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Transition between inpatient hospital settings and community or care home settings for adults with social care needs

About

What is covered

This pathway covers transition between inpatient hospital settings and community or care homes for adults with social care needs including older people. It aims to improve people's experience of transfers into and out of hospital and to ensure safe and consistently high quality services.
The Care Quality Commission uses NICE guidelines as evidence to inform the inspection process.
In line with the Care Act 2014, the pathway covers health and health-related provision (including housing), and other care and support.
Who is it for?
  • Health and social care practitioners
  • Health and social care providers
  • Home care managers and workers
  • Adults with social care needs who are moving between being admitted to or discharged from hospital and the community (including care homes), and their families and carers.
  • Commissioners and providers of health and social care services designed to support people during transition between hospital and the community, including care homes.
  • Health and social care practitioners.
Commissioners of hospital, care home and home care services should ensure that any service specifications take into account the recommendations in this pathway.

Updates

Updates to this pathway

30 November 2016 Transition between inpatient hospital settings and community or care home settings for adults with social care needs (NICE quality standard 136) added.
4 July 2016 Link added to NICE pathway on oral health for adults in care homes.
11 April 2016 Stroke in adults (NICE quality standard 2) removed.

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Transition between inpatient hospital settings and community or care home settings for adults with social care needs

What is covered

This pathway covers transition between inpatient hospital settings and community or care homes for adults with social care needs including older people. It aims to improve people's experience of transfers into and out of hospital and to ensure safe and consistently high quality services.
The Care Quality Commission uses NICE guidelines as evidence to inform the inspection process.
In line with the Care Act 2014, the pathway covers health and health-related provision (including housing), and other care and support.
Who is it for?
  • Health and social care practitioners
  • Health and social care providers
  • Home care managers and workers
  • Adults with social care needs who are moving between being admitted to or discharged from hospital and the community (including care homes), and their families and carers.
  • Commissioners and providers of health and social care services designed to support people during transition between hospital and the community, including care homes.
  • Health and social care practitioners.
Commissioners of hospital, care home and home care services should ensure that any service specifications take into account the recommendations in this pathway.

Updates

Updates to this pathway

30 November 2016 Transition between inpatient hospital settings and community or care home settings for adults with social care needs (NICE quality standard 136) added.
4 July 2016 Link added to NICE pathway on oral health for adults in care homes.
11 April 2016 Stroke in adults (NICE quality standard 2) removed.

Quality standards

Transition between inpatient hospital settings and community or care home settings for adults with social care needs

These quality statements are taken from the transition between inpatient hospital settings and community or care home settings for adults with social care needs quality standard. The quality standard defines clinical best practice for transition between inpatient hospital settings and community or care home settings for adults with social care needs and should be read in full.

Medicines management in care homes

These quality statements are taken from the medicines management in care homes quality standard. The quality standard defines clinical best practice for medicines management in care homes and should be read in full.

Quality statements

Information sharing on admission

This quality statement is taken from the transition between inpatient hospital settings and community or care home settings for adults with social care needs quality standard. The quality standard defines clinical best practice for transition between inpatient hospital settings and community or care home settings for adults with social care needs and should be read in full.

Quality statement

Adults with social care needs who are admitted to hospital have existing care plans shared with the admitting team.

Rationale

Improved communication between community and hospital services leads to a smoother transition. For example, people who are admitted to hospital and their families or carers do not have to keep repeating the same information to different people. It can also improve people’s experience of hospital because the admitting team is given a range of information about their needs, wishes and circumstances.

Quality measures

Structure
Evidence of local arrangements to ensure that existing care plans for adults with social care needs are shared with the admitting team when they are admitted to hospital.
Data source: Local data collection.
Process
The proportion of adults with social care needs who have existing care plans shared with the admitting team when they are admitted to hospital.
Numerator – the number in the denominator where the person’s existing care plans are shared with the admitting team.
Denominator – the number of hospital admissions of adults with social care needs.
Data source: Local data collection.
Outcome
People’s experience of hospital admission.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as hospitals, GPs, community services and local authorities) ensure that systems are in place to transfer existing care plans for adults with social care needs to the admitting team when they are admitted to hospital. This may include the use of Summary Care Records, hospital passports or other profiles containing important information about the person’s needs and wishes.
Health and social care practitioners (such as care home managers, GPs and social workers) ensure that they share existing care plans with the admitting team when they arrange a hospital admission for adults with social care needs.
Commissioners (clinical commissioning groups, local authorities and NHS England) ensure that they commission services in which adults with social care needs have existing care plans shared with the admitting team when they are admitted to hospital. This may include the use of Summary Care Records, hospital passports or other profiles containing important information about the person’s needs and wishes.

What the quality statement means for patients and carers

Adults with social care needs know that, when they go into hospital, all the necessary information about them will be given to the hospital team.

