2. Discharge Liaison Team (North) Back To Basics

3. Background W Background • Confusion over the application of the Continuing Healthcare eligibility criteria • Lack of understanding of the wider implications of failure to adhere to the process inclusive of the financial implications for families and health • Inaccurate completion of the relevant documentation • No outcomes or justification of assessments documented • Staff were unaware of how to determine what is a complex discharge • Lack of understanding of categories of care • Increase in delayed transfers of care due to a breakdown in the assessment process • Challenges from third parties on outcomes of assessment by means of retrospective claims • Misinterpretation of roles and responsibilities between agencies • Disempowerment of staff • Inappropriate discharges identified via the incident reporting mechanism

4. Key Issues • Patients with complex needs being discharged without a comprehensive assessment • Staff were unaware of what constitutes a simple/complex discharge • Lack of understanding of categories of care • Inaccurate completion of the relevant documentation • No outcomes or justification of assessments documented • Confusion over the application of the Continuing Healthcare eligibility criteria • Lack of understanding of the wider implications of failure to adhere to the process which includes the financial implications for families and health

5. Multi-agency Assessment and discharge W Background How did we address these issues ? • Increase in delayed transfers of care due to a breakdown in the assessment process • Increase in challenges from third parties due to process issues • Increased requests for a structured training programme from staff • Misinterpretation of responsibilities between agencies • Disempowerment of staff Multi-agency Assessment and Discharge Training Programme Development of a multi-agency Training programme

6. Agencies involved W Agencies Involved Cwm Taf NHS Trust (North) Rhondda Cynon Taf Local authority Merthyr Tydfil Local Authority Rhondda Cynon Taf Local Health Board

7. Programme content W Programme Content • Information Sharing • Unified Assessment Process • Discharges - simple or complex • Legal Framework • Roles and Responsibilities/Care co-ordination • Categories of care • Overview of Ombudsman report and update of cases locally

8. Back To Basics

9. Unified Assessment Process continuum UA • LTC ONGOING • CARE • NHS FNCNH • INTERMEDIATE • CARE • RESIDENTIAL • CARE • ONGOING • HOSPITAL CARE OUTCOMES CONTACT OVERVIEW SPECIALIST COMPREHENSIVE SUMMARY RECORD OUTCOMES • HOME + • INDEPENDENT • HOME WITH • SS PACKAGE • HOME + RESPITE • REFER • CROSS BORDER • HOUSING • WARDEN CONT • SHELTERED

10. Triggers For a Comprehensive Assessment Health Issues Social issues Environmental issues

11. Health There is a significant reduction in the patients ability to care for self due to effects of treatment or the debilitating symptoms of a progressive disease Patient has a limited prognosis requiring complex package of palliative care Patient has high social/nursing needs which suggest a substantial care package within the community or a residential/nursing home placement

12. Social Tr Social Issues High dependency on a carer for all or most aspects of physical care Carer shows signs of stress or questions their ability to continue caring Patient is carer for their partner Vulnerable Adult issues Dependency on children under 18 years old.

13. Environmental triggers Environmental Issues Housing is unsuitable – Access problems, or inadequate heating, electricity or water supplies Patient is homeless or threatened with homelessness.

14. Current Position Currently holding monthly training sessions 25 places are available for each session All sessions fully attended Recently Undertaken 6 month review of evaluation Positive feedback

15. Future • Extend programme for a further 12 month period • Introduce day 2 programme to consider case scenario • Arrange shadowing opportunities for staff • Consider programme as part of mandatory training • Consideration of accreditation of the training programme in the • future

16. Any Questions