You are on page 1of 29

Care and Discharge

A Guide for Service Providers

Serial No: 032/SDD19/DEC06











Components Of A Care And Discharge Plan



Guiding Principles






The Process










Youth and Sports • Methodist Welfare Services • Society for the Physically Disabled • Singapore Anti Narcotics Association 2 .Acknowledgements The National Council of Social Service would like to acknowledge the following organisations for their invaluable inputs to the development of this guide: • Disability Information and Referral Centre • Hua Mei Care Management Service • Ministry of Community Development.

Resources. 3 . and scroll down to Service Guides] © National Council of Social Service. including photocopying. http://www. recording or any information storage and retrieval system.Feedback This document is published in November 2006 and will be reviewed periodically.asp?show_page=templates/template_c ontent4. without written permission from the National Council of Social Service.html [Visit NCSS‟ No part of this manual may be reproduced or transmitted in any form or by any means. go to “VWO Corner”. electronic or mechanical.ncss. All rights reserved. Please write in to: Strategy and Specialisation Department Service Development Division National Council of Social Service 170 Ghim Moh Road #01-02 Singapore 279621 A copy of this guide can be downloaded from NCSS‟ website. NCSS welcomes your feedback.

The minimum standard for Care and Discharge Planning as outlined in the Service Standards Requirements are: Care Planning (1) The programme has written procedures on individual care planning. and Intake and Assessment . currently a self-assessment checklist of 54 areas.A General Guide for Service Providers (2004). Case Management Service . (2) Discharge plans are discussed at the onset of service provision with the service user. his/her family and concerned individuals involved in the care of the service user. 4 .Foreword Purpose This guide is part of a series of guides 1 on good practices for service delivery. 2 The Best Practice Guidelines. will be streamlined to the Service Standards Requirements (SSR) from April 2007. Occupational Therapists & Speech-Language Therapists (2003). Standards of Practice For Physiotherapists. (3) Re-assessment of care plans are conducted at regular intervals (at least 6 monthly) or as agreed between NCSS and the VWO. 2 It is hoped that the guide will help improve processes to achieve the programme‟s outcomes for its clients. Specialised Caregiver Services . Discharge Planning (1) The programme has written procedures on discharge planning. (2) Care plans are tailored individually to meet the unique needs and preferences of the service user and/or his/her family.A Guide for Service Providers (2006). This guide is designed to provide a reference on care and discharge planning processes for community-based social service agencies in Singapore.A Guide for Service Providers (2004). It also serves to highlight the minimum standards which agencies should strive to achieve. The SSR is a set of 16 mandatory requirements which have a direct impact on client outcomes. 1 Other Guides already published are: Guidelines for Practising Therapists in VWOs (2003). These guides compliment the Best Practice Guidelines 2 checklist for Voluntary Welfare Organisations (VWOs) and Non-Profit Organisations (NPOs) to conduct selfassessment of their organisational practices and processes.

• the processes for the development of the care and discharge plans. as opposed to group-based programmes. 6 This guide is intended for the following programmes: • • • • • • • • • • • • • • • • • • Aftercare Case Management Service Befriending Services Caregiver Support Service Client Re-integration and Family Services Community Case Management Service Counselling Centres Day Care Centres for Seniors (Social. and. The programmes are typically client-centred. Target audience 5 This guide is designed primarily for organisations that provide communitybased social services for persons with disability. However. seniors. children. and accordingly.3 This guide consists of: • the guiding principles for the development and delivery of quality care and discharge planning. These factors will influence the type and extent of care and discharge plans adopted for each client. youth and families in the community. 4 Organisations are expected to develop and customise their care and discharge policies and procedures using pointers from this guide. • checklists and templates for care and discharge planning. the availability of human and financial resources. agencies which conduct group programmes and mass outreach may also adopt a care plan for their vulnerable clients. The framework recognises that the nature and clientele of each programme varies. in Singapore. Dementia and Rehabilitation) Early Intervention Programme for Infants and Children Family Service Centres Home Help Service Home Therapy Hostels – Disability and Mental Health Integration Support Programmes Production Workshop Mentoring Services School Social Work Sheltered Workshops (employment services) Training and Transition Programmes 5 .

