DISTRICT NURSE LIAISON DEPARTMENT RLI

Learning Outcomes

Focus on discharging planning An overview of our role Discharge process at the RLI Increased knowledge of the journey of Section 2 The assessment process An overview of continuing care process and the

Decision Support Tool

Who are we?

Employed by NHS North Lancashire (was NLtPCT)

2 WTE (0.6 WTE seconded from RLI) to cover the entire RLI site

District Nurse Liaison teamtel: 01524 583600 Fax: 01524 516307

Discharge planning

Planned Individualised - Patients wishes Needs identified - health and social Safe Supported Communication Accurate updated information

Planned

Maybe use a checklist Avoid Friday pm discharges Timescales:

Integrated palliative care scheme IPCS (pilot Lancaster locality) refer DN team

Fast track refer to DNLO and DN teamRoutine DN team

Needs identified

Refer to MDTAssessmentEquipmentCare packageAdvice and support

Safe

Patient fit to travel Environment assessed as appropriate Access to home clarified Consider Piperline/Telecare

Supported

Who – family or friends Need for care and or support from

professionals or voluntary agencies

-refer DN or community matrons

Communication:

Information: Accurate and updated including demographics Use section 2 not the old single page referral

Written and verbalPick up the phone

Role of the District Nurse Liaison Department To help facilitate a seamless patient journey To undertake holistic assessments of patients

with complex health needs A member of the MDT involved around decision

making regarding placement on discharge Facilate working relationships between primary

and secondary care

Role of the District Nurse Liaison Department – Cont’d Provide nursing assessments for Social

Services To screen and assess for consideration for

NHS funded Continuing Healthcare Endeavour to provide on-going education

and advice to other health professionals

How we work

Reactive service – via section 2 referrals Routine MDTs/panel meetings each week

What else do we do:

Assess for and order nursing equipment Beds/ pressure relieving equipment

Attend: Weekly MDTs ward 50, oncology and MU2

wards Daily allocation meetings with hospital SW team Weekly Panel meeting with Social Services

Cont.

Attend case conferences General Liaison with other MDT members Continuing Health Care advice to all Telephone advice about the assessment

process, including with patients families Sign posting and information Service development and management Education

We do not:

Organise home oxygen Organise TNP (topical negative pressure) Fax referrals to DN teams in this locality Complete assessments for incontinence

products

Section 2 journey: (the process for complex discharge) Wards send updated Section 2 – discharge team -

DNLO – discharge team – SW/MDT DNLO screen referral (section 2)

Possible outcomes: Assessment with ward staff and patient arranged Deferred if patient not medically fit for assessment Refer back to discharge team

The Assessment Process

Prior to assessment: Ward staff to advise patient of referral If possible ward staff to ascertain patient and

family’s wishesNurse Assessor (DNLO) attend ward to: Gain consent, completes NHS continuing

healthcare needs checklist if no referral for full consideration required →

Continues to complete Assessment

The Assessment Process – Cont’d

Discuss with patient and ward staff/MDT outcome and recommendation of level of care and potential placement

Document recommendation and outcome of NHS needs checklist in discharge pathway/discharge communication

cont.

Information gained from: Patient and carers Ward staff and the MDT including District Nurses Hospital Notes

Copy of nursing assessment given to

discharge team

Referral for NHS Continuing Healthcare (non fast track)Identified by needs checklist: MDT organised by ward staff to include patient and/or family MDT led by health lead (usually nurse assessors) Ascertain needs and whether choice of discharge is safe and

appropriate Review of needs – if still triggers MDT complete DST (Decision Support Tool) and health lead submit

to NHS North Lancashire Commissioning Department with recommendation

Panel meet every 2 weeks (if potentially LCC funding patient cannot be discharged until outcome of panel)

Continuing Healthcare Fast track

Ascertain discharge appropriate and timely DNLO and DN team involved asap Ascertain patient’s needs and wishes DNLO complete checklist and Fast track form

completed (faxed to NHS North Lancashire) Discharge planned Pt discharged

What to do at the weekend

Phone DN teams to liaise Fax to DN teams comprehensive

section 2 and phone to confirm ? Eligible for ICPS

Consider that Community core services are skeleton services

Referal (Section 2) to District Nurses

(Ward to fax directly to DN Teams using referral pack).Please ensure information is: Accurate Adequate Updated and needs identified

Please be aware District Nurses: Usually work alone Cannot commit to time or length of visit Do not carry a supply of dressings/catheters or medicationDNLO will endeavour to keep the pack with up to date contact

details

Useful Website

2009 revised Continuing Healthcare tools and information

www.dh.gov.uk/.../SocialCare/Deliveringadultsocialcare/Continuingcare/index.htm -

Learning Outcomes

Focus on discharge planning An overview of our role Increased knowledge of the journey of Section

2 The assessment process An overview of continuing care process and the

Decision Support Tool Information to take forward into practice

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