20 - Discharge Planning, Transfers of Care Flashcards
What factors should you consider when planing a complex discharge?
What is the NHS initiative where we discharge Ps home who are medically fit and their care requirement is decided by an assessor when they get home?
Discharge to Assess
What is sheltered accommodation?
What is the difference between residential and nursing homes?
Who pays?
What will the NHS pay for in terms of care?
Complex care needs - those with complex, severe and unpredictable need
or
Rapidly progressive, high care need, short life expectancy
both under NHS Continuing Health Care. Can be fast tracked if terminal phase.
How much savings is a P allowed to have in savings?
$23,250
When will social services fund care?
If savings < 23,250
How much is
- NHS Nursing home contribution?
- Attendance allowance?
(1). 210 per week
(2). 68-101 per weel
Give examples of advanced care planning
Which advanced care plans required a lawyer?
LPA
Advance Decision to refuse Treatment
What does an advance decision do?
Who completes a DNA-CPR?
Most senior available HCP - not FY1s!
What are examples of advanced care plans?
ReSPECT
PEACE
Treatment Escalation Plan
Are advanced care plans legally binding?
No
What is the aim of rehabilitation?
To both restore function and adapt to reduced function
What measurement instruments are there for rehabilitation progress?
Barthel Index of ADL
Timed Get Up and Go Test
Elderly Mobility Scale
MOCA / MMSE
What is the SMART acronym for setting targets in rehab?
Targets must be
- Specific
- Measurable
- Realistic
- Time-bounded
