Kettering General Hospital From Admission to Discharge. Information and Advice for Families and Carers. Information

Transcription

1 Kettering General Hospital From Admission to Discharge Information and Advice for Families and Carers Information

2 Having someone you care for in hospital can be a very worrying, stressful and confusing time, especially if that person can no longer care for him or herself in the same way as they did before. You may have concerns about whether you can provide the on-going care and support that is needed. You might also be worried about what will happen throughout the patient s hospital stay, during the discharge planning process and who you can turn to for help. This information aims to provide guidance and answers to some of these concerns enabling you to feel more knowledgeable about: What might and what you should expect to happen. Those services which could support you and the person you care for. Who to go to for more detailed information and further support. Discharge planning Support is available specifically for informal carers of patients who are admitted to Kettering General Hospital via the Carer Assessment & Support Worker (CASW) Service. CASW will also provide information, advice and promote carer awareness and highlighting carers concerns to the hospital staff. 2

3 Following discharge, the CASW may also provide: shortterm support, carry out carer assessments, support planning and crisis prevention as well as make referrals to other identified services and organisations such as Northamptonshire Carers which acts as an access to ongoing carer support in the community. What do carers need to know before the patient is discharged? Carers might need advice and information on: A patient s illness or disability and medication. The hospital discharge process. Practical help available for the patient following their discharge. Carers Rights there is a hospital carers policy and charter. The different professional roles. Who to contact if it all gets too much. Many of these issues/concerns can be addressed by the CASW who can help to guide and support you through the process. How can the CASW help? Following contact from you or from a member of the hospital staff, on your behalf, a discussion between you, as the carer, and CASW will take place. This will be to address any immediate concerns that you may have and to agree any further actions or support required. 3

4 What is a discharge plan? When patients are admitted to hospital, a treatment plan is agreed and the process of discharge planning should begin. This will determine the services and support that is required for the patient when they are ready to leave. By the time the patient is ready to be discharged, clear arrangements should be in place. Each ward has a nominated discharge coordinator. It is advisable to raise any concerns you may have about the patient s discharge as soon as possible. The CASW can help you to do this. The Patient s Medical Condition Information should be provided regarding medication, treatment and any future medical appointments. You should also be advised on the names of the consultant and nurse in charge of the patient s care. Services and Support Information about the services that have been agreed and will be in place for when the patient returns home, for example visits from Home Care Assistants or a Community/District Nurse. Also included should be information on local points of contact and where needed, specialist information. 4

5 What are my rights? The most important right you have as a carer is to be listened to and to have your views taken into account. This means: You should be consulted about the services that could be provided for the person you care for. You should be asked if you are able and willing to provide or continue to provide care for that person. As a carer you are entitled to a Carers Assessment If you need further advice or information, please do not hesitate to contact the CASW How discharge arrangements are planned If the patient needs to be cared for and supported for the first time, or if their care and support needs have changed, discharge planning is important to ensure that the right care and support is provided. It is essential that the patient and you as their carer are involved in decisions and choices about their future care. It may be that services were already in place for the patient and for you as their carer. If this is the case, then the main reason for forming a discharge plan is to ensure that services will continue as before or whether they need reviewing. It is important to inform the patient s named nurse as early on in the process as possible if you feel you can no longer provide care or to let them know if you have your own health issues that mean caring would be difficult for you. The CASW can support you with this. 5

6 The following are key people who can or will be involved in the discharge planning process: The Nurse in charge of the patients Care - is the main contact person while the patient is in hospital overseeing the care provided and plans for discharge. In mental health cases, the Community Psychiatric Nurse (CPN) may also be involved. The Consultant - decides what medical care should be provided and when the patient is medically fit to be discharged from hospital. Occupational Therapist (OT) - will aim to help the patient to be as independent as possible in everyday tasks such as washing, dressing and meal preparation. They can work on building the patient s confidence and will identify and ensure the patient has the right equipment and adaptations needed for them to use at home. Physiotherapist (PT) - will works with patients to help them regain lost movement, improve balance and mobility and to maintain safe independence in activities such as walking and transferring, for example from bed to chair and using the stairs. Health Partnership Team - will assess and provide a care package to support the patient in their own home or in a residential/nursing care home, if the patient is eligible for this. 6

7 They will talk to the patient and you as their carer about what the patient needs and wants. They will also discuss if there are costs to be met by the patient, for the care they require. Hospital Intermediate Care Team a multi-disciplinary team of professionals. If appropriate, they will assess and provide short term rehabilitation for the patient at home. Hospital Discharge team - an integrated multi professional team who will liaise with the ward staff to ensure the patient has everything they need before they are discharged. They will always work towards discharging the patient back to their own home first, wherever possible. In some instances, such as waiting for a rehabilitation bed or package of care to become available, the patient may need to access one of several care facilities in the community so that beds are made available at the hospital for other patients. Speech and Language Therapist (SALT) - work with the patient and can offer advice and information on communication, speech and language, as well as eating and swallowing difficulties. Dietician - can offer information and advice to the patient and you as their carer, if the patient requires a special diet. The Pharmacist - provides the patients medication and information on how it should be taken. 7

8 They can contact the community pharmacist to provide information on any changes to the medication or supply details. Summing Up Before leaving hospital the patient and you as their carer should receive information on discharge arrangements. This is not only provided verbally but also in a discharge letter that is to be taken home by the patient with a copy sent by the ward to the patients GP. What to think about before the patient comes home Here are some useful prompts to think about to help make the transition from hospital to home go as smoothly as possible: Are all the services to support you and the patient you care for in place? Has the patient got enough medication and/or dressings to last until they see their GP and/or District nurse? Has essential equipment been delivered and made ready to use? Has transport arrangements been made? Let staff know if there is a problem. Has the patient got a key or someone to let them in at home? Has the patient got suitable clothing and foot wear to travel home in? 8