Source guidance

Comprehensive geriatric assessment

This quality statement is taken from the transition between inpatient hospital settings and community or care home settings for adults with social care needs quality standard. The quality standard defines clinical best practice for transition between inpatient hospital settings and community or care home settings for adults with social care needs and should be read in full.

Quality statement

Older people with complex needs have a comprehensive geriatric assessment started on admission to hospital.

Rationale

Older people make up a significant proportion of hospital admissions and many have complex medical, functional, psychological and social needs. Carrying out a comprehensive assessment helps practitioners to develop a long-term plan to manage those needs. This could reduce the length of hospital stay and help people regain their independence sooner and maintain it for longer.

Quality measures

Structure
Evidence of local arrangements to ensure that older people with complex needs have a comprehensive geriatric assessment started on admission to hospital.
Data source: Local data collection.
Process
Proportion of older people with complex needs who have a comprehensive geriatric assessment started on admission to hospital.
Numerator – the number in the denominator where a comprehensive geriatric assessment is started on admission to hospital.
Denominator – the number of hospital admissions of older people with complex needs.
Data source: Local data collection.
Outcome
a) Length of hospital stay for older people with complex needs.
Data source: Local data collection.
b) Delayed transfers of care for older people with complex needs.
Data source: Local data collection. National Delayed transfers of care data is published by NHS England.
c) Permanent admissions to residential and nursing care homes in the 12 months after hospital admission.
Data source: Local data collection. National data on permanent admissions to residential or nursing care are available as part of the Adult social care outcomes framework – indicator 2A.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (hospitals) ensure that systems are in place to start comprehensive geriatric assessments when older people with complex needs are admitted to hospital.
Health and social care practitioners (such as geriatricians) ensure that they start a comprehensive geriatric assessment when older people with complex needs are admitted to hospital.
Commissioners (clinical commissioning groups) ensure that they commission services in which older people with complex needs have a comprehensive geriatric assessment started when they are admitted to hospital. For emergency admissions, this supports NHS England’s Seven day services clinical standards, standards 2 and 3.

What the quality statement means for patients and carers

Older people with complex needs have a thorough review of their needs when they go into hospital. This is done by healthcare professionals with specialist knowledge in caring for older people. The aim is to make a long-term plan to provide the support they need after they leave hospital.

Source guidance

Definitions of terms used in this quality statement

Older people with complex needs
Older people who need a lot of support because of physical frailty, chronic conditions or multiple impairments (including dementia). Many will be affected by other factors linked to poverty, disadvantage, nationality, ethnicity and lifestyle. Older people are generally people who are 65 or older, but could include people who are younger, depending on their general health, needs and circumstances.
The presence of 1 or more of the following in older people should trigger a comprehensive geriatric assessment:
  • falls
  • immobility
  • delirium and dementia
  • polypharmacy
  • incontinence
  • end of life care.
Comprehensive geriatric assessment
A comprehensive geriatric assessment is an interdisciplinary diagnostic process to determine the medical, psychological and functional capability of someone who is frail and old. The aim is to develop a coordinated, integrated plan for treatment and long-term support.

Coordinated discharge

This quality statement is taken from the transition between inpatient hospital settings and community or care home settings for adults with social care needs quality standard. The quality standard defines clinical best practice for transition between inpatient hospital settings and community or care home settings for adults with social care needs and should be read in full.

Quality statement

Adults with social care needs who are in hospital have a named discharge coordinator.

Rationale

Poor coordination related to plans for leaving hospital can result in distress and reduced quality of life for people using services and their carers. Making a single health or social care practitioner responsible for coordinating discharge can help to make the transition smoother (for example, this person can liaise with community services to arrange follow-up care). The discharge coordinator should be involved in discharge planning from admission, and throughout the person’s hospital stay.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with social care needs who are in hospital have a named discharge coordinator.
Data source: Local data collection.
Process
Proportion of discharges from hospital of adults with social care needs where there is a named discharge coordinator.
Numerator – the number in the denominator where there is a named discharge coordinator.
Denominator – the number of discharges from hospital of adults with social care needs.
Data source: Local data collection.
Outcome
a) Delayed transfers of care for adults with social care needs.
Data source: Local data collection. National Delayed transfers of care data is published by NHS England.
b) Experience of the discharge process for adults with social care needs.
Data source: Local data collection.
c) Readmission rates for adults with social care needs.
Data source: Local data collection. National data on emergency readmissions within 30 days of discharge from hospital are available from the NHS Digital Indicator Portal as part of the NHS outcomes framework – indicator 3b.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (hospitals) ensure that systems are in place so that adults with social care needs have a named discharge coordinator.
Health and social care practitioners (for example, members of the hospital-based multidisciplinary team) ensure that they involve the discharge coordinator in all decisions about discharge planning for adults with social care needs.
Commissioners (clinical commissioning groups) ensure that they commission services that provide a named discharge coordinator for adults with social care needs.

What the quality statement means for patients and carers

Adults with social care needs who are in hospital are given the name of the person who will be responsible for coordinating their discharge. This person will work with the adult, and their family or carers, to plan their move out of hospital.

