that no older person who is admitted to an acute hospital from their own home is discharged directly to long-term care.
2.3 It should be recognised that when a transfer to a registered care home is the agreed outcome, proper opportunity for maximum rehabilitation and consideration of this major life decision should have taken place prior to a long term placement being made.
3.1 The Choice of Accommodation Directions only applies to Care Home placements, which the Local Authority has a responsibility to provide[3]. The Directions do not apply to care home placements for Continuing NHS Healthcare. However some of the principles (particularly around patient preferences, suitability, availability and to some extent cost) can provide helpful guidance to the NHS when arranging Continuing NHS Healthcare placements.
3.2 For a minority of people the agreed care plan may be a direct transfer from an NHS bed to a registered care home. Where this is the case, and the individual has been assessed as ineligible for Continuing NHS Healthcare, the Choice of Accommodation Directions require Local Authorities to honour individual preferences for a particular home providing:
3.3 Councils must not limit choice:
3.4 The guidance states:“ Where for any reason, a Council decides not to arrange a place for someone in their preferred accommodation it must have a clear and reasonable justification for that decision which relates to the criteria of the Directions and is not in breach of the Regulations”. This decision should be available in writing for the designated Health and Social Care officers responsible for ratifying delayed transfers of care in order to agree reimbursable days if appropriate.
4.1 This section highlights some key technical points, relating to the DoH Guidance on the Directions on Choice, of which all staff in the NHS and Social Services should be aware. In addition those staff with managerial responsibility for overseeing the implementation of policy in this area should be fully conversant with the DoH Directions, and all subsequent amendments to the Directions, and should ensure that all new staff are made aware of the guidance.
4.2 Interim Placements
4.3 Where a place is not available in the individual’s preferred care home, the Guidance states that remaining in an NHS bed (once a multi-disciplinary assessment has confirmed that the patient is medically fit and safe to transfer) is undesirable for the patient’s welfare. There are particular risks of increasing dependency and acquiring infections. In addition the provision is needed for others with health care needs.
4.4 The Choice of Accommodation Directions makes it clear that, as long as an interim placement meets the needs of an individual, it is acceptable for a person to move from an NHS bed to an interim placement until a permanent/alternative choice becomes available.
4.5 Interim solutions may be wide ranging. Such packages should be based on:
4.6 Suitability of Accommodation
4.7 Suitability is based on the assessment of an individual's needs and risks and must be agreed on a case-by-case basis.
4.8 In addition, the accommodation must be managed by an organisation or person who is registered under Part II of the Care Standards Act 2000.
4.9 Meeting the Cost of Accommodation – Interim and Long Term Care
4.10 Unless the assessment of the individual’s care needs indicates that they meet the criteria for Continuing NHS Healthcare they will be expected to meet, or contribute towards, the cost of their care according to the National Assistance (Assessment of Resources) Regulations 1992 and the Charging Policy (including top-ups and third party payments) of the Social Services Authority responsible for their care.
4.11 Where the cost of interim accommodation is higher than the usual cost paid by Social Services due to a shortage of care homes, market conditions or other commissioning difficulties the person and/or third parties should not be asked to pay more towards their accommodation than s/he would normally be expected to contribute.
4.12 Where an individual explicitly chooses to enter or remain in accommodation (either temporary or long term), which will cost more than Social Services would usually expect to pay, arrangements can be made for third party top up fees to be paid, subject to local Social Services Charging Policies.
4.12 Council’s should not seek resident or third party contributions in cases where the Council itself decides to offer someone a place in more expensive accommodation in order to meet assessed needs or for other reasons.
4.13 Some people may choose to remain in the home, which has provided the interim care on a long-term basis, even if their original preferred accommodation becomes available. The decision that the person wishes to remain living in the home which has provided the interim care should only be made following a full review, which includes a reassessment of the individuals care needs. If, following this review, the individual decides to remain in the home, which has provided the interim care, and fees for the long term care charged by the home are more than the Council would usually expect to pay for accommodation for someone with the individual's assessed needs, the person or third party will be asked to pay the additional costs according to the Local Authority Charging Policy.
4.14 All of this underlines the importance of clear and accurate communication with patients and their carers about discharge arrangements in order to encourage appropriate and realistic expectations from the outset.
5.1 Strictly speaking the Choice of Accommodation Directions only applies to Care Home placements, which the Local Authority has a responsibility to provide[4].
5.2 The Directions do not apply to Care Home placements for Continuing NHS Healthcare and therefore are not the direct responsibility of the NHS. However guidance issued in the Capacity 2001/2002 HSC Circular (2) states that there should be jointly reviewed policies, procedure and protocols in place. This guidance confirms that this is a whole system approach with delivery being the responsibility of all the partners of a health and social care economy.
