The Clatterbridge Cancer Centre. NHS Foundation Trust. Hospital discharge. Rehabilitation and Support. A guide for patients and carers

Transcription

1 The Clatterbridge Cancer Centre NHS Foundation Trust Hospital discharge Rehabilitation and Support A guide for patients and carers

2 Contents Planning to leave hospital...1 Who co-ordinates your discharge...2 Occupational therapy...3 Physiotherapy...4 Oncology social worker...4 Dietitians...5 Speech & language therapy...5 Palliative care...5 Macmillan Welfare Benefits Advisor...5 Additional Support on Discharge District nurse care...6 Intermediate care...6 Social services...7 Continuing health care...8 Moving from hospital straight to a nursing home...9 Hospice...9 Referral to another hospital...9 Voluntary sector organisations...9 Macmillan nurse support...10 Support for families and carers...11 What to expect on your day of discharge...11

3 1 This booklet is designed to inform you of the planning process that takes place when preparing you for discharge from hospital. This leaflet will explain who is involved in planning your discharge and how all of the different healthcare professionals work together to safely discharge you home with the services, support and equipment you may need. Planning to leave hospital Shortly after your admission to our hospital, you will be informed of your Estimated Date of Discharge (EDD). This is the date by which the clinical team delivering your care feel you will be ready to leave the hospital. Please note however, this date may be changed (due to alterations in your treatment plan or your condition or needs), it provides a goal for the multi-disciplinary team (MDT) and guidance to you and your relatives/carer as to when you are likely to be ready to leave this hospital. There is a lot of preparation and coordination that must occur in order to ensure you have a safe discharge. The care that is planned for you when you go home will depend on your particular needs. It s important that you and your relatives or carers, if you wish, are involved as much as possible in these plans. There may be medication to be arranged, follow up appointments to be booked, recovery instructions to be managed, transport to be booked and contact numbers of healthcare professionals you can contact for further advice/support if required.

4 2 Whilst you re in hospital, the healthcare professionals looking after you will make a plan for your discharge often called a discharge plan. Some patients may not need additional support upon discharge but for others they may require the extra support which is explained in this booklet. Upon admission the nursing staff will ask you questions so they can assess your needs and find out what support you may need when you go home. Who co-ordinates your discharge Hospital Team Medical staff Nursing staff Multi-disciplinary Team Physiotherapist Occupational Therapist Speech & Language Therapist Dietitian Psychological Medicine Benefits Advisor Social Worker CHC Funding & Package of Care/Nursing Home/Residential Home Primary Care Team GP/District Nurses Pharmacy Patient/ carer families Additional Needs Clinical Specialist Transport Ambulance Voluntary Support Carers Organisation Age UK Crossroads Specialist Nurses Macmillan Nurses Cancer Nurse Specialists Palliative Services Hospice Care Hospice@Home Social Services Package of Care/ Nursing Home

5 3 Whilst you are in hospital you may need to be referred to the multidisciplinary team (MDT).The team consist of various professionals including nurses, physiotherapists, occupational therapists, dietitian, social worker, speech & language therapists, palliative care and welfare benefits. Below is a brief overview of the work which is carried out by the various professionals who may assess your needs when preparing for your discharge. Occupational therapy Occupational therapists work with people of all ages, helping them to carry out the activities that they need or want to do in order to lead healthy and fulfilling lives. They will help to make sure you have a safe discharge with appropriate services and equipment in place. They work with people who have physical, mental and/or social needs and aim to enable them to achieve as much as they can for themselves, in order to get the most out of life. Occupational therapists can work with you if you cannot do the things that are important to you such as getting dressed, having a wash or undertaking a favourite hobby an occupational therapist can help you in many ways, based on your individual needs and lifestyle. They may also be involved with assessment, if you need intermediate care (see page 5) after your treatment plus ongoing rehabilitation needs.

