What is being done?

Staff at Weston General Hospital are using a new shared transfer of care letter during discharge which better captures the health needs of the patients with dementia.

Download the Shared transfer of care letter

From the Trust nursing documentation group it was agreed that a new transfer letter from hospital was needed as the old one was outdated and did not capture the health needs of the patient. Following debate with the group it was decided that a shared transfer of care form would be ideal, not only would we send our patients out with a clear picture of their immediate health needs but it could also be used for care homes in North Somerset to send their patients into hospital with information that would really benefit the trust. The Trust has a matron lead for Nurse documentation, Dementia care and Learning Disability, she took the idea to the Learning Disability steering group, the North Somerset Dementia Strategy Group and the ward sisters.

All agreed it would be beneficial from a community and hospital perspective. A draft of the proposed form was sent to the managers of general and Learning Disability care homes. Feedback was sought and the shared transfer of care form was developed. It took time to agree the format and how to complete with a duplicate copy retained in the notes. The Trust would fund their duplicate printing and the community could decide how best to fund and use it for their needs.

What is new and different?

It gives a lot more depth of history and allows the staff to also document anxieties expressed by the patient. It gives a clear plan of current care received and possible further care required on discharge, i.e. patient required bed rails on this admission and did not use them prior to this visit, this is not always handed over to the accepting care home on the existing form but is now a prompt for the staff completing. Likewise it requires care home staff to give specific details required by an emergency team accepting the patient in the Emergency department.

What difference does this seem to be making?

This is still in its infancy but the fact that so many community managers were keen to use it was very reassuring.