5.3 The aim of this policy is to ensure that all health and social care communities jointly review existing arrangements and ensure that operational procedures are in place to ensure that Local Authorities are able to fully discharge their responsibilities under the Choice of Accommodation Directions.
5.4 Health and social care communities must work together to ensure that frontline staff are able to:
5.5 Individuals and carers should:
6.1 If pre-admission assessment identifies a clear likelihood that long term care could be the outcome either individuals and their families should be advised of the need to look for care homes and consider interim arrangements.
6.2 On or after admission, as soon as assessments indicate the possibility of a long term care placement individuals and their families should be advised of the need to look for care homes appropriate to their needs and to consider interim arrangements
6.3 Multidisciplinary team completes full needs assessment in line with assessment (section 2) and discharge (Section5) notifications and the SHA Joint Policy on Reimbursement.
6.4 NHS members of the multidisciplinary team must consider eligibility for Continuing NHS Healthcare. If the individual is eligible then the responsible NHS commissioners identify care options and arrange necessary care package in liaison with the individual and their family. The Choice of Accommodation Directions do not apply.
6.5 If the individual is ineligible for Continuing NHS Healthcare but has identified long term care needs that can only be met in a care home this must be agreed by the multi-disciplinary team, the person and the carer.
6.6 Social care staff should ensure the individual/carer are clear they need to identify a preferred home and consider interim arrangements either in a care home or another setting. Individuals should have a named social services worker who should be proactive in offering information on availability of local care homes and individuals’ rights and responsibilities under the Choice of Accommodation Directions.
6.7 An individual does not have the right to occupy a hospital bed where the sole reason for doing so is because the individual’s preferred form of onward care is unavailable. Where the preferred choice of care home is not available, or the person has not identified a home of their preferred choice within six working days of the assessment outcome recommending long term care, the individual will be asked to accept an interim package of care on a temporary basis[5].
6.8 Within the six working days individuals and their families should be ready to move either to the home of their choice or to an appropriate interim arrangement that has been agreed with them. The relevant NHS and Social Services staff must pro-actively support the individual/carers/family to achieve this and agree who is doing what and when.
6.9 Where Social Services are responsible for providing services and a person’s preferred home of choice is not immediately available, they should offer an interim package of care. All interim arrangements should be based solely on the patient’s assessed needs and aim to sustain or improve their level of independence. If the individual is in an acute bed and if no alternative can be provided which can meet the patient’s needs, Social Services are liable for reimbursement[6].
6.10 Individuals do have the right to refuse to enter a care home including those who are awaiting discharge from hospital.[7] In such cases Social Services should work with the person/carer/family and the NHS and, if appropriate Housing staff, to explore alternative options, including a package of health and social care in the person’s own home or suitable alternative accommodation.
6.11 Social Services are required to make reasonable efforts to arrange an interim package that takes account of all facts, the circumstances relevant to the person, an individual’s needs and preferences and ensures the individual is aware of the consequences of failing to reach agreement. Evidence of these efforts should be recorded on case notes and be available to the lead officers from Health and Social Care who are responsible for ratifying delayed transfers of care.
6.12 The Local Authority will be liable for reimbursement where it cannot demonstrate it has fulfilled its statutory duty to asses and offer appropriate interim services and the person is willing to move.
6.13 Where interim care is arranged by the NHS as part of delivering a package of NHS Continuing Care the responsibilities set out in 6.10 will apply to the NHS agency arranging the continuing care.
6.14 If after the initial six working (see 6.7) days a person continues to unreasonably refuse the care package offered they cannot stay in a hospital bed indefinitely and will need to make their own arrangements so that they can be discharged safely.
6.15 The NHS will take lead responsibility for managing the reluctant discharge of the individual in these circumstances. This will be under the policy for Reluctant Discharges and the Local Authority is no longer liable for reimbursement.
6.16 If at a later date further contact is made with Social Services regarding the patient, the Council should re-open the care planning process as long as it is satisfied that the patient’s needs justify the provision of services and there is no longer reason to think that the patient will persist in refusing such services unreasonably. Councils may wish to take their own legal advice in such circumstances.
7.1 Each PCT and NHS Acute Trust will need to develop and implement a local policy for Reluctant Discharge. This should include joint protocols to ensure that that people will not be delayed in an NHS bed whilst waiting for a vacancy in a Care Home of their choice or an interim placement in suitable alternative accommodation, or for intermediate or other onward care.
7.2 The following is a process and timeframe based on the Interim Transitional Care Policy of North & East Cornwall PCT and revised by senior officers of the South Devon health and social care community. PCTs and local stakeholders should use this as the basis for developing a local policy.
