PROTOCOL FOR
HOSPITALTO AREA
TRANSFER OF CASES
AUTHOR:
Planning and Policy Officer
Nov 1998
AUTHOR OF REVISION: Nic Davis
Planning and Policy Officer
DATE OF REVISION December 2004
REVISION NUMBER: 1
1
PROTOCOL FOR HOSPITAL TO AREA TRANSFER OF CASES
Contents
Page
1. Statement
3
2. Purpose
3
3. Scope
4
4. Mandatory Procedures
4-6
5. Practice Guidance – Hospital Social Work Teams
6
6. Practice Guidance – Area Social Work Teams
6
7. Implementation
7
8. Monitoring and Review
7
Appendices
8-10
2
PROTOCOL TO ENSURE CONTINUITY OF CARE HOSPITAL TO AREA TRANSFER OF CASES
1
Statement
It is this Directorate’s intention that people, who are admitted to hospital and
who are subsequently assessed as needing a community care service, have
their case managed in the most effective way. The transfer of responsibility
should be clear throughout a person’s movement through the health and social
care systems.
2
Purpose
This protocol aims to make clear the trail of responsibility for case managing
and co-ordinating the care required to meet the community care needs of
people who are admitted and discharged from hospital and that good practice
is maintained.
The guidelines contained here are primarily intended to ensure that when
cases are transferred from hospital social work teams to area teams, practical
and administrative arrangements are co-ordinated effectively to ensure that
service users, carers and appropriate agencies benefit from a process that
provides ‘continuity of care’.
In using these guidelines it may prove helpful to re-iterate two key service
delivery principles that set the broad boundaries of responsibility between
Hospital and Area staff:
Community Care
1. Hospital social care staff assume responsibility for an adult admitted to
hospital if they are not:
 already open to social worker, fieldwork support assessor or care
manager within a local fieldwork team*;
 already open to a worker in the Partnership Trust including workers
from the Learning Disability Team;
*Please note: cases open on STAR/ERIC to “central office” should be
interrogated to determine if there is active involvement from staff in any
local fieldwork team (including specialist teams). Care management
responsibility will be negotiated in these cases and the record will be
amended to indicate the case being open to the agreed team.
2. Once responsibility is accepted, the hospital social worker will retain
responsibility for a case until the service user leaves hospital. Where they
arrange care home placements, they will transfer the case to an area office
within 2 weeks of the placement date.
Before transfer, the hospital social care staff must undertake a check (by
telephone is fine) to ensure that there are no immediate problems with the
3
placement. This check is made to ensure cases are only transferred
between workers in hospital and areas if they are stable. The notes of the
check will be recorded in the file but should not be recorded on STAR /
ERIC as the initial review. The Area Team will have the responsibility to
undertake subsequent monitoring and initial review before setting up the
next planned (at least annual) review.
Where hospital social care staff arrange a care package that involves the
provision or purchase of domiciliary care services, they will retain
responsibility up to the date the service user leaves hospital. The
purchasing officer will have the responsibility to arrange the provision or
purchase of the care package. Subsequent monitoring and reviewing will
take place as in existing procedures.
3
Scope
These guidelines are intended for all social care staff working in acute and
community hospitals, including those, where a social work service is offered to
accident and specialist clinics. It also covers staff working in care management
in all area offices, including outlying offices.
User groups covered are older people and those with a disability, though this is
not exclusive. These guidelines are not appropriate for the transfer of work
between Partnership Trust and Areas, due to the different nature and working
practices of the specialist teams.
Priorities and practices vary between hospitals and areas due to differences in
capacity and response times required in hospitals. Area teams must balance
acute demands with chronic longer- term work, often developing allocation
waiting lists, and it is acknowledged that this can be a source of conflict
between workers.
Hospital and Area staff are encouraged to work together to develop local
arrangements which provide flexibility in responding to demands or ensure
more efficient use of resources.
These guidelines are aimed at promoting good practice underpinned by open
communication between hospital and area based staff, based on awareness
and recognition of each other’s work circumstances. Team Managers from both
settings will inevitably need to discuss particular cases or circumstances that
will require a negotiated agreed response.
4
Mandatory Procedures for Hospital and Area Staff
4.1
Open Cases
For service users who are admitted to hospital, the general principal is that
where their record is ‘open’ on ERIC/STAR to area based social workers / care
managers and fieldwork support assessors, care management will remain the
4
responsibility of the named social worker and Area, unless there has been no
contact previously.
(note: this excludes cases open to other staff such as Occupation Therapists
and fieldwork support assistants but this rule does depend on the extent of
involvement required by staff whilst the person remains in hospital).
4.2
Recently Closed Cases
To ensure consistency and continuity, where a case has been closed within two
weeks of admission to hospital, it is good practice to re-allocate the previous
worker, if possible, so that the case remains the responsibility of the Area.
With 4.1 and 4.2 being the acknowledged baseline, local negotiations do and
will continue to provide agreed one-off or open-ended variations.
4.3
Negotiated Arrangements
When people are admitted to hospital the responsibility for their care
management should be specifically negotiated and agreed between hospital
and area based staff.
Factors that will have a bearing on which area is best placed to take
responsibility will be the resources available within the team to allocate and
take on the work in a timely manner, the practical implications for the staff
involved, and the extent of prior knowledge and involvement with the person
previously. The latter is especially important if the needs are complex.
If area office based staff take responsibility for care management for people
who are in hospital, then they should strive to ensure that, where possible, their
action contributes positively to the achievement of any hospital response
standards.