Source guidance

Definitions of terms used in this quality statement

Discharge coordinator
A single, named health or social care practitioner responsible for coordinating the person’s discharge from hospital. A discharge coordinator may be a designated post or the task may be assigned to a member of the hospital- or community-based multidisciplinary team. They should be chosen according to the person’s care and support needs. A named replacement should always cover their absence.
The discharge coordinator should work with the hospital- and community-based multidisciplinary teams and the person receiving care to develop and agree a discharge plan.
The discharge coordinator should be a central point of contact for health and social care practitioners, the person and their family during discharge planning, and should be involved in all decisions about discharge planning.
During discharge planning, the discharge coordinator should share assessments and updates on the person's health status, including medicines information, with both the hospital- and community-based multidisciplinary teams.
They should arrange the details of follow-up care, discuss the need for any specialist equipment and support with community services and, once assessment for discharge is complete, agree the plan for ongoing treatment and support with the community-based multidisciplinary team.
[Adapted from NICE’s guideline on transition between inpatient hospital settings and community or care home settings for adults with social care needs, recommendations 1.5.1, 1.5.2, 1.5.5, 1.5.14, 1.5.17, 1.5.18 and 1.5.19]

Equality and diversity considerations

Barriers to communication can hinder people’s understanding of transitions and how they can be involved in discharge planning. These barriers could include: learning or cognitive difficulties; physical, sight, speech or hearing difficulties; or difficulties with reading, understanding or speaking English. Adjustments should be made to ensure all adults with social care needs can work with the discharge coordinator on plans for their discharge and follow-up care, if they have the capacity to do so.

Discharge plans

This quality statement is taken from the transition between inpatient hospital settings and community or care home settings for adults with social care needs quality standard. The quality standard defines clinical best practice in transition between inpatient hospital settings and community or care home settings for adults with social care needs and should be read in full.

Quality statement

Adults with social care needs are given a copy of their agreed discharge plan before leaving hospital.

Rationale

The discharge plan is an important part of a coordinated discharge process. To ensure adults with social care needs have a positive experience of this process, they need to understand and agree their own discharge plan, if they have the capacity to do so. If the person chooses to share the plan with everyone involved with their ongoing care and support this can lead to successful transfers and reduce the chance of hospital readmission.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with social care needs are given a copy of their agreed discharge plan before being leaving hospital.
Data source: Local data collection.
Process
Proportion of discharges from hospital of adults with social care needs that include the person being given a copy of their agreed discharge plan before leaving hospital.
Numerator – the number in the denominator where the person is given a copy of their agreed discharge plan before leaving hospital.
Denominator – the number of discharges from hospital of adults with social care needs.
Data source: Local data collection. The Care Quality Commission’s Adult Inpatient Survey gives national data.
Outcome
a) Readmission rates for adults with social care needs.
Data source: Local data collection. National data on emergency readmissions within 30 days of discharge from hospital are available from the NHS Digital Indicator Portal as part of the NHS outcomes framework – indicator 3b.
b) The experience of discharge from hospital for adults with social care needs.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (hospitals) ensure that systems are in place for adults with social care needs to be given a copy of their agreed discharge plan before they leave hospital.
Health and social care practitioners (discharge coordinators and members of the hospital- and community-based multidisciplinary teams) ensure that they give a copy of the agreed discharge plan to adults with social care needs before they leave hospital.
Commissioners (clinical commissioning groups) ensure that they commission services in which adults with social care needs are given a copy of their agreed discharge plan before leaving hospital. This supports NHS England’s Seven day services clinical standards, standard 1.

What the quality statement means for patients and carers

Adults with social care needs are given a copy of the plan for their move out of hospital before they leave. The plan should be easy for them to read and understand, and people giving them this information should also offer to explain it to them.

Source guidance

Definitions of terms used in this quality statement

Discharge plan
A document that describes the coordination of care and support for discharge from hospital. It is in addition to a discharge summary that is sent to a person’s GP on discharge. It is a working document for the multidisciplinary teams. A discharge plan should take account of the person’s social and emotional wellbeing, as well as the practicalities of daily living. It should include:
  • details about the person’s condition
  • contact information after discharge
  • arrangements for continuing social care support
  • arrangements for continuing health support
  • details of other useful community and voluntary services.
The discharge plan should also include a complete, accurate list of their medicines, including any changes made to medicines during their hospital stay. This includes information about when to take the medicine, correct dosage and an explanation of what it is for.
The discharge plan should be shared with the adult and all those involved in their ongoing care and support, if the adult agrees. All the information, including information about medicines, should be in a format that is easy for the person to understand.
[Adapted from NICE’s guidelines on transition between inpatient hospital settings and community or care home settings for adults with social care needs (glossary, recommendations 1.1.2, 1.1.6, 1.5.15 and 1.5.16) and medicines optimisation (recommendation 1.2.4), and expert opinion]

Equality and diversity considerations

The discharge plan should be provided in a format that suits people’s needs and preferences and meets the requirements set out in NHS England's Accessible Information Standard.
Barriers to communication can hinder people’s understanding of transitions and how they can be involved in discharge planning. For example, these barriers can include: learning or cognitive difficulties; physical, sight, speech or hearing difficulties; or difficulties with reading, understanding or speaking English.
Adjustments should be made to overcome these barriers and ensure all adults with social care needs can be involved in making decisions about their discharge and follow-up care, if they have the capacity to do so. Support for people with communication difficulties may include access to advocacy services.

