4.3.3 Hospital and Community Teams Case Transfer Protocol

1. Introduction

This document is to guide staff through the process of ensuring a smooth transfer between hospital and community social work teams. The general principle governing this protocol is to ensure that there is clarity on how service users will be supported when they are in hospital and the community respectively, and the social work team that will provide such support. It provides guidance on policy and practices with the aim of facilitating effective communication and interface working within care management teams to ensure the welfare of both service users and carers are met.

This protocol also includes the case work responsibility of safeguarding incidents across hospital and community teams.

In line with the Care Act, Lambeth Adult Social Care seeks to ensure that an appropriate proportionate response is taken in the delivery of social care intervention. Therefore, nothing in this protocol diverts away from the Care Act core principles.

2. Principles

The outcome for the service user must be the primary consideration in all cross-team negotiations and casework decisions.

It is the duty of both Team Managers and Practitioner Managers across social work teams to apply this protocol in a way that supports the transition of service users and their carers between social work teams.

Any difficulties in reaching agreement on issues relating to case transfer should be resolved as soon as possible and without any detrimental effect to the service users and their carers (see Section 7, Resolution Process.)

All operational decisions must be recorded on Mosaic and must be consistent with the principles and standards set out in this protocol. In particular, service provision should be based on the needs of the service user and their carers.

It is essential that service users do not wait in limbo or go without services while issues of case responsibility are being resolved.  Disputes relating to case responsibility must be dealt with promptly by managers and must not involve the service user or be allowed to impact on their welfare.

The originating team must do all they can to prevent a client from being discharged from hospital where it is clear that the person would be unable to cope in the community. In such circumstances the originating team must follow up to ensure adequate support packages are in place prior to handing over to the appropriate community team. It is important that clients are not left in limbo and adequate safe discharge plans are completed and implemented as best as possible. The receiving team will be expected to complete the 6 to 8 weeks review where appropriate.

• The expected timeframe of transfer should be completed within 3 working days following discharge from hospital irrespective of the client’s duration in hospital setting. However, case responsibility remains with the originating team until hand over has been completed. With the exception of those cases which have been tasked to the reablement team, all hospital discharges must be followed up within 48 hours by telephone contact with the service user and/or their representative to determine if the level of service initiated is appropriate.
• Where changes are required and can be made within 72 hours this will be pursued by the hospital team prior to transfer to a community team. Where work will require an extended period of involvement, issues should be highlighted to the relevant community team who will be expected to follow up on any outstanding tasks.

3. Case Work Responsibility

The hospital social work teams are responsible for facilitating hospital discharges for Lambeth citizens from the age of 18, who are hospitalised and require social care intervention post hospital discharge. These teams will also deal with service users who enter the hospital setting, are not formally admitted but require social care involvement to ensure their continued health and wellbeing away out of hospital.

Where a worker in the community social work team is assigned to the client, then they will complete a summary of past and present issues before proceeding to transfer the case to the relevant hospital social work team. Where the relevant summary is not completed then the hospital social work team may decide not to accept the case until this action has been completed by the originating team / worker. Casework responsibility cannot be relinquished until the handover has been completed. Therefore, case transfers should be facilitated as quickly as possible.  

When someone leaves the hospital and returns to the community either back to their home or to a care home placement, the hospital social work teams should disengage their involvement after ensuring the client’s immediate needs are met. Where it is apparent that the person is not settled following discharge then the hospital team will follow up to ascertain causes of the instability and whether readmission is necessary or an increase in support package. It is envisaged that the originating hospital teams will transfer discharged cases within 3 days of the clients leaving hospital.

The hospital social work teams will ensure all cases are transferred within the agreed timeframe. If the hospital social work team fails to transfer a case within the agreed timeframe then they will be responsible for any work which arises whilst case remains with the team. Case transfer should only occur once immediate tasks have been completed.

The originating team may use their discretion not to transfer a case to a different social work team or to delay the transfer because it may affect the on-going interaction developed with the assigned worker. However, this will be a decision made entirely by the originating Team Manager.

In all situations where cases are transferred, the receiving team must decide whether to re-assign the case sent by the originating team or wait nearer their 6 to 8 weeks review. The reason for not reassigning transferred cases where there are outstanding actions must be clearly recorded on the client’s case note. However, all outstanding tasks highlighted following discharge must be followed up by the receiving team.

It is not acceptable for any team to refuse to accept referral due to capacity levels in the team. Issues regarding capacity at a specific period should be discussed with the appropriate Service Manager or Head of Service.

4. Case Transfer Process

See Section 5 which specifically deals with transfer of adult safeguarding cases.

