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
 2 WTE
(0.6 WTE seconded from RLI) to cover the
entire RLI site
 District Nurse Liaison team
tel: 01524 583600 Fax: 01524 516307
Discharge planning
 Individualised - Patients wishes
 Needs identified - health and social
 Safe
 Supported
 Communication
 Accurate updated information
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 team
 Routine DN team
Needs identified
Refer to MDT
 Assessment
 Equipment
 Care
 Advice and support
Patient fit to travel
 Environment assessed as appropriate
 Access to home clarified
 Consider Piperline/Telecare
Who – family or friends
 Need for care and or support from
professionals or voluntary agencies
-refer DN or community matrons
Written and verbal
Pick up the phone
 Accurate and updated including demographics
 Use section 2 not the old single page referral
Role of the District Nurse Liaison
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
 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
 Weekly MDTs ward 50, oncology and MU2
 Daily allocation meetings with hospital SW team
 Weekly Panel meeting with Social Services
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
We do not:
Organise home oxygen
 Organise TNP (topical negative pressure)
 Fax referrals to DN teams in this locality
 Complete assessments for incontinence
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
 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 wishes
Nurse 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
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
 Review of needs – if still triggers
 MDT complete DST (Decision Support Tool) and health lead submit
to NHS North Lancashire Commissioning Department with
 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
DNLO will endeavour to keep the pack with up to date
contact details
Useful Website
2009 revised Continuing Healthcare tools
and information
tsocialcare/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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