Choosing a care home on discharge from hospital: guidance

The Choice Process

Roles and responsibilities

Patients, family members and proxies

1. The patient, family or proxy should participate fully in discussions with health and social care professionals regarding the patient’s future care needs, and choice of care home.

2. If it appears the patient lacks capacity to make these decisions, and a proxy has not already been appointed, and s13za cannot be used as justification for moving the person, the family, carer or representative will need to consider applying for Welfare Guardianship. This should be done as quickly as possible to ensure the patient is not delayed unnecessarily in hospital.

3. Family members applying for Guardianship should take into account the guidance contained in A guide for Carers to making an application for Guardianship and Intervention Orders.

4. Proxies should also take into account the guidance contained in the Code of Practice for persons authorised under intervention orders and guardians under the Adults with Incapacity (Scotland) Act 2000.

5. Patients, family or proxies will need to choose a care home which is able to meet the patients assessed needs. They can choose up to three homes, one of which should have a suitable vacancy that will be available within a reasonable period. This should be done in consultation with social work or social care staff.

6. If the preferred home(s) are unlikely to have a vacancy available by the agreed discharge date the patient, family or proxy will need to choose a temporary (interim) home to move to and await a vacancy in their preferred home of choice.

7. The patient or proxy cannot ask to wait in hospital until their preferred home becomes available.

All Professionals

8. All staff involved in the patient’s care should give a clear and consistent message that remaining in hospital, once the patient is clinically ready for discharge, is not an option (see page 7).

The Clinician

9. The clinician in charge of the patient’s care will assess and decide when the patient is clinically ready for discharge. A PDD will then be agreed as part of the multi-disciplinary assessment process.

10. It is not the role of the clinician alone to make decisions regarding the next stage of the patients care (i.e. whether or not the patient will need to go home, or to a care home). These decisions are best made following a thorough assessment process, with earlyh involvement of health, social care and other relevant agencies.

11. The clinician will support all decisions regarding the next stage of care made by the social work team, and other relevant agencies and should not agree to patients remaining in hospital purely to wait for their preferred choice of care home to become available.

12. The clinician will be informed by the case worker of any cases where the patient,family or proxy are unwilling to engage with the choice process or accept an interim move. Where resolution cannot be attained with the support of the clinician the case should be referred immediately to the Medical Director.

Senior Charge Nurse & Ward Staff

13. The Senior Charge Nurse will work with the nursing staff to ensure there is effective and inclusive communication with patient, family or proxy throughout the discharge and choice process. And ensure that patients, families and carers have a positive experience during the hospital stay, and understand when discharge is planned.

14. The Senior Charge Nurse will also manage and develop the nursing teams knowledge and experience in discharge planning through appropriate regular training, to ensure the best quality care, information and advice is provided at all times.

15. Similarly, it is not the role of nursing staff alone to decide on the next stage of care for the patient. This assessment process will be led by social work staff, involving healthcare professionals, and other agencies as appropriate.

16. In cases where the patient, family or proxy continue to refuse to actively engage with the choice process or refuse to leave the hospital on the agreed discharge date the Senior Charge Nurse will escalate cases to the Medical Director for action. This should be done through the clinician in charge.

Social Work / Social Care Staff

17. Social work staff have lead responsibility for the assessment of needs, and provision of social care services on discharge from hospital. They also have lead responsibility for convening and chairing meetings with the patient, family and/or proxy to discuss future care arrangements.

18. As part of setting the PDD, social work and ward staff should ensure that the choice process is started as early as possible in the patient’s journey; always ensuring that any possibility of the patient returning home, with support is explored first. The assessment should be carried out jointly with other health and social care staff, and should fully involve the patient, family (where the patient agrees) or proxy from the outset. Results from the assessment should be communicated to the patient, family or proxy in an appropriate format.

19. Social work staff are also responsible for carrying out a financial assessment, and discussing likely costs of care with the patient, family or proxy.

20. Social work staff should provide the patient, family or proxy with a list of appropriate care homes, able to meet the patients assessed needs. They should work with the patient, family or proxy to help them make appropriate choices. They should also clearly explain the choice process to all concerned, highlighting that:

• The patient cannot remain in hospital to wait for their preferred choice of home to become available once they are clinically fit for discharge.
• Up to three choices should be made – one of which should have a vacancy available by the agreed ready for discharge date (see page 16).
• If none of the preferred homes have a vacancy available then the patient will have to move to another care home to wait for a vacancy in a preferred home.

21. In cases where the patient, family or proxy refuse to engage with the choice process social work staff should inform the Senior Charge Nurse within 24 hours, so that the case can be escalated to the Medical Director, through the consultant in charge, for action.

Medical Director

22. Once informed by the Consultant the Medical Director will write to the patient, family or proxy informing them that a discharge date has been set and that the patient will be discharged from hospital on that date to a care home that can meet the needs of the patient and has a vacancy available.