6 .• Other organisations involved in the care of clients.

or to enable him to tap on support and resources within his family or the community. Discharge planning is a process used to decide what a client needs to maintain his present level of well-being or to move on to the next level of care.Chapter 1 INTRODUCTION A What is a care and discharge plan? 1 A care plan puts down on paper who is providing which service to meet the needs of the client. and • Ensures continuity of care. ambiguities may arise as to the role and expectations of service providers. Without the plan. in consultation with the client. Goals and outcomes are set. 2 A discharge plan puts down on paper the end-goals of the care plan. and the client himself. to maximise his potential to live independently. and their caregivers. to have a clear understanding and expectation of the plan of action. • Encourages a team approach by both formal and informal caregivers. B How does it benefit clients? 3 Clients benefit from care and discharge planning because it: C • Sets goals with and for the client and provider according to client‟s needs. as well as the 7 . which ultimately aims to empower the client to make decisions and be resilient. if any. including his expected discharge. and a plan of action is decided within specified timeframes. Why do we need the plan? 4 A documented care and discharge plan would help all parties involved in the care of the client. • Manages long-term care by setting milestones.

They typically require well-coordinated care and supportive services. i. co-ordinate and monitor the progress of care and client‟s readiness for discharge. helps providers bear in mind the ultimate aim of providing supportive services to the client. eCMS allows for information sharing across service providers. Examples of clients who would benefit from a care and discharge plan would be frail older persons who live alone or with minimal family support. E Who needs care and discharge planning? 6 Clients who have multiple or complex needs arising from the interaction of physical. 8 Usually. For more information on intake assessment. which would facilitate referral. F When is care and discharge planning conducted? 7 Care and discharge planning should be conducted within an optimal timeframe for clients. The care plan spells out milestones of achievement as well as decides on the agreed outcomes of intervention. If necessary.motivation of the client to engage actively in the programme. when planned at the start of engaging the client. Organisations should develop their own timeline for care and discharge plans.e. G Who is involved in care and discharge planning? 10 The case manager would take the lead to implement. it is important for service providers not to under or over-provide for the client. children and adults with disabilities and ex-offenders. monitoring of client progress and follow-up. D Why is it important to conduct care and discharge planning together? 5 In the business of caring and providing social service. in tandem with its philosophy of care and intended client outcomes. 9 Agencies can use the electronic Case Management System (eCMS) to document care plans. refer to NCSS‟ Guide on Intake and Assessment (2006). a multi-disciplinary 8 . to empower the client to maximise his potential and autonomy given his abilities and unique conditions. They need skilled assessment and comprehensive management of services. A discharge plan. and there is a need for ongoing monitoring and review of the client‟s changing care needs. medical. The client and caregiver (parent.. guardian or family) and/or significant others should also be actively engaged and consulted in the care and discharge planning. social and emotional needs will benefit from a clearly documented care plan. care and discharge planning would be conducted after intake assessment.

9 .team involving various professionals would assess the client and recommend strategies and a plan of action to achieve the agreed outcomes.

or factors of uncertainty which may tilt the client‟s life equilibrium. and any changes that may have occurred as a result of intervention /service rendered. Achievable. (5) Transition and discharge plans. volunteers and others in the support network (e. including factors of stability within client‟s circle of support. including criteria for discharge or transfer. and caregiver needs. (5) Community and sources of social support for client and caregivers. (4) The potential impact of caregiving on the caregiver. 10 . (3) Recommendations for follow-up care or services. family/caregiver. (2) An interpretive summary.g. (3) Specific. and. Measurable.Chapter 2 COMPONENTS OF CARE AND DISCHARGE PLANNING 11 12 Care planning should include consideration of the following: (1) Strengths. staff. Needs. neighbours). (6) Roles of client. (2) Anticipated symptoms. Abilities and Preferences (SNAP) of the client. training and resources. mental and social condition). (4) Intervention plans and community partners to achieve goals. problems or changes that may occur after discharge. Discharge planning should include consideration of the following: (1) The client‟s current condition (physical. Realistic and Time-bound (SMART) milestones and outcomes. including agencies that provide services such as transportation.

books and websites. job referral and volunteer services. videos. (7) Contact details (including name of contact person. telephone and email) of the discharging organisation for information or help. home care. and. (6) Information resources such as pamphlets. 11 .equipment maintenance. respite care.