Agreements can range from a temporary hold to an overall transfer. Ideally
arrangements will be agreed between the staff dealing with the work as it
arises, but on occasions it may be necessary for respective Team Managers to
negotiate an arrangement.
4.4
Pending Referrals
Where a referral is pending allocation in an area office, and no further
assessment has happened, if the service user is admitted to hospital, the
hospital social worker should assume responsibility. The hospital social care
worker’s screening process should ensure that the area is informed of the
admission and subsequent actions.
4.5
Named Contact Person
If a service user is discharged from hospital while pending domiciliary care
service provision, a standard letter must be sent to inform them that their case
is being transferred to another worker, if this is the case. See appendix 1.
4.6
Carer’s Admission to Hospital
Where a Carer has been admitted to hospital, the Carer, if referred, will be
5
the responsibility of the Hospital worker, unless alternative arrangements are
agreed. The service user remaining in the community will be the responsibility
of the Area Team. The need for hospital and area staff to work closely in these
circumstances is essential, wherever possible taking into account the needs
and wishes of both the service user and carer.
4.7
Emergency Duty Team
Where staff from the Emergency Duty Team are involved with a person who is
admitted to hospital, they must notify the hospital social work team on the next
working day, providing details of the key information and the relevant events,
unless the case is open to a area worker and then EDT should make a referral
to the area team.
5
Practice Guidance for Hospital Social Work Teams
5.1
Screening
Upon receipt of a Section 2 notification or other referral, check previous/current
information on ERIC/STAR for all patients being dealt with.
Where a service user is open to an Area based worker it is necessary to make
contact with the worker to exchange information and agree an intervention.
Local working arrangements will determine whether discussion is with duty
workers or Team Managers if the ‘allocated worker’ is not available. After initial
contact and screening, all relevant information collected needs to be recorded
on ERIC/STAR and any incorrect or out of date information needs to be
updated.
5.2
Assessment
Where hospital based staff have undertaken to complete and co-ordinate an
assessment, this will be in accordance with established policies and
procedures of the relevant service user group, involving users and carers
accordingly.
5.3
Out-Patients / Day Patients
Where a person, or their situation, seems to present as at immediate risk,
and is not known to social services, and appears to require Social Services
intervention that person should be initially screened / assessed by staff from Inreach team. These may be from a single point of access that includes
Intermediate Care.
Where patients go home, and issues are unresolved and/or there are ongoing
concerns, where there may be social services responsibilities, details should be
referred to customer service officers for information/action. A standard letter
“SU/posthospdischarge/july2004” at http://staffnet/media/word/5/i/stage1.3.doc
(appendix 2) should be sent to the patient.
5.4
Care Management - Residential/Nursing Home Placement
6
A person’s file needs to be delivered to the area team within two weeks of the
user’s admission date. On those occasions where Hospital Social Care staff
agree to follow up placement support/monitoring or reviewing, a suitable
transfer to the Area Team needs to be negotiated.
6
Practice Guidance for Area Social Work Teams
6.1
Post Discharge, Un-allocated Referrals, Named Contact Person
Where an area team is unable to allocate work referred from the hospital team,
the relevant Team Manager should ensure a named worker is identified as a
contact point and notify this to the service user / family. This could be dealt with
in the sending of a standard delay letter “CM/delay/july2004” at
http://staffnet/media/word/s/o/stage2.3.doc (appendix3). This relates only to
cases post discharge.
6.2
Case Conferences
Occasionally hospital teams will be involved in certain complex situations that
will require a case conference. If an area worker is involved, Area Team
Managers need to ensure that a worker can attend. If not the Team Manager
should attend.
7
Implementation
This protocol will take immediate effect.
8
Monitoring and Review
This guidance will be reviewed within the policy management framework.
7
Appendix 1
Social Services Directorate
Margaret Sheather
Executive Director of Social Services
Gloucestershire
www.gloucestershire.gov.uk
Please ask for:
Our Ref:
Telephone:
Date: 15/02/2016
Notification of Record Transfer
Dear
,
During your recent stay in hospital we assessed your care needs.
We agreed that you have eligible needs and work to decide how
best these can be met is on-going. In the mean time, the care
management responsibility for your case has been transferred to:
Social Services Area Office
Telephone
If problems arise, or your needs or circumstances change before
your service starts, then please contact the help desk on 426880
and explain the change in your situation.
Yours sincerely
Hospital Social Worker
SU/Hosptoareal/Dec2004
8
Appendix 2
Social Services Directorate
Margaret Sheather
Executive Director of Social Services
Gloucestershire
www.gloucestershire.gov.uk
Please ask for:
Our Ref:
Dear
Date: 15/02/2016
,
Following your recent discharge from
, please note the
contact details for Social Services Helpdesk on 01452 426868.
You should contact this number if you want to discuss any problems
you have with managing at home.
Yours sincerely,
Hospital Social Worker
9
SU/posthospdischarge/july2004
Appendix 3
Social Services Directorate
Margaret Sheather
Executive Director of Social Services
Gloucestershire
www.gloucestershire.gov.uk
Please ask for:
Our Ref:
Dear
Telephone:
Date: 15/02/2016
,
I have recently received a referral requesting a visit to assess your
care needs. Unfortunately there will be a delay of approximately
weeks before anyone can visit. Should it become possible to
visit earlier then we will contact you to arrange a time.
If your circumstances change, or you want to discuss your present
circumstances before someone can visit, please contact
.
Yours sincerely,
Care Manager / Social Worker
CM/delay/july2004
10