6 4 Physiotherapy We also provide a physiotherapy service to you while you are undergoing treatment and are experiencing difficulties that are directly related to, or made worse by, your cancer or treatment. The inpatient physiotherapy service helps people by: Adapt to changes in mobility and function Working to regain/maintain mobility and function following a period of bed rest or because of reduced movement, via exercise and use of mobility aids Helping to alleviate symptoms of chest infections and/or breathing difficulties Helping to alleviate pain by use of TENS machines, heat and ice Helping to alleviate the symptoms of stress/anxiety through the use of relaxation and breathing exercises. The physiotherapist may be involved in your discharge by making sure that appropriate equipment and services are in place on discharge. They would also be involved with assessment if you need intermediate care after your treatment at Clatterbridge Cancer Centre. Oncology social worker The Oncology Social Worker will provide support and advice to patients and their families when they need social services input, health and voluntary services once discharged from hospital. They

7 5 can act on behalf of the patient who may need packages of care, intermediate care, or have other problems at home. Speech & language therapy You will be referred to speech and language therapy if you have any swallowing problems i.e. on eating and drinking or need help re-introducing oral intake. You may also be referred if you have difficulty communicating verbally which may be as a result of surgery or treatment effects. Dietitian Dietetic services may be involved in your discharge to make sure that you get the appropriate nutrition during and after treatment. They will liaise with community based dietitians in your local area if necessary to ensure that you have the appropriate equipment and service, for example feeding pumps. Palliative care The aim of palliative care is to achieve the best quality of life for patients and their families. If you require specialist palliative care for symptom management and or other supportive care, then they will be involved in your discharge plan. This could involve being discharged to home, hospice or another residential setting. Macmillan Welfare Benefits Advisor The Macmillan Welfare Benefits Advisor offers confidential and comprehensive advice to patients attending the Centre for their treatment. They will assess entitlement to benefits and advise and assist patients to claim the benefits they may be entitled to.

8 6 Additional Support on Discharge District nurse care District nurses work closely with your GP and can make regular visits to patients and their families at home if it is needed. They provide help, advice and support with the practical aspects of nursing care, including wound dressings, flushing of central lines, injections, help with managing feeding tubes. District nurses can also arrange for you to have certain equipment, such as a commode, bedpan, urine bottle or a special mattress, at home if you need it. They can assess your care needs when you re at home and refer you for help from other healthcare professionals, if needed. Intermediate care Intermediate care is a structured programme of care (available to adults over the age of eighteen) provided for a limited period of time to assist a patient to maintain or regain the ability to live in their own home. This service is free of charge to any patient to whom it is provided for any period up to and including six weeks. The range of services that form part of an intermediate care package can vary across the region. The service can be provided in your home, another hospital, a nursing home or other residential setting. You may be assessed by Occupational Therapy and Physiotherapy to see if you would meet the need for referral for intermediate care.

9 7 The range of services is varied throughout the region, and it may be difficult sometimes to access intermediate care in your area due to the high demand of the service, we will however make the referrals if you have been assessed as needing intermediate care and endeavour to get the appropriate support in place. Social services Social care services may be arranged by your local Social Services department if you need a package of care at home. A package of care means that carers would support you at home with personal care and meal preparation. A referral will be made while you are in hospital to your local Social Services who will arrange this service. While you are in hospital you may be assessed by the Occupational Therapist, Physiotherapist and Social Worker, who will than liaise with your local Social Services on what support you may need at home. Your local Social Services can also arrange a community alarm so you can summon help in an emergency, and a key safe which is fitted outside of your house so that the carers can gain access if necessary (there may be a charge for this service). If you require ongoing care after being discharged from hospital you will have a financial assessment from your local authority, which will assess if you have to pay for your care. If you would like to discuss further what support Social Services can be provided, you can request to speak to the Oncology Social Worker.

10 8 Continuing health care If you have complex nursing care needs, you may be eligible for NHS continuing healthcare. This is a package of care funded solely by your Clinical Commissioning Groups when it is established that the primary need for care is a health need. If you are eligible you would not need to pay for your care. If staff think you may be eligible they will conduct a checklist which will identify if you should have a full assessment to determine your eligibility. Staff will tell you if the checklist tool indicates that you need a full assessment Staff will then complete a full assessment for continuing health care. If you are eligible for the full assessment does not mean that you will receive continuing health care. The forms will be sent to continuing health care in your area who will then make a decision to determine if you are eligible to receive it. Continuing health care can fund a nursing home or a package of care at home. A booklet NHS continuing healthcare and NHS funded nursing care explains the process in more detail, nursing staff will supply you with this booklet. If you would like to discuss further about continuing health care ask to speak to the oncology social worker who can help you with any questions you may have.