The caseworker should also tap on the client‟s natural support network. should give due understanding of the client‟s strengths. and follow-up accordingly. abilities and preferences. neighbours and nearest provider to his home. abilities and preferences. B Flexibility 15 The care plan should be flexible to address changes in the client‟s circumstances and environment. The agency should then refer the client to a provider who can meet the needs. in the helping effort. this should also be recorded. If the agency is unable to provide a particular service to address the client‟s needs. apart from focussing on the clients‟ needs. This will ensure that the care plan remains relevant. needs. 12 . Caseworkers. and based on his strengths.Chapter 3 GUIDING PRINCIPLES 13 The following are some guiding principles to consider in care and discharge planning. carefully consider his preferences. which can be tapped on to ensure success of intervention. such as family. and be sensitive to his unique life experience and circumstances. The care plan should be appropriate to the client‟s culture and age. A Client-centred 14 A caseworker should proactively engage and empower the client (and caregiver. C Communication to client 16 A caseworker should explain the purpose. and address their concerns. religious and ethnic sensitivities). reviewed regularly and modified accordingly. benefits and process of care planning to the client and caregivers. The care plan should be conveyed to the client in a manner and at a level and pace that is appropriate to their: • personal background (profession. if any). The client should be asked for his concensus and kept informed of any changes made to the care plans.

The driving principle should be that the changes proposed should enhance the quality of life of the client and his family. 13 . The caseworker should hence obtain the client‟s or his parent‟s/guardian consent through signing of a consent form. the caseworker needs to be open and honest about what action plans are critical and necessary. There is a need to prioritise the action plan. D Enhance quality of life 17 When assessing a client. The client should also be informed that his personal information may be required for typically aggregated statistical studies of trends and patterns. • their current intellectual. mental and emotional states. if necessary. Refer to Annex 1 for guiding principles of information sharing. or where the safety of the client may be compromised. service reviews or service planning. The above may not apply to emergency situations. the caregiver can be asked to acknowledge the plan. cultural background and principles may influence their assessments. hearing and visual).• language and preferred ways of communicating. as not all changes can be effected immediately. • the presence of any physical impairment (e. In the event that the client is unable to do so. Due discretion must be applied. to ensure continuity of care. and what is open to compromise and negotiation. or caregivers. E Respect client confidentiality 18 The client or client‟s parent/guardian should be informed that personal information may or will be shared with other various service providers.g. and respect his wishes if there is any personal information that he does not wish to be disclosed to any particular person or agency. F Acknowledged by client and provider 19 Both client and provider should sign the care plan after it has been presented to him. Caseworkers must be aware that their individual values. and.

if necessary by a multi-disciplinary team Interpretive summary Establish care and discharge plan in consultation with client and caregiver/significant others Implement care plan Monitor outcomes.Chapter 4 WORKFLOW Intake assessment Chart 1: Care and Discharge Planning Process Admission Needs assessment. review care plans according to client‟s changing needs and progress Prepare for discharge – detailed discharge plan. including follow-up plans Discharge Follow-up 14 .