Involving carers in discharge planning

This quality statement is taken from the transition between inpatient hospital settings and community or care home settings for adults with social care needs quality standard. The quality standard defines clinical best practice for transition between inpatient hospital settings and community or care home settings for adults with social care needs and should be read in full.

Quality statement

Adults with social care needs have family or carers involved in discharge planning if they are providing support after discharge.

Rationale

Families and carers can play a significant role in helping adults with social care needs return home after a hospital admission. It is therefore important that they are involved in decisions about the person’s discharge plan, if they and the person agree. They can provide information about the person’s needs and circumstances beyond medical conditions or physical needs. This means discharge planning can be more comprehensive and may reduce the likelihood of the person being readmitted to hospital.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with social care needs have family or carers involved in discharge planning if they are providing support after discharge.
Data source: Local data collection.
Process
Proportion of discharges from hospital of adults with social care needs where family or carers are involved in discharge planning if they are providing support after discharge.
Numerator – the number in the denominator where family and carers are involved in discharge planning.
Denominator – the number of discharges from hospital of adults with social care needs where family or carers are providing support after discharge.
Data source: Local data collection.
Outcome
a) Delayed transfers of care for adults with social care needs.
Data source: Local data collection. National Delayed transfers of care data is published by NHS England.
b) Readmission rates for adults with social care needs.
Data source: Local data collection. National data on emergency readmissions within 30 days of discharge from hospital are available from the NHS Digital Indicator Portal as part of the NHS outcomes framework – indicator 3b.
c) Family and carer satisfaction with involvement in discharge planning for adults with social care needs.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (hospitals) ensure that systems are in place to enable adults with social care needs to have family or carers involved in discharge planning if they are providing support after discharge.
Health and social care practitioners (such as discharge coordinators and members of the hospital-based multidisciplinary team) ensure that adults with social care needs have family or carers involved in discharge planning if they are providing support after discharge.
Commissioners (clinical commissioning groups) ensure that they commission services in which adults with social care needs have family or carers involved in discharge planning if they are providing support after discharge. This supports NHS England’s Seven day services clinical standards, standard 1.

What the quality statement means for patients and carers

Adults with social care needs have family or carers involved in planning their move out of hospital if they are going to provide them with support at home.

Source guidance

Definitions of terms used in this quality statement

Carer
A carer is someone who helps another person, usually a relative or friend, in their day-to-day life. This is not the same as someone who provides care professionally or through a voluntary organisation.

Record-keeping

This quality statement is taken from the medicines management in care homes quality standard. The quality standard defines clinical best practice for medicines management in care homes and should be read in full.

Quality statement

People who transfer into a care home have their medicines listed by the care home on the day that they transfer.

Rationale

It is important that information about medicines is available for people who transfer into a care home, either for the first time or, for example, when moving back into the care home after a hospital stay (during which their medicines may have been changed). This will allow information about a person’s medicines to be available to relevant health and social care practitioners (while taking care to respect confidentiality), improving continuity of care and ensuring that people get the right medicines at the right time at the care home they have transferred to.

Quality measures

Structure
Evidence of local arrangements to ensure that a list is made of a person’s medicines on the day that they transfer into a care home.
Data source: Local data collection.
Process
Proportion of transfers of people into a care home where a list of the person’s medicines is made by the care home on the day of transfer.
Numerator – the number in the denominator where a list of the person’s medicines is made by the care home on the day of transfer.
Denominator – the number of transfers of people into a care home.
Data source: Local data collection.
Outcome
Time between a person moving into a care home and completion of a list of their medicines.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (care homes) ensure that they make arrangements to produce a list of a person’s medicines on the day that they transfer into a care home.
Health and social care practitioners ensure that they coordinate the listing of a person’s medicines on the day that they transfer into a care home.
Commissioners (local authorities) ensure that they commission services that make arrangements to produce a list of a person’s medicines on the day that they transfer into a care home.

What the quality statement means for patients, service users and carers

People who move into a care home (either for the first time or moving back after a hospital stay) have their medicines carefully recorded by the care home on the day that they move.

Source guidance

Sharing information

This quality statement is taken from the medicines management in care homes quality standard. The quality standard defines clinical best practice for medicines management in care homes and should be read in full.

Quality statement

Providers of health or social care services send a discharge summary, including details of the person’s current medicines, with a person who transfers to or from a care home.

