DISTRICT NURSE LIAISON

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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 team
• tel [phone] Fax [phone]

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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 team
• Routine DN team

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Needs identified

• Refer to MDT
• Assessment
• Equipment
• Care package
• Advice 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

• Written and verbal
• Pick up the phone

• Information
• Accurate and updated including demographics
• Use section 2 not the old single page referral

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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
Contd

• 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
  familys 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

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The Assessment Process Contd

• 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 patients 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
  medication
• DNLO 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/Deliveringadultsocial
  care/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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THANK YOU FOR LISTENING