Strata ITOCH SOP: Transfer of Care hub Discharge to Assess Pathway 1 provider selection and management V1.0

Procedure overview

Guidance for Transfer of Care Hub (ToCH) prioritisers and progress workers/administrators who triage and case manage hospital discharge referrals respectively on how to refer to commissioned Pathway 1 providers.

Guidance

Generally acute and community hospital wards will raise a hospital discharge referral on Strata and describe not prescribe a person’s needs or the services required.

The ToCH will triage and determine the correct Discharge to Assess Pathway triage outcome This guidance applies to people who have been identified as requiring reablement at home, discharge to assess Pathway 1a – Reablement/Rehabilitation.

Referring Royal Cornwall Hospital NHS Trust (RCHT) wards can liaise directly with Chaos, Disability Cornwall and STEPS to agree care plans and provision as these providers have been instructed by commissioners to proactively identify people who are suitable for their services.
In community hospitals the same applies with Age UK.

Where this occurs, the referrer should specify on the Strata referral form what has been agreed and whether any additional support is required.

The ToCH will respect the arrangement that has been made between the hospital and the provider and ensure the correct transactions in Strata are completed, e.g. onward referring to Disability Cornwall as well as making referrals to other services such as community nursing. This allows the ToCH to maintain oversight of all P1a hospital discharges and for Strata to be the single source of truth for all hospital waiter reports..

The ToCH should not override the decision made by the ward and the receiver service without prior discussion and agreement. The ToCH does not need to send the referral on to other reablement providers for this element of care, but may need to for example to organise house cleans or district nursing support.
Where a hospital referrer has not made a direct arrangement with a reablement care provider, the ToCH prioritiser should generally always refer to ALL reablement providers to give all an equal chance of responding and to maximise the chance of care being found quickly. These services are listed on the Strata Send and Manage referrals screen under “Community support at home including reablement and voluntary sector P0-P1”. Appendix 1 compares the different provider offers. NB whilst the Voluntary Sector Gateway can handle requests for reablement provision by onward referring to Chaos and Humans, it is recommended that IToCHs refer direct to the required providers.

Prior to the referral being sent to any voluntary sector provider, the IToCH should liaise with the referrer to ensure consent has been obtained to share referral information with these providers. The referrer should provide this information by completing the Referral Information tab on Strata:

The ToC prioritiser sending the onward referrals should add a comment to clearly state who the referral is being sent to so that all receiver services are aware, e.g “Referral being sent to Home First, STEPS, Disability Cornwall, Chaos for reablement, voluntary sector gateway for house clean and general support and district nursing for wound dressing. The IToCH will keep all parties briefed on referral status including care offers made and accepted. If the care is no longer required, the IToCH will cancel the referral. Please do not deny a referral because your service currently does not have capacity. Please hold on your waiting list until the IToCH cancels or capacity becomes available.”

Referrals should be sent even if it is suspected that the provider will not have capacity to respond immediately. This allows the provider to hold a waiting list should capacity become available.

Receiver services can only deny a referral if the person does not meet their service criteria – NOT if there is no capacity.

Only referrers and IToCH’s can cancel referrals to receiver services i.e. the receiving service cannot cancel or disable a referral. The referral will remain on their work queue until notified by the referrer/IToCH that referral is no longer needed.

Strata receivers will use the request for information function to gain further information and to make a service offer either to the referrer direct or via the IToCH using the reason codes listed below:

IToCH - Further clinical information required
IToCH - Insufficient information on referral
IToCH - Other
IToCH - Please send to additional service provider
IToCH – Service offer made. Response needed. (To add in details of when care / support can commence / or if they only have capacity to do mornings etc)
Referrer - Best interest information required
Referrer - Further clinical information required
Referrer - Insufficient information on referral
Referrer - Mental Capacity Act information required
Referrer - Other
Referrer - Safeguarding information required
Referrer - Service offer made. Response needed
Referrer - Therapy update required

The receiver service is responsible for following up on RFIs raised direct with referrers i.e. selecting a reason code prefaced with Referrer, not the ToCH.

Once a receiver service has confirmed a care offer with a receiver service, they should notify the IToCH using RFI “IToCH Service offer made. Response needed” reason code, detailing the care that can be provided. This allows the IToCH progress worker to update other receiver services and update the planned discharge date on Strata.

The ToCH case manager/progress worker responsible for monitoring all triaged hospital discharge referrals plays an important role in ensuring all receiver services are kept briefed on activity relating to the referral as per the example scenarios below:

The ToCH case manager/progress worker is responsible for monitoring referral status with downstream receiver services and at the appropriate time admitting the referral to the ToCH This should usually take place after the receiver services have admitted the referral which should take place once the person has been discharged from hospital and the first visit taken place. The ToCH are responsible for updating the actual discharge date field on the Triage question set.