Rationale

Good communication about a resident’s medicines is a key factor in preventing medication errors when care home residents transfer between care settings, and also promotes continuity of care following transfer. Providers of health or social care should ensure that comprehensive records of medicines are sent with a person when they are transferred from one care setting to another, including information on what medicines are being taken and related information, such as dosage.

Quality measures

Structure
Evidence of local arrangements to ensure that a discharge summary, including details of a person’s current medicines, is sent with a person when they transfer to or from a care home.
Data source: Local data collection.
Process
a) Proportion of transfers of people to a care home in which a discharge summary, including details of a person’s current medicines, is sent with the person.
Numerator – the number in the denominator in which a discharge summary, including details of a person’s current medicines, is sent with the person.
Denominator – the number of transfers of people to a care home.
Data source: Local data collection.
b) Proportion of transfers of people from a care home in which a discharge summary, including details of a person’s current medicines, is sent with the person.
Numerator – the number in the denominator in which a discharge summary, including details of a person’s current medicines, is sent with the person.
Denominator – the number of transfers of people from a care home.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as care homes, hospitals, intermediate care services) ensure that a discharge summary, including details of a person’s current medicines, is sent with a person who transfers to or from a care home.
Health and social care practitioners compile and send a discharge summary, including details of a person’s current medicines, with a person who transfers to or from a care home.
Commissioners (such as local authorities, NHS England and clinical commissioning groups) stipulate that providers of health or social care services have processes in place that enable the sharing of a discharge summary, including details of a person’s current medicines, when a person transfers to or from a care home. NHS England area teams and clinical commissioning groups should ensure that health and social care providers are aware that these processes should be in place.

What the quality statement means for patients, service users and carers

People who move into or from a care home have an accurate and complete summary of their details and care, including detailed information about their current medicines, sent from their previous place of care to their new place of care so that they can safely continue with their treatment.

Source guidance

Definitions of terms used in this quality statement

Discharge summary
A discharge summary should contain the following information as a minimum:
  • the person’s details, including full name, date of birth, NHS number, address and weight (for those aged under 16 or where appropriate, for example, frail older residents)
  • GP’s details
  • details of other relevant contacts defined by the resident and/or their family members or carers (for example, the consultant, regular pharmacist, specialist nurse)
  • known allergies and reactions to medicines or ingredients, and the type of reaction experienced
  • medicines the resident is currently taking, including name, strength, form, dose, timing and frequency, how the medicine is taken (route of administration) and what for (indication), if known
  • changes to medicines, including medicines started, stopped or dosage changed, and reason for change
  • date and time the last dose of any ‘when required’ medicine was taken or any medicine given less often than once a day (weekly or monthly medicines)
  • other related information, including when the medicine should be reviewed or monitored, and any support the person needs to carry on taking the medicine (adherence support)
  • what information has been given to the resident and/or family members or carers.
[Managing medicines in care homes (NICE guideline SC1), recommendation 1.7.3]

Self-administration

This quality statement is taken from the medicines management in care homes quality standard. The quality standard defines clinical best practice for medicines management in care homes and should be read in full.

Quality statement

People who live in care homes are supported to self administer their medicines if they wish to and it does not put them or others at risk.

Rationale

It is important for people living in care homes to maintain their independence, and that they have as much involvement in taking their medicines as they wish and are safely able to. However, when a person enters a care home staff will often automatically assume responsibility for managing their medicines. It should be assumed that people who live in a care home can take and look after their medicines themselves, unless a risk assessment has indicated otherwise. It is important to take into account a person’s choice over whether or not they wish to self administer their medicine and also to consider if self administration will be a risk to them or others. Risk assessments are also important to determine what support a person needs to help them to self administer different medicines (for example, a resident may be able to manage oral tablets but not eye drops), allowing care homes to ensure that necessary support is provided. Risk assessment should be reviewed periodically, and whenever circumstances change, to address if any adjustment to support is needed.

Quality measures

Structure
a) Evidence of local arrangements that care home staff provide support for residents to self administer their medicines unless a risk assessment has indicated otherwise.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that individual risk assessments are carried out that identify and document any support that a care home resident needs to self administer their medicines.
Data source: Local data collection.
Process
a) Proportion of people who live in a care home who have an individual risk assessment to identify any support they need to self administer their medicines.
Numerator – the number in the denominator who have an individual risk assessment to identify any support they need to self administer their medicines.
Denominator – the number of people who live in a care home.
Data source: Local data collection.
b) Proportion of people who live in a care home who wish to self administer their medicines, and who have not had a risk assessment that indicates that this would put themselves or others at risk, who self administer their medicines.
Numerator – the number in the denominator who self administer their medicines.
Denominator – the number of people who live in a care home who wish to self administer their medicines, and who have not had a risk assessment that indicates that this would put themselves or others at risk.
Data source: Local data collection.
Outcome
Feedback from care home residents that they feel supported to self administer their medicines, if they wish to and if they have not had a risk assessment that indicates that this would put themselves or others at risk.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (care homes) ensure that staff support people to self administer their medicines if they want to, unless an individual risk assessment has indicated that they are not able to do so safely.
Health and social care practitioners support people to self administer their medicines if they want to, unless an individual risk assessment has indicated that they are not able to do so safely.
Commissioners (local authorities) ensure that services they commission support people to self administer their medicines if they want to, unless an individual risk assessment has indicated that they are not able to do so safely.