Stage 1: Planned Date of Discharge (PDD)

1. PDD should begin the moment someone is admitted to hospital. This process should begin with engaging with the patient, carer and family, indicating when the person is likely to be going home. Discharge planning should be across 7 days and should be particularly focussed in getting someone home during day time hours.

2. PDD should consider not just the position from the acute ward but what matters to the person, what (they can do) and how they want to continue to live.

3. It is good practice to have one person responsible for coordinating a patients discharge plan. This could be a member of ward staff, discharge facilitator, AHP or other. The discharge plan and PDD should be clearly placed in the notes and shared with the patient, carer and family.

4. Local information on discharge planning should be given in an accessible format. National resources explaining the Discharge without Delay programme and Planned Date of Discharge are also available. These include a a video explaining Planned Date of Discharge explaining Planned Date of Discharge, and a Discharge without Delay Comms Starter pack. NHS Lanarksire have also developed a range of material explaining the DwD programme and PDD.

4. If the assessment of the patient concludes that that the patient’s needs and abilities may prevent them from returning home, and their long term care needs can only be met in a care home, it is essential that the MDT have considered whether the patient can be moved and assessed outwith the hospital to review whether:

• All other care options have been explored including the potential to support needs with care (including equipment and adaptations) at home, or in another community setting.
• The potential for reablement and/or rehabilitation has been fully explored.
• The patient, family or proxy have been fully involved throughout the process.

5. Patients, family and proxy’s have the right to challenge the clinical decision that the patient is ready for discharge. However, this right does not extend to insisting that the patient remains in hospital, purely on grounds of choice. The Guidance on Hospital Based Complex Clinical Care provides guidance on appealing the discharge decision.

6. The outcome of the multi-disciplinary assessment, and any further assessments or meetings and conversations must be appropriately recorded in the patient’s records, along with copies of all letters or leaflets issued during the discharge process.

7. Clear information is essential to ensure that everyone, including professionals, understand what will happen during the hospital stay and beyond. However, staff should not rely on the provision of written information alone. It is essential that medical, nursing and social work staff spend time with the patient, family or proxy to discuss discharge and post-discharge issues in an open and sensitive manner. There is national information available on PDD which can be shared with the patient and family. The leaflet Ready for Discharge? What happens next also provides information on the discharge process.

8. Information relevant to the discharge process, will be provided to the patient, family or proxy. This should be written in plain language, and in a format appropriate to the patient, and should clearly explain:

• Admission, transfer and discharge policies
• The local choice policy
• Why a care home is the most appropriate place for a person to move to
• Why remaining in hospital is not an option
• The need to make realistic choices from suitable, available care homes
• Procedures for interim moves, if a home of choice is not available.
• Any costs to the individual.
• The NHS and local authority complaints procedures.

Stage 2: Choosing a preferred care home and, where necessary, an alternative interim home

Further Interpretation of the Directions on Choice

The Directions on Choice state that local authorities should make arrangements for people to move to a care home of their choice, provided the caveats below are met.

a) The accommodation is suitable to meet the person’s eligible needs, as assessed by the local authority. This should be interpreted as:

• The home is able to meet the person’s assessed needs.
• The home is registered with the Care Inspectorate and is of an acceptable standard. In considering this, local authorities should take account of any outstanding enforcement action being taken by the Care Inspectorate. They should also take account of Care Inspectorate inspection reports, including their recommendations and requirements.

b) It will not cost the authority more than it would usually expect to pay.

• The placing local authority will provide advice and guidance on their local charging policies and care home rates normally paid.

c) The accommodation will be available within a reasonable period. This should be interpreted as:

• One of the care homes of choice has a suitable vacancy, and is prepared to allocate that room to the patient in time to facilitate discharge by the agreed date of discharge.
• If it is unlikely that a preferred home will be available by the agreed date of discharge then the patient will be asked to make interim arrangements that will facilitate discharge within that period.

d) The person in charge of the accommodation is willing to provide the accommodation, subject to the authority’s usual terms and conditions.

• If the home is unwilling or unable to provide accommodation the patient should be advised immediately and asked to make another choice

Choosing a preferred home

1. The assigned care manager will explain the outcome of the MDT assessment to the patient, family or proxy and discuss the need for them to choose a suitable care home.

2. The care manager will also clearly explain the choice policy, and provide the patient, family or proxy with a copy of the leaflet Moving to a care home from hospital, or local alternative.

3. Patients, families or proxies will be asked to identify a preferred home of choice, suitable to meet the assessed needs of the patient. Up to three homes can be identified but ideally, one of these should have a suitable vacancy available by the agreed date of discharge.

