Strata IToCH SOP: Procedure: Transfer of Care hub management of hospital discharge referrals with a triage outcome of Pathway 3 V0.9

Procedure overview

This procedure provides guidance to Integrated Transfer of Care Hubs (IToCH’s), the Independence and Wellbeing Service (IWS) receiver service and Cornwall and Isles of Scilly Integrated Care Board Continuing Healthcare (CHC) Team receiver service on how to manage referrals where the IToCH has received a hospital discharge referral from either a community or acute hospital and determined a triage outcome of Discharge to Assess Pathway 3 (D2A P3).

D2A P3 is suitable for people who require bed-based 24-hour care who will have such complex needs that they are likely to require 24-hour bedded care on an ongoing basis following an assessment of their long-term care needs.

Other (reference documentation)

Strata IToCH SOP – Hospital Discharge Referral Caseload management for Pathway 3 by IToCHS and IWS

Requirements

Ward referrers describe, not prescribe needs.
IToCH triages referrals and determines the outcome
All referrals are sent on to the local IWS receiver service
There are separate IWS-managed processes thereafter that happen outside of Strata depending on which type of hospital the referral originated from and whether social care and CHC assessments take place in that hospital. The person employed by IWS working in the IToCH takes responsibility for updating Strata with relevant information.
The IToCH is required to onward send a referral to the CHC team for all nursing placements after IWS have admitted the referral and the person has arrived in the care home.

Procedure

IToCH Triage

IToCH Hospital Discharge Triager

· Accept referral

· Review the information in the grey tabs

· Edit the referral by clicking on Edit Client and Triage

· Selects a Pathway 3 outcome

· End of Life (Residential/Nursing)

· Learning Disability (Residential/Nursing)

· Mental Health (Residential/Nursing)

· Dementia (Residential/Nursing)

· General Nursing

· General Residential

· Update triage outcome on Nervecentre or RIO

IToCH liaison with ward using Request for Information (RFI) to ensure person / family discussion held and to obtain other missing information.

Send RFI to ward. Reason ‘Other’. ‘IToCH tiaged this person requires transfer to a D2A P3 bed for assessment of long term needs. Please discuss with person/family and gain consent to commence placement search’. NB it may also be necessary to request further information before the referral can be sent to the IWS receiver service.

Hospital review of RFI, discussion with person/family and respond to RFI

When all consent and information obtained from ward, IToCH send referral to IWS

Outside of Strata – IWS liaise with CHC team as required to complete assessment in community hospitals, complete Service Request Form, Short Term Placement and source placement via Brokerage.

IToCH IWS staff monitor progress of placements using Planned Discharges report and Mosaic updating Date SRF completed field, Assign referral to ‘Sent to Brokerage’ and Brokerage Response tab when appropriate

IWS receiver service admit when person has arrived at care home

After IWS has admitted referral If nursing placement, ITOCH ensure brokerage response tab completed and send referral to CHC.

CHC team confirm via comment that all information is accurate and IToCH can ADMIT the referral

IToCH can now ADMIT referral

CHC ADMIT the referral after the assessment has been completed