What the quality statement means for patients, service users and carers

People who live in care homes are given support to take and look after their own medicines if they want to, unless they have had an assessment that shows it might not be possible or safe.

Source guidance

Definitions of terms used in this quality statement

Risk assessment
Health and social care practitioners should carry out an individual risk assessment to find out how much support a care home resident needs to carry on taking and looking after their medicines themselves (self administration). Risk assessment should consider:
  • the resident’s choice
  • if self administration will be a risk to the resident or to other residents
  • if the resident can take the correct dose of their own medicines at the right time and in the right way (for example, do they have the mental capacity and manual dexterity for self administration?)
  • how often the assessment will need to be repeated based on individual resident need (during periods of acute illness, a resident’s capacity and ability to self medicate may fluctuate, needing more frequent assessment)
  • how the medicines will be stored
  • the responsibilities of the care home staff, which should be written in the resident’s care plan.
The care home manager should coordinate the risk assessment and should help to determine who should be involved. This should be done individually for each resident and should involve the resident (and their family members or carers if the resident wishes) and care home staff with the training and skills for assessment. Other health and social care practitioners (such as the GP and pharmacist) should be involved as appropriate to help identify whether the medicines regimen could be adjusted to enable the resident to self administer.
[Adapted from Managing medicines in care homes (NICE guideline SC1) recommendations 1.13.2. and 1.13.3]
Support to self-administer medicines
Support may include practical help to self administer medicine, such as providing a glass of water with which to take medicine, reminder charts, large print labels, hearing labels, easy to open containers, help measuring liquids, devices to help with the use of inhalers, colour coding of labels (for example, for different times of day) and providing prompts for when medicines should be taken, (for example, with or after food or on an empty stomach).
Support may also involve providing the person with suitable information about the medicine, information on how to take the medicine and advice on any potential side effects.
Individual risk assessments should identify how much support a resident needs to take and look after their medicine.
[Adapted from expert consensus and Managing medicines in care homes (NICE guideline SC1)]
Self-administration
Self administration of medicines is when a resident stores, or stores and administers, their own medicines.
[Managing medicines in care homes (NICE guideline SC1)]

Equality and diversity considerations

Consideration should be given to a number of factors that can affect a resident’s ability to self administer their own medicines, including their mental health, mental capacity, health literacy, vision, hearing, language and culture. Health and social care practitioners need to ensure that these factors are considered for each resident, and any barriers to self administration of medicines are identified and taken into account.

Prescribing medicines

This quality statement is taken from the medicines management in care homes quality standard. The quality standard defines clinical best practice for medicines management in care homes and should be read in full.

Quality statement

Prescribers responsible for people who live in care homes provide comprehensive instructions for using and monitoring all newly prescribed medicines.

Rationale

If too few instructions are given to a resident (if self administering) or the care home staff it can reduce the effectiveness of a medicine or even potentially increase the risk of harm. Clear instructions are therefore important to ensure resident safety. This is particularly the case with variable dose or ‘when required’ medicines (when a clear indication of the circumstances to administer the medicine is needed). If a resident’s capacity changes, care home staff may need to start administering the person’s medicine for them, and will need instructions. Requirements for recording clear instructions on how a medicine should be used and monitored should be included as part of a clear written process for prescribing and issuing prescriptions for people who live in care homes (see recommendation 1.9.1 in NICE’s guideline on managing medicines in care homes).

Quality measures

Structure
Evidence of local arrangements that prescribers responsible for people who live in care homes provide comprehensive instructions for using and monitoring all newly prescribed medicines.
Data source: Local data collection.
Process
The proportion of newly prescribed medicines for people who live in care homes that are provided with comprehensive instructions for use and monitoring.
Numerator – the number in the denominator that are provided with comprehensive instructions for use and monitoring.
Denominator – the number of newly prescribed medicines for people who live in care homes.
Data source: Local data collection.
Outcome
Medicines related problems attributable to incomplete information provided with a prescription.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (such as GP practices, pharmacies) ensure that comprehensive instructions for using and monitoring all newly prescribed medicines are provided for people who live in care homes.
Healthcare professionals (such as GPs, pharmacists and nurse prescribers) provide comprehensive instructions for using and monitoring all newly prescribed medicines for people who live in care homes.
Commissioners (such as NHS England and clinical commissioning groups) ensure that any services they commission that prescribe medicines for people who live in care homes provide comprehensive instructions for using and monitoring all newly prescribed medicines for people who live in care homes.

