Platform 6: Contributing to Integrated Care

An older patient is being discharged home after a hip fracture and will need help with washing and dressing. Who should be involved in planning the discharge?

• AThe patient's family alone, since they will provide the care
• BThe discharging doctor alone, since discharge is a medical decision
• CThe multidisciplinary team including therapists, the patient, their family and social care✓
• DThe ward nursing staff alone, since they know the patient's needs best

Answer: Safe discharge is planned by the multidisciplinary team with the patient and those who will support them, so that equipment, care packages and follow-up are in place before the person leaves. A discharge planned by one profession alone often fails.

What is the main purpose of a person-centred care plan?

• ATo provide evidence for the Care Quality Commission that care has been delivered
• BTo record the tasks staff must complete on each shift in the order they are due
• CTo document the medical diagnosis and the treatment the doctors have prescribed
• DTo set out care that reflects the person's own needs, preferences and goals, agreed with them✓

Answer: Person-centred care starts from what matters to the individual; the plan is agreed with the person and reviewed with them. Task lists, medical records and inspection evidence may draw on it, but they are not its purpose.

A patient with a learning disability is admitted for surgery. Which document, if they have one, will help the ward understand their needs and how to communicate with them?

• ATheir hospital passport✓
• BTheir GP's most recent letter
• CTheir consent form for the surgery
• DTheir discharge summary from the last admission

Answer: A hospital passport is a document held by the person that describes how they communicate, what they like and dislike, and what support they need, so that staff who do not know them can provide reasonable adjustments. The other documents record clinical events, not the person's needs.

A patient tells a nursing associate that they are the main carer for their partner at home and are worried about how they will cope after discharge. What should the nursing associate do?

• AReassure the patient that they will manage as they did before the admission, since most people cope better than they expect to once they are home
• BAdvise the patient to ask a neighbour or friend to help with their partner's care for the first few weeks while they recover from the operation
• CTell the nurse in charge so that a carer's assessment and support for the partner can be arranged before discharge✓
• DNote the comment in the record and take no further action, since arranging support for a partner at home is not the hospital's responsibility

Answer: Carers are entitled to an assessment of their own needs under the Care Act 2014, and a discharge that leaves a dependent person at home without support is unsafe. Raising it early allows social care and community services to be arranged.

A community nursing associate visits a patient whose home is cold and who has very little food. The patient has capacity and says they are managing. What is the most appropriate action?

• ADiscuss their concerns with the patient, offer information about support services, and with the patient's agreement make referrals to social care or welfare advice✓
• BArrange for the patient to be admitted to hospital for a few days so that they are warm and fed while their home circumstances are looked into by social services
• CReport the situation to the local authority as a safeguarding concern without telling the patient, since a referral made without their knowledge cannot be refused by them
• DAccept the patient's view entirely, since they have capacity and have said they are managing, and take no further action beyond the visit that was planned

Answer: A person with capacity can decline help, but the nursing associate should still explore the situation, explain what support exists, and act on the person's wishes. Self-neglect may become a safeguarding matter, but the starting point with a capacitous adult is informed choice and consent to referral.

Why is continuity of information between hospital and community services important at discharge?

• ASo that the GP and community teams know about changes to medicines and care needs and can continue treatment safely✓
• BBecause the patient is not allowed to see their own discharge summary, so the information has to be sent to the GP instead
• CSo that the hospital can close the patient's record, archive it and free up storage space on the electronic system
• DSo that the community team can bill the hospital for the care they provide to the patient in the weeks after the discharge

Answer: Medication changes, new diagnoses and outstanding follow-up are the commonest things lost at the transition between hospital and community, and a clear discharge summary is how they are carried across. The patient should also receive and understand the information.

Which of these is an example of reasonable adjustment for a patient with a hearing impairment attending a clinic?