The referring team must ensure all possible tasks where appropriate are finished before cases are sent over to the receiving team.  Before a case is transferred between teams on Mosaic, contact must be made by the originating Team Manager or Practitioner Manager with their counterpart via an email with a copy of the transfer summary sent to all the receiving team leads.

At the point of transfer the originating team must update the service user case note on Mosaic of the transfer confirmation.

The originating team is responsible for contacting the service user or their carers to tell them what has been decided and which team will be dealing with the case. This must be confirmed in writing with clear contact details so that the service user understands what is going to happen next. All actions taken must be recorded on Mosaic.

If the receiving team later realised the case has been inappropriately sent to them despite initially agreeing to the transfer then they should arrange a case transfer to the correct team and must accept casework responsibility until this has been completed.  The case should not be returned to the originating team.

5. Transfer of Safeguarding Adult Cases

Teams must be sensitive to cases under safeguarding adults and the expectation is that safeguarding concerns and enquires would be immediately transferred to the responsible community team without delay, unless they relate to service provision within the hospital. The team that receives the concern must record the safeguarding concern on Mosaic before transferring. Where an immediate protection plan is required then the originating team must ensure this is in place.

The hospital teams will not be expected to lead adult safeguarding enquires where the abuse took place in the community prior to admission or even when it comes to light whilst the person is in hospital or immediately following their discharge. However, all concerns and enquiries where the hospital trust is the source of risk will be dealt by hospital social work teams.

Where the enquiry relates to an incident in the community and the person is in hospital then hospital teams will continue to case manage the discharge plans and the community teams will be responsible for progressing the safeguarding enquires. Clearly, this will require good communication between the teams so that both have a shared understanding of what risks have been identified and how they should be managed.

The originating team must let the receiving team know of any safeguarding concerns before any transfer is completed in order to ensure effective handover. There must be phone or face-to-face discussion with the receiving manager before any transfer is done. Reliance only on emails to communicate urgent matters is not enough.   

After gathering and evaluating the information available to them, the originating team should decide whether the safeguarding concerns will lead to an adult safeguarding enquiry. The expectation is that if the person who may have been caused harm remains in hospital then both teams will work together as required.  This will reduce doubling up of staff attending hospitals to speak to the same client.

The decision whether the concern should lead to an enquiry needs only to be based on a reasonable belief that the tests in s42 of the Care Act 2014 are met. It may be that there needs to be some work done to gather information to inform this decision, but this need not be a drawn out process. As a general guide, if at the end of the working day after the concern arose a decision has not yet been arrived at then the presumption should be that there needs to be an adult safeguarding enquiry.

If a service user is admitted to hospital and there is already an on-going adult safeguarding enquiry which is managed by a community team, it is expected that this team will continue to hold responsibility for this work. In these instances and in order to minimise disruptions to the service user, managers should liaise in order to plan how the strands of work are taken forward, which might include considering the appropriateness of a new worker becoming involved.

6. Reablement Service

It is anticipated that some cases from the hospital teams will be transferred to the Reablement Service for intervention as long as they meet the Service’s eligibility criteria.

The eligibility for the Service will focus on whether there is potential for rehabilitation and gaining independence and will hold responsibility for case work until the end of their involvement. The only exception to this is in relation to adult safeguarding enquiries where the Reablement Service will determine the proportionality of their involvement.

The Reablement Service will transfer cases to the community teams after the period of their reablement. This will occur following completion of their final review. Where there are outstanding issues then the summary of actions should be documented and transferred to the community teams to follow up. All teams should adhered to the transfer process described in Section 4, Care Transfer Process.

Where there are no outstanding issues and no further requirement for social care input the case will be closed and service user notified by the reablement team.

7. Resolution

It is envisaged that this protocol on case responsibility is clear and the scope for disagreement to arise has been mitigated. However, if a disagreement arises between Team Managers as to which team should hold care management responsibility, the case will remain with the originating team until the matter is resolved.

The expectation within Adult Social Care is that Team Managers should take responsibility for cases assigned to their teams and should only attempt to transfer cases to another team when it is appropriate to do so.

When there is disagreement over responsibility for case management between teams then the two Team Managers should arrange to discuss by phone or to meet by the next working day in order to reach a consensus.

Care management support should be rendered to the service user as appropriate while the dispute is being resolved. Service users’ well-being and protection should not be compromised in anyway due to delays in transferring to another team.

On the rare occasion where both the managers cannot reach a decision following their discussion then they should submit a statement each to the Head of Service and or Service Manager on the same day of their meeting, clearly stating their position.

The Head of Service and or Service Manager would review the statements and the information about the case and respond immediate with a decision. If the dispute falls in another area of the business then both heads of service or service managers should confer and agree on which team should manage the case.  If this is not possible then they should meet within 2 working days to resolve the dispute.

Decision by the Head of Service or Service Manager is final.