11 9 Moving from hospital straight to a nursing home Admission to hospital, whether planned or unexpected, can be a worrying time and whilst we always strive to help people return home, this is not always possible. If long term decisions have to be made about moving to a nursing home, our oncology social worker will ensure that we talk to you, and with your permission, your family, your carer or representative. Who pays for a residential or nursing home depends on your health needs and if you are eligible for continuing health care, and what savings you have. Hospice For some people it may be necessary for you to go a hospice for ongoing specialist palliative care. A referral will be made to the palliative care team who will discuss this with you in more detail. Referral to another hospital It may be necessary for you be discharged to another hospital for ongoing medical care. This will be arranged by your ward team, who will keep you fully informed. Voluntary sector organisations Local voluntary sector organisations such as Age UK, British Red Cross, Crossroads Care many be able to offer support at home following discharge from hospital. The voluntary sector can

12 10 offer low level support which Social Services may not be able to provide this may include some of the following: Housework Luncheon clubs and day centres Advocacy Handyperson schemes The loan of equipment such as wheelchairs and commodes Information and advice Carers support Some of these services may be free if you meet certain criteria, however in most cases you may have to pay for some of this care. For further information ask to speak to the oncology Social worker, who will be able to give you further information on what is available in your area. Macmillan nurse support Should you require specialist palliative care when you are at home then you can be referred by the nursing staff or specialist palliative care team prior to discharge. You may be offered an outpatient appointment at your local hospice or a Macmillan nurse may visit you at home. Sometimes the Specialist Palliative Care Team can follow you up in their outpatient clinic at Clatterbridge Cancer Centre. Please be aware that sometimes, your district nurse/ community nursing team may manage this entirely and you may never need to see a Macmillan Nurse.

13 11 Support for families and carers Many people looking after someone do not recognise themselves as carers. You are a carer if you provide or intend to provide practical and/or emotional support to a relative, friend or neighbour who is disabled, ill, frail, or recovering from an episode of illness. Caring may not always be easy emotionally or physically. Caring can have a major effect on your emotions, time, relationships and everyday life; you have needs of your own. Services are available to help and support you, as well as the person you are caring for. You are entitled to a carer s assessment by your local authority to see if you would be entitled to any services to help you. If you would like further information on what may be available in your area ask the oncology Social Worker who will give you further information. What to expect on your day of discharge The nursing staff will go through a checklist with you which will include medication if you have any to take home and your GP letter etc. Nursing staff will ensure that any follow up appointments are made as required and liaise with transport to book an ambulance to take you to your discharge destination (if required). They will ensure your discharge destination has been informed if applicable.

14 12 We hope you have had a comfortable stay at our hospital and feel well informed and confident in our clinical expertise, high standards of care and hospital cleanliness. We expect high standards from our staff who are dedicated to caring for you in a warm and professional manner. We are always looking for ways to improve our service and care, so if you have any feedback on your stay, please speak to a member of the nursing team. Telephone Triage Helpline: If you have any concerns over the 2 months after finishing treatment contact the Triage help line (24 hours) on and ask for bleep After this time period contact your GP. The team working with you: Team Member Ext. No.

15 13 Healthcare Professionals who may be in contact with you once you leave the Clatterbridge Cancer Centre Team Member Telephone Numbers District Nurses Therapies Social Worker Specialist Palliative Care Team Dietician Community Specialist Palliative Care Team

16 How we produce our information All of our leaflets are produced by staff at The Clatterbridge Cancer Centre and this information is not sponsored or influenced in any way. Every effort is made to ensure that the information included in this leaflet is accurate and complete and we hope that it will add to any professional advice you have had. All our leaflets are evidence based where appropriate and they are regularly reviewed and updated. If you are concerned about your health in any way, you should consult your healthcare team. We rely on a number of sources to gather evidence for our information. All of our information is in line with accepted national or international guidelines where possible. Where no guidelines exist, we rely on other reliable sources such as systematic reviews, published clinical trials data or a consensus review of experts. We also use medical textbooks, journals and government publications. References for this leaflet can be obtained by telephoning If you need this leaflet in large print, Braille, audio or different language, please call If you have a comment, concern, compliment or complaint, please call The Clatterbridge Cancer Centre NHS Foundation Trust Clatterbridge Road, Bebington, Wirral, CH63 4JY. Tel: Web: Issue date: 1/12/13 Issue no: 1.0 Reference: LCRZHDISC Review date: 01/12/15