7.3 Reluctant Discharge Protocol Framework
7.4 If the patient / relative does not agree to a move because they disagree with their health needs assessment local resolution will be sought. A leaflet entitled “Eligibility for Long Term NHS Health Care - A Guide for Patients and Carers“ and a copy of the “South West Peninsula Strategic Health Authority Continuing NHS Healthcare Policy” (see Discharge Toolkit) should be made available to help explain decisions that have been taken.
7.5 If the dispute continues and a review of a decision regarding Continuing NHS Healthcare Eligibility is being sought another leaflet called “Long Term NHS Care Review Panels - A guide for Patients and Carers” (see Discharge Toolkit) must be given and the Strategic Health Authority’s Standing Independent Continuing Care Review Procedure applied.
7.6 This Standing Independent Continuing Care Review Procedure only reviews the processes and decisions taken, not the eligibility criteria themselves or the package of care proposed as a result of the needs assessment. If the individual is entitled to a review under the terms of this policy then the person should remain in the NHS bed whilst the review is conducted. National Guidelines stipulated that this process must not take longer than 2 weeks[8].
7.7 Other complaints should be dealt with via the NHS Complaints Procedure if local resolution has failed to resolve them to the patients / family members satisfaction. However if a complaint is being investigated the individual does not have the right to occupy an NHS bed and Stage 1 of the Reluctant Discharge process must be applied.
7.8 Stage 1
7.9 During the six working days the individual and their family have to identify a Care Home (see 6.7) or to accept an alternative form of care NHS and Social Services staff should be working together with the individual and their family to ensure they understand it is not possible for them to stay in the NHS bed.
7.10 At the point at which the funding is made available or the decision to move to a Care Home of choice is made the Senior Nurse/ Social Worker should explain the process of discharge and the use of interim placements to the patient and their relative/carer and provide them with a copy of the Social Services Policy in writing.
7.11 For cases where discharge is likely to prove complex to achieve the ward Senior Nurse/Social Worker should arrange an urgent multi disciplinary case conference ensuring that the patient / family member has written information prior to it so they are not surprised to hear the NHS intends in effect to give them “notice”
7.12 The purpose of the case conference will be to agree an action plan to move the patient to an interim placement i.e. alternative accommodation as soon as possible. The accommodation will be deemed suitable only following an assessment of nursing needs by suitably qualified personnel. Practical consideration MUST be given to the suitability of any interim placements such as within visiting distance for relatives.
7.13 A letter, which reiterates the agreement reached at the case conference, should be sent to the patient / relative within 12 hours of an action plan being formulated.
7.14 Stage 2
7.15 At the end of 6 working days, if there is no discharge date to an identified destination within an agreed timeframe, the Modern Matron/Clinical Ward Manager/Discharge Co-ordinator (it is for each organization to agree the lead person for managing this process) will give 7 calendar days written notice of the intention to facilitate the patients move into an interim placement in a suitable Care Home.
7.16 If the patient/next of kin has not accepted this action plan by the end of this time their rights should be explained once more by the person identified as lead for managing this process.
7.17 The identified lead should check that all stages of this process have been addressed and providing they have and do not need repeating then a suitable transitional Care Home placement should be identified and the patient and/or next of kin should be informed. The Director of Operations/Director of Nursing and Senior Local Authority representative should be notified of proceedings to date.
7.18 The PCT or NHS Trust will then discharge the patient to the identified transitional location and inform relevant Social Services General Manager.
7.19 Wherever a person moves to an interim care placement a member of health or social care staff will be identified (according to the person’s needs/circumstances) to remain in touch with the individual and work with them to ensure that they do not become a low admission priority for the Care Home of their choice.
8.1 The NHS in the Peninsula is reporting significant delays resulting from unco-ordinated and unclear local polices on the Choice of Accommodation Directions and Reluctant Discharge. The monitoring of the implementation of the policy and these supporting guidelines will be undertaken by the SHA Policy Lead for Older People as part of the agreed Peninsula Standing Agenda Work Programme[9]
[1] www.doh.gov.uk
[2] Draft Guidance on the National Assistance Act 1948 (Choice of Accommodation) Directions 1992[2] and the National Assistance (Residential Accommodation) (Additional Payments and Assessment of Resources) (Amendment) (England) Regulations 2001 (the “Draft Guidance on Choice of Accommodation 2003”)
[3] Under Section 21 of The National Assistance Act 1948 (provision of accommodation)
[4] Under Section 21 of The National Assistance Act 1948 (provision of accommodation)
[5] In local policies this timing should coincide with reimbursable days i.e. includes Saturdays but not Sundays and Bank Holidays
[6] HSC 2003/009 LAC (2003)21 Section 97
[7] Except those placed under Part II of the Mental Health Act 1983
[8] South West Peninsula Strategic Health Authority Arrangements for reviewing decisions on Eligibility for Continuing NHS Healthcare and other NHS services including Registered Nursing Care
[9] Work programmed agreed December 2003 by Peninsula Chief Executives
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