4. The caveats listed on the previous page should be fully explained to the patient, family or proxy along with any additional restrictions specific to the patient’s assessed needs, e.g. relating to specialist care needs. Advice should also be given by social care staff on the practical and financial implications of the options available, and assistance with visits to homes should be provided, where necessary.

5. All staff involved must be clear that the patient cannot remain indefinitely in hospital once they are fit and ready for discharge.

Waiting for a preferred care home: Interim arrangements

6. Waiting for the preferred home does not mean that the person’s care needs are not met in the interim, or that they wait in a setting unsuitable to their assessed needs, including a hospital bed.

7. If there is unlikely to be a vacancy in any of the preferred homes by the agreed date of discharge the Care Manager should ask the patient, family or proxy to choose an alternative interim home from a list of care homes, with vacancies currently available, that are able and willing to meet the patient’s assessed needs.

8. The need to proceed with discharge, though the preferred home(s) is not available, must be reinforced during this process. It needs to be explained to the patient, family or proxy why an interim move is considered to be in the best interests of the patient, and they need to be reassured that they will remain on a waiting list for their preferred home(s), and will be offered the opportunity to transfer there when a place becomes available, if that is their wish.

Stage 3: Dealing with Reluctant Discharges

1. The procedures outlined below should be followed if, at any stage, the patient, family or proxy are unwilling to engage with the choice process by either:

• disputing the decision to discharge, or
• refusing to make a choice of preferred home, or
• refusing to make a choice of interim home, or
• are unwilling to accept/pay for a move to the interim home.
• any other dispute affecting timely discharge.

When the patient (with capacity) disagrees

2. If the patient declines to reasonably co-operate with the Choice Guidance or discharge planning arrangements, the Care Manager will continue to make the practical arrangements for the patient to move to a suitable care home. A further meeting should be arranged with the patient, family or proxy to discuss the reasons they are unwilling to make the necessary choices, or move to a temporary home, and discuss a way forward.

3. It must be made clear that refusal to make a choice does not mean the patient can remain indefinitely in hospital.

4. If no progress is made the patient will be discharged to one of the listed homes with a vacancy, where the patient can be more appropriately cared for whilst awaiting a vacancy in their preferred home, or can be supported to continue to look for a preferred home.

5. If no progress is made the case should be referred to the Medical Director. The Medical Director should then write to the patient, reiterating the planned date of discharge and the urgent need for the patient, family, carer or proxy to choose a suitable care home, from the list of vacancies provided.

When the patient (without capacity) family or carers (without proxy powers) disagree

6. If the patient or any family members disagree with any decision about the patients future care needs (including making an interim move) Section 13za of the 1968 Act cannot be used. Where this occurs the family should be advised that a Welfare Guardian is required.

7. Social care staff should continue to work with the family to ensure the patient is discharged to an appropriate care home once guardianship is in place. In cases where it is clear that the family are unwilling to agree to discharge to an appropriate interim or permanent care home the local authority should consider applying for Guardianship.

8. Where a private application for Guardianship is being progressed, a realistic timescale for processing the application should be agreed with the family. They should be advised that if this is not adhered to the local authority will apply for guardianship themselves.

When the proxy disagrees

9. The proxy should be reminded of their duty to follow the principles of the 2000 Act when making decisions on behalf of the adult. Specifically, actions or decisions taken ‘must benefit the adult’ and should be the options that ‘restricts the person’s freedom as little as possible’. The Health Board should explain why it believes that remaining in hospital is not in the best interests of the patient. The reasons highlighted in section one, paragraph 11 are relevant to this.

10. A proxy is in no stronger a position than the adult, had they retained capacity . As such, they cannot make a decision requiring that the adult remains in hospital once they are fit for discharge.

11. If a proxy continues to object to the patient being discharged they should be urged to go to the Sheriff that granted Guardianship under Section 3 of the 2000 Act to ask for directions as to whether they can use their power to insist the adult is not moved.

12. Section 3 of the AWI Act states that “On application by any person (including the adult himself) claiming an interest in the property, financial affairs or personal welfare of an adult, the sheriff may give such directions to any person exercising functions conferred by this Act”.

13. This means that any professional, including the consultant or social worker involved in the patients care, can also apply to the sheriff at any time for direction on the decision to discharge the patient to a care home.

Progressing reluctant discharges

14. This section does not aim to provide formal legal advice. Health Boards are advised to consult their own solicitors before taking any legal action.

15. As stated elsewhere in this document remaining in a hospital bed once all treatments are complete is not good for the health and wellbeing of the individual concerned. Furthermore, the hospital is health service property and patients are allowed on that property because the Health Board consents to them being there. There is no legal provision entitling a person who no longer requires treatment to remain in hospital.

16. Where the patient, family or proxy continue to unreasonably refuse to engage with the choice and/or discharge process a Health Board can choose, as a last resort, to seek enforcement of the discharge through the courts.