9 Do you have a telephone contact number to call if you have any worries or concerns? Is everything ready at home house is warm enough, sufficient food available etc? Has the patient taken all their property/belongings from the ward? Has the patient got their discharge letter to take home and any medication needed? After leaving hospital services in your community who may provide support To be involved in planning services and support for the person you care for, you will need to know what services are available. Here are a few of the main services: Community Care The key to receiving community care services is a Community Care Assessment. This is normally carried out by a Care manager or care coordinator from the Health Partnership Team and will form a central part of on going support for the patient at home. The assessment determines what support is required to allow the patient to live as independently as possible at home or in a nursing/residential care environment. 9

10 Here are some of the services that can be provided and or referred for: Medical/Social rehabilitation Personal care package Sensory equipment Respite care Referrals can also be made to support those patients who are self-funding for their care. This list is not exhaustive but it provides a starting point for you and the person you care for to think about what you might need or want. There may be charges for these services. The Care Manager will be able to discuss this with you and the patient. Home Care Services If the patient is assessed as needing support with personal care etc at home, then they will be discharged initially with either SERVE in the short term or Olympus Care Services (OCS). Both of these services employ staff that are fully trained and have been checked by the Criminal Records Bureau (CRB). These services provide short-term care at home. Usually If OCS are unable to support on discharge, then SERVE will support for a few days until OCS can take over. SERVE is a voluntary organisation and registered charity who provide services to assist older people and adults with disabilities in East Northamptonshire. 10

11 OCS is a service that supports patients going home from hospital, free of charge for up to six weeks following discharge. During the six-week period, OCS will carry out their own assessments and refer to a Community Care Manager if it is felt a long-term package of care is required. An on-going care package will then be provided. If the cared for person is self-funding for their on-going care needs, OCS will provide some advice and information as to what services are available to continue to meet the patient s needs. It will then be up to the patient and/or their family to arrange for this care to be provided, prior to OCS finishing. It is advisable to let OCS know if you would like to be involved in the patients review / plans for future care. Adult Care Team Patients can be discharged home without requiring any care package. However, if the situation changes or the support you provide becomes too much for you, then it is advisable to contact the Adult Care Team. They will take all the details and if appropriate, carry out an assessment to determine what help the cared for person now requires. General Practitioner (GP) The GP provides on going medical care and advice when the patient has been discharged from hospital. The GP will receive information and the discharge letter from the 11

12 hospital consultant and nursing staff about the patient s medical needs. This should include information on discharge planning. They will also be able to answer questions on medical matters following the discharge process and can refer the patient back to the consultant at the hospital if required, as well as refer to other services. Community Nursing Team The team includes District Nurses, Health Visitors and Practice Nurses, all with specialist knowledge in community health. District Nurses provide care in the GP surgery or health centre Health Visitors provide advice/information on health related issues Practice Nurses can visit at home and can help with a range of issues including continence care etc. Community Mental Health Team This Includes Community Psychiatric Nurses (CPN) and Care Managers/Coordinators who provide a range of services and nursing care for people with severe and enduring mental illnesses. They may be involved in the discharge planning process. 12

13 Voluntary Sector The Voluntary sector is a term used to refer to the wide range of services provided by voluntary or charitable organisations such as Northamptonshire carers. Some services can provide support for both the carer and the patient. These may include, for example, services provided by SERVE or Age Concern. Helpful information about services at this hospital for carers Carers badges In certain circumstances you may be able to visit the patient outside of normal visiting hours, for example to support them with feeding etc. This needs to be agreed with the Ward Sister who can request a Patient Carer Badge. Procedure You will need to complete a Patient Carer Badge Request Form that can be obtained from the Ward sister. The completed form should then be taken either to the Patient Advice and Liaison Office (PALS) between 9.00am-5pm or the Main Reception between 8.30am-5pm. Badges can also be supplied by the Carers Support Worker or the Disability Facilitator. You will need to sign for the Carers Badge and so that other carers can also utilise this service. Please return the Carers Badge to either the PALS Office or the Main Reception after use. 13

14 It is important to note that if the patient is moved to another ward, any previous agreement for visiting outside of normal visiting hours will need to be renegotiated. The ward Sister also has the right to change visiting arrangements if it is felt to be in the best interest of the patient and running of the ward. Car parking You can obtain a Concessions Car Parking slip from the ward staff. This needs to be completed and taken to the car parking office which is situated within the main car park. You will then be issued with a weekly parking ticket at a reduced charge. There is no limit to your stay each time and you can come and go as many times as you please. You will need to renew your weekly ticket by collecting another concession slip from the ward. Blue badge parking There are spaces for people with disabilities close by the entrances to the hospital. If all of these parking bays are full, you can park in any parking bay of the main two car parks A and B for You will need to take your parking ticket and Blue Badge to the car parking ticket office, where you will be issued with this concession. 14

15 Contact information Please contact one of the following for further advice, information or support. Carer Assessment and Support Worker Service Answer phone facility Monday to Thursday: 08:30am to 4:30pm Fridays: 08:30am to 4.30pm Alternatively, you can speak to a member of the ward staff or Northamptonshire Carers who will get in touch with the CASW on your behalf. Northamptonshire Carers Support Line The Disability and Sensory Impairment Facilitator (Only available Thursdays at Kettering General Hospital) Answer phone facility Adult Social Care APCOA for more information on parking at Kettering General Hospital 15

16 If you need this information in another format or language, please telephone Further information about the Trust is available on the following websites: KGH - NHS Choices - Ref: PI.676 April 2014 Review: January 2016