What the quality statement means for patients, service users and carers

People who live in care homes have accurate and complete information given to them and to the care home staff about any new medicines they are prescribed. This should include information about how and when their medicines should be used, and any checks that should happen.

Source guidance

Definitions of terms used in this quality statement

Comprehensive instructions for using and monitoring newly prescribed medicines
These include:
  • recording clear instructions on how a medicine should be used, including how long the resident is expected to need the medicine and, if important, how long the medicine will take to work and what it has been prescribed for (use of the term 'as directed' should be avoided)
  • providing any extra details the resident and/or care home staff may need about how the medicine should be taken
  • any tests needed for monitoring.
When prescribing variable dose and 'when required' medicine(s), information should include:
  • dosage instructions on the prescription (including the maximum amount to be taken in a day and how long the medicine should be used, as appropriate) so that this can be included on the medicine's label
  • instructions for:
    • when and how to take or use the medicine (for example, 'when low back pain is troublesome take 1 tablet')
    • monitoring
    • the effect the medicine is expected to have.
[Adapted from Managing medicines in care homes (NICE guideline SC1), recommendations 1.9.1 and 1.9.2]

Medication reviews

This quality statement is taken from the medicines management in care homes quality standard. The quality standard defines clinical best practice for medicines management in care homes and should be read in full.

Quality statement

People who live in care homes have medication reviews undertaken by a multidisciplinary team.

Rationale

Many care home residents have multiple and complex conditions. These conditions can change, and the medicines that residents receive to treat these conditions need to be reviewed regularly to ensure that they remain safe and effective. The frequency of multidisciplinary medication reviews should be based on the health and care needs of the resident, with their safety being the most important factor when deciding how often to do the review. The interval between medication reviews should be no more than 1 year, and many residents will need more frequent medication reviews. There can be uncertainty over who should undertake medication reviews. While a number of different health professionals can conduct medication reviews for care home residents, the review should involve a multidisciplinary group of key people who agree and document the roles and responsibilities of each member of the team and how they work together.

Quality measures

Structure
Evidence of local arrangements that medication reviews for people who live in care homes involve a multidisciplinary team who agree and document the roles and responsibilities of each member of the team and how they work together.
Data source: Local data collection.
Process
Proportion of medication reviews carried out for people who live in care homes that involve a multidisciplinary team.
Numerator – the number in the denominator that involve a multidisciplinary team.
Denominator – the number of medication reviews carried out for people who live in care homes.
Data source: Local data collection.

What the quality statement means for health and social care practitioners and commissioners

Health and social care practitioners (such as GPs and care home managers) ensure that medication reviews involve a local team of health and social care practitioners (multidisciplinary team) who agree and document the roles and responsibilities of each member of the team and how they work together.
Commissioners (such as NHS England area teams and local authorities) stipulate that medication reviews in care homes involve a local team of health and social care practitioners (multidisciplinary team) who agree and document the roles and responsibilities of each member of the team and how they work together.

What the quality statement means for patients, service users and carers

People who live in care homes have their medicines reviewed by a team of people who look after their health and social care to check for any problems.

Source guidance

Definitions of terms used in this quality statement

Medication review
Health and social care practitioners should discuss and review the following during a medication review:
  • the purpose of the medication review
  • what the resident (and/or their family members or carers, as appropriate, and in line with the resident’s wishes) thinks about the medicines and how much they understand
  • the resident’s (and/or their family member or carer’s, as appropriate, and in line with the resident’s wishes) concerns, questions or problems with the medicines
  • all prescribed, over the counter and complementary medicines that the resident is taking or using, and what these are for
  • how safe the medicines are, how well they work, how appropriate they are, and whether their use is in line with national guidance
  • any monitoring tests that are needed
  • any problems the resident has with the medicines, such as side effects or reactions, taking the medicines themselves (for example, using an inhaler) and difficulty swallowing
  • helping the resident to take or use their medicines as prescribed (medicines adherence)
  • any more information or support that the resident (and/or their family members or carers) may need.
[Managing medicines in care homes (NICE guideline SC1), recommendation 1.8.5]
Multidisciplinary team
Health and social care practitioners ensure that medication reviews involve the resident and/or their family members or carers (if appropriate) and a local team of health and social care practitioners (multidisciplinary team). This may include a:
  • pharmacist
  • community matron or specialist nurse, such as a community psychiatric nurse
  • GP
  • member of the care home staff
  • practice nurse
  • social care practitioner.
The roles and responsibilities of each member of the team and how they work together should be carefully considered and agreed locally. GPs should work with other health professionals to identify a named health professional who is responsible for medication reviews for each resident. This should take into account the clinical experience and skills of the health professional, how much they know about the resident and the resident’s condition, and whether they can access the relevant information.
[Managing medicines in care homes (NICE guideline SC1), recommendations 1.8.2 and 1.8.3]

Equality and diversity considerations

Consideration should be given to potential barriers to care home residents taking an active role in their medication review. These include mental health problems, lack of (mental) capacity to make decisions, health problems (such as problems with vision and hearing) and difficulties with reading or speaking. Some illnesses can restrict the capacity of residents to be involved in a medication review and a resident’s capacity to be involved in decisions about their medicine may vary over time. Consideration should be given to adjusting the timing of a review to occur when a resident has the capacity to be involved, and potentially allowing time for a resident to recover from any acute illness before conducting the review. If appropriate, family members and carers could be involved in the decision making process about investigations, treatment and care. The views of residents in care homes about who should and should not be involved in their care are important and should be respected. If the resident lacks the capacity to decide who should and should not be involved, health and social care practitioners must act in the resident’s best interests, taking account of the provisions in the Mental Capacity Act 2005.