• ASpeaking loudly and slowly so that the patient can follow the conversation
• BArranging a British Sign Language interpreter or written information as the patient prefers✓
• CGiving the patient the standard information and asking them to read it later
• DAsking a relative to attend and relay the information afterwards

Answer: Reasonable adjustments under the Equality Act 2010 mean adapting communication to the person's needs in the way they prefer, such as an interpreter or written formats. Shouting, relying on relatives, or leaving the person to manage the standard information do not meet the duty.

A patient nearing the end of life wishes to die at home. What is the nursing associate's role in supporting this?

• ARecord the wish in the notes and take no further action until the patient's condition changes and discharge becomes something that needs to be discussed
• BLeave the arrangements entirely to the family, since the decision about where someone dies is a personal one for them and their relatives to make
• CExplain that end-of-life care is safer in hospital, where symptoms can be controlled quickly, and encourage the patient to stay on the ward
• DEnsure the wish is recorded and shared, and support the team in arranging community palliative care, equipment and anticipatory medicines✓

Answer: Supporting a person's preferred place of care is central to good end-of-life care. The nursing associate makes sure the wish is documented and known, and helps the team put in place the community services, equipment and medicines that make dying at home safe and comfortable.

A patient with a long-term condition is being discharged with a new package of care. Who is responsible for making sure the patient understands their medicines?

• AThe GP, at the patient's first appointment after discharge
• BThe patient's family, who will be managing the medicines at home and can read the leaflets in each box when they have time
• CThe community pharmacist, when the first repeat prescription is collected from the pharmacy a few weeks after discharge
• DThe nursing team, with the pharmacist, before discharge, checking understanding and providing written information✓

Answer: Medicines reconciliation and counselling happen before the patient leaves, with written information to take home. Leaving it to the GP, family or later pharmacy visit creates a gap in which errors happen.

What is the role of a social worker in the discharge of an older patient who needs support at home?

• ATo prescribe the equipment the patient will need at home
• BTo decide whether the patient is medically fit to leave hospital and to sign the discharge letter
• CTo provide the personal care in the patient's home themselves
• DTo assess the person's care and support needs and arrange services under the Care Act 2014✓

Answer: Social workers carry out needs assessments and arrange care packages; medical fitness is a clinical decision, equipment is usually assessed by occupational therapists, and hands-on care is delivered by care workers.

A patient with a learning disability is due for a routine health check. Why does NHS England recommend an annual health check for this group?

• ABecause it is a legal requirement before benefits can be paid
• BBecause people with a learning disability cannot request appointments themselves and would otherwise never be seen by a GP
• CBecause the check replaces all other GP appointments for the year, so the practice only needs to see the person once
• DBecause people with a learning disability have poorer health outcomes and conditions are often missed or diagnosed late✓

Answer: Annual health checks for people aged 14 and over on the learning disability register exist because this group dies on average much earlier than the general population, often from preventable or treatable conditions that were not identified.

A community nursing associate visits a patient whose carer is exhausted and says they cannot go on. What is the most appropriate action?

• AListen to the carer, and with their agreement arrange a carer's assessment and information about respite and support✓
• BArrange for the patient to be admitted to hospital for a fortnight so that the carer can rest and recover before caring resumes
• CTell the carer gently that the patient's needs have to come first and that they must find a way to continue for the time being
• DNote the comment in the visit record and mention it at the next multidisciplinary team meeting, which is in a fortnight

Answer: Carers are entitled to their own assessment, and carer breakdown is a common and preventable cause of crisis admissions. Dismissing the carer, an unnecessary admission, or delaying action all fail both people.

Which document travels with a person moving between care settings to make sure their needs are understood?

• AA signed consent form covering all future treatment, so that consent does not have to be sought again at the new setting
• BA copy of their birth certificate and proof of address
• CThe full set of clinical notes from every previous admission, printed out so that nothing is left behind
• DA care plan or transfer summary that describes their needs, preferences and current treatment✓

Answer: Continuity depends on a concise, current record of needs and treatment that the receiving team can act on. Identity documents, blanket consent forms and complete archives do not serve that purpose.