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DISTRICT NURSE LIAISON DEPARTMENT RLI
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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
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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
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Discharge planning
Planned Individualised - Patients wishes Needs identified - health and social Safe Supported Communication Accurate updated information
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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
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Needs identified
Refer to MDTAssessmentEquipmentCare packageAdvice and support
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Safe
Patient fit to travel Environment assessed as appropriate Access to home clarified Consider Piperline/Telecare
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Supported
Who – family or friends Need for care and or support from
professionals or voluntary agencies
-refer DN or community matrons
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Communication:
Information: Accurate and updated including demographics Use section 2 not the old single page referral
Written and verbalPick up the phone
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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
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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
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How we work
Reactive service – via section 2 referrals Routine MDTs/panel meetings each week
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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
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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
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We do not:
Organise home oxygen Organise TNP (topical negative pressure) Fax referrals to DN teams in this locality Complete assessments for incontinence
products
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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
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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
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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
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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
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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)
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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
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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
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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
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Useful Website
2009 revised Continuing Healthcare tools and information
www.dh.gov.uk/.../SocialCare/Deliveringadultsocialcare/Continuingcare/index.htm -
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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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2617
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