Covert medicines administration

This quality statement is taken from the medicines management in care homes quality standard. The quality standard defines clinical best practice for medicines management in care homes and should be read in full.

Quality statement

Adults who live in care homes and have been assessed as lacking capacity are only administered medicine covertly if a management plan is agreed after a best interests meeting.

Rationale

The covert administration of medicines should only be used in exceptional circumstances when such a means of administration is judged necessary, in accordance with the Mental Capacity Act 2005. However, once a decision has been made to covertly administer a particular medicine (following an assessment of the capacity of the resident to make a decision regarding their medicines and a best interests meeting), it is also important to consider and plan how the medicine can be covertly administered, whether it is safe to do so and to ensure that need for continued covert administration is regularly reviewed (as capacity can fluctuate over time). Medicines should not be administered covertly until after a best interests meeting has been held. If the situation is urgent, it is acceptable for a less formal discussion to occur between the care home staff, prescriber and family or advocate to make an urgent decision. However, a formal meeting should be arranged as soon as possible.

Quality measures

Structure
Evidence of local arrangements to agree a management plan after a best interests meeting in which a decision is made to covertly administer medicines to an adult care home resident.
Data source: Local data collection.
Process
Proportion of adults in a care home being covertly administered medicine who have a record of a best interests meeting and management plan.
Numerator – the number in the denominator with a record of a best interests meeting and management plan.
Denominator – the number of adults in a care home being covertly administered medicine.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (care homes) ensure that if a decision is taken to covertly administer medicine to an adult care home resident, then a management plan is also agreed and recorded after a best interests meeting.
Health and social care practitioners who participate in a best interests meeting agree and record a management plan after the best interests meeting if a decision is taken to covertly administer medicine to an adult care home resident.
Commissioners (local authorities) ensure that service specification contracts for care home providers include a requirement to ensure that if a decision is taken to covertly administer medicine to an adult care home resident, then a management plan is also agreed and recorded after a best interests meeting.

What the quality statement means for patients, service users and carers

Adults who live in care homes who may not be able to make decisions about their treatment and care may need to be given their medicines without them knowing (known as ‘covert administration’), for example hidden in their food or drink. Care home staff should have a meeting with healthcare professionals and family members to discuss this and agree whether it is the best option for the person. If it is agreed, a plan should be made after the meeting to make sure it is done safely and reviewed regularly to check if it should continue.

Source guidance

Definitions of terms used in this quality statement

Best interests meeting
When covert administration of medicines is being considered, there should be a ‘best interests’ meeting. The purpose of this meeting is to agree whether administering medicines without the resident knowing (covertly) is in the resident’s best interests. A best interests meeting should be attended by care home staff, relevant health professionals (including the prescriber and pharmacist) and a person who can communicate the views and interests of the resident (this could be a family member, friend or independent mental capacity advocate depending on the resident’s previously stated wishes and individual circumstances). If the resident has an attorney appointed under the Mental Capacity Act for health and welfare decisions, then this person should be present at the meeting.
[Managing medicines in care homes (NICE guideline SC1)]
Covert administration
When medicines are administered in a disguised format without the knowledge or consent of the person receiving them, for example in food or in a drink.
[Managing medicines in care homes (NICE guideline SC1), full guideline glossary]
Management plan
This would usually include:
  • medication review by the GP
  • medication review by the pharmacist to advise the care home how the medication can be covertly administered safely
  • clear documentation of the decision of the best interests meeting
  • a plan to review the need for continued covert administration of medicines on a regular basis.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Members of a community-based multidisciplinary team could include:
  • GP
  • community nurse
  • community mental health practitioner
  • social worker
  • housing officer
  • voluntary sector practitioners
  • community pharmacist
  • therapists
  • registered manager.

Glossary

someone who helps another person, usually a relative or friend, in their day-to-day life. This is not the same as someone who provides care professionally or through a voluntary organisation
someone who helps another person, usually a relative or friend, in their day-to-day life. This is not the same as someone who provides care professionally or through a voluntary organisation
generally this refers to people aged 65 years and over. But it could refer to people who are younger, depending on their general health, needs and circumstances

Paths in this pathway

Pathway created: November 2015 Last updated: November 2016

© NICE 2017

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