This section relates to procedures specific to working with customers in hospitals or related to discharge from hospital.
Chapter 15,Integration Cooperation and Partnerships, Care and Support Statutory Guidance covers guidance relating to working with the NHS, including delayed transfers of care from hospitals.
December 2018: This chapter has been updated throughout as a result of local review.
1. Lincolnshire Acute Hospitals
There are three main acute hospital sites in Lincolnshire that have hospital social care teams based on site:
- Lincoln County Hospital;
- Boston Pilgrim Hospital;
- Grantham and District Hospital.
The social care team based at Lincoln County Hospital are also responsible for supporting the discharge of Lincolnshire residents who are patients within North Lincolnshire and Goole Trust which comprises of Hull, Grimsby, Goole and Scunthorpe acute hospitals.
As well as the Lincolnshire based acute hospitals, Lincolnshire Adult Care Discharge Teams work closely with North West Anglia Foundation Trust (see 3.3, Out of County Hospitals). There is a hospital social care team that support with the discharge of patients who are Lincolnshire residents from Peterborough and John Van Geest, Stamford are based either on site at Peterborough Hospital or from Stamford Area Office. In addition the team also support discharge patients at Queen Elizabeth Hospital at Kings Lynn who are Lincolnshire residents.
The hospital teams are responsible for managing discharges from these hospitals, ensuring social care needs are addressed and services in place to facilitate safe discharge and further assessment.
The hospital based Adult Care teams receive referrals directly from the wards and from the Integrated Discharge Hub. The hospital social care teams wherever possible have a social care professional aligned to each ward who will attend the daily ward meetings and participate as a member of the Multi-disciplinary team. This supports early identification of patients who will require support from social care to ensure a safe discharge and prevents unnecessary delays.
Where customers have an active key worker in the community, following a discussion around the complexity of the case and the level of involvement of the worker between the key worker and the hospital team it may be appropriate for the key worker, to manage the discharge with support from the hospital team.
When the plan is agreed to provide a safe discharge, the customer will leave the hospital to return to their normal place of residence. If following a comprehensive social care assessment of the person’s needs a return home is not possible, short term care in a residential care home may be considered. The hospital team will close the case on discharge and where required transfer to the community team who will review the customer’s needs within two weeks of discharge from hospital.
2. Lincolnshire Non-acute Hospitals
Lincolnshire has a number of non-acute community hospitals:
- John Coupland Hospital, Gainsborough;
- County Hospital, Louth;
- Johnson Hospital, Spalding;
- Skegness and District General Hospital.
Area teams are responsible for discharges from these hospitals with the referral route through Customer Service Centre and managed like any other request for assessment or unscheduled reassessment.
At Louth and Skegness, there are key workers linked to the hospital who are part of the hospital Multi-Disciplinary Teams.
At John Coupland Hospital, there is a Trusted Assessor Process in place where ward staff can arrange up to 10 hours of home care per week.
3. Out of County Hospitals
Requests for social care assessments and discharge planning for Lincolnshire residents admitted to out of county hospitals are managed by the relevant area team for the home address of the customer, unless they are from a nominated out of county hospital covered by the in-county hospital teams, which are:
- Lincoln County Hospital – Scunthorpe general, Diana Princess of Wales- Grimsby, Lincoln Elderly Hospital Complex, West Lincoln Hospital, Castle Hill, Hull Royal infirmary, North East Lincolnshire Care Trust Hospital, Goole and District Hospital;
- Grantham Hospital – Nottingham QMC, Nottingham University Hospital, Nottingham City Hospital, Northern General, Sheffield Care NHS Trust, Royal Hallamshire, Medway Maritime Hospital, Sherwood Forest Trust Hospital, Wythenshawe Hospital, Pinderfields Hospital, Royal Brimpton Hospital, Leicester General Hospital, Leicester General Hospital NHS Trust, Glenfield Hospital – Leicester;
- Peterborough Hospital – Queen Elizabeth Hospital, Kings Lynn Hospital, Papworth Hospital, Addenbrookes Hospital, Wisbech Hospital, Hinchinbrooke Hospital;
The in-county hospitals which cover their nominated hospitals have their own referral arrangement with each hospital.
Otherwise, referrals are received through Customer Service Centre. Where there is an open key worker they will be responsible for the assessment. Where there is no key worker, the request will be sent to the appropriate community team to assess and facilitate discharge.
4. Hospital Discharge Planning and Delayed Discharge Process
The Care Act sets out the process for notification of discharge when an adult has care needs, and the requirement for assessment. It amends the mandatory system of fining / reimbursement to discretionary, where the local authority has not carried out its duties by the day of discharge.
Additional information on hospital discharge including discharge process, notices and timescales can be found in Annex G: The process for managing transfers of care from hospital for patients with care and support needs.
You can also access A Simple Guide to the Care Act and Delayed Transfers of Care.
5. Reporting Inappropriate Hospital Discharges
The Inappropriate Discharge Form enables concerns relating to unsafe hospital discharges to be reported back to United Lincolnshire Hospitals NHS Trust to address issues and improve practices and joint working.