hobbies and past work history 3 . 15 . The eligibility criteria should be transparent to users and well-documented. to understand and agree on each party‟s role and responsibilities. A home visit can be conducted. Singapore. If possible. B Admission 22 The client is admitted to the programme if he meets the agency‟s eligibility criteria. audiology or psychological evaluation. Care must be taken to ensure that all parties. agree with the plan. including the client. this may not be possible in some cases. However. Agencies can be flexible in terms of where and how the planning is conducted. home medication use. formal and informal support systems. family and social history. The key assessor in charge of putting together the care plan is required to get a “whole picture” of the client‟s circumstance to best and most effectively meet the needs of the client. Assessment should include the client‟s physical and mental health profile. 21 It is important to note that clients with special needs and concerns may require additional assessments such as speech. As 3 4 Reference: Guidebook on Dementia Day Care Centres. community and financial resources. 2002 Ibid. mental and emotional status. interests. during this stage or when feasible to identify home safety issues. if necessary.Chapter 5 THE PROCESS A Intake assessment 20 Assessment is a way of learning important information about a client so that his critical and real needs are ascertained and appropriate service determined. C Needs assessment 23 It would be ideal if all who are involved in the care and discharge of the client meet to discuss on the care and discharge plans. activities of daily living. use of or need for adaptive devices and the optimal functioning of the client and caregiver at home 4 . Ministry of Health. the caregiver should attend the initial assessment with the client to give a more holistic picture of the client.

Monitoring of the progress of the client should be conducted systematically. Familiarity with the client will ensure continuity of care. The summary links co-occurring issues and makes a professional judgment on the connections between all issues raised in order to prioritise goals and intervention. This would help motivate the client and the caseworker as there is a sense of achievement. the case manager should develop an interpretive summary. at scheduled review dates or when the client‟s circumstances had changed. particularly when difficult lifestyle changes need to be made. D Interpretive summary 24 Once the client‟s strengths. Ideally. abilities and preferences are identified in the intake or needs assessment. family and community care resources. and if necessary. The purpose of discharge planning is to identify the client‟s plans after exiting the programme. The goals/desired outcomes should be described in terms of observable client response. This summary indicates the caseworker‟s diagnosis or interpretation of the client‟s needs based on information obtained during assessment. achievable and realistic outcome/s within an optimal timeframe. E Establish care and discharge plan 25 The care plan lists and prioritises set specific. it is important to involve and empower the client. 28 Case workers coordinate discharge for the client by collaborating with the client. due care must be taken to ensure minimal misunderstanding or miscommunication. a thorough care system should be adopted where the caseworker who assessed the client and who developed the care plan should oversee the discharge. optimal use of resources and the client‟s existing support 16 . G Discharge 27 Discharge planning should start at the time or even prior to admission. measurable. and the support which the client and caregiver would require after discharge. and ensure self-determination as far as possible. Important milestones should also be set and clearly stated to measure progress. needs. F Implement care plans 26 Whilst implementing the intervention strategies to achieve the stated outcomes.the plan may involve professionals from one or multiple agencies.

as well as responsiveness to the client‟s preferences and anticipated change in H Follow-up 29 The date and proceeds of the post-discharge review should be indicated in the case notes. As with developing the care plan. Questions to ask the client in order to assess the adequacy and effectiveness of the discharge process include: • How are you coping? • Do you have any questions? • Have you received the services arranged prior to the discharge (for e. the discharge plan should also be welldocumented. home chores/meal services? • Is your caregiver able to provide adequate support? • What has changed? 17 . escort and transport service for medical appointments.

(2) Discharge plan checklist (sample at Annex 2). The checklist provides guiding questions to ensure standards of care for clients when providers develop care and discharge plans. (5) Letter of referral to next agency (according to each agency‟s procedure and practice). (3) Template for care and discharge planning (sample at Annex 3). (4) Letter of consent on disclosure of personal data for emergency and statistical compilation (according to each agency‟s procedure and practice). Below is the suggested list of standard documents which can be applied:(1) Care plan checklist (sample at Annex 2). 18 .Chapter 6 CHECKLISTS 30 The adoption of standard checklists. templates. forms or letters will ensure clarity and objectivity in assessments. thoroughness in the process and common understanding and interpretation of needs and treatment.

Is there a legitimate purpose for you or your agency to share the information? 2. Have you properly recorded your decision? Source: Every Child Matters. agencies need to consider: 1. UK. 19 . If the decision is to share. is there sufficient public interest to share the information? 7. “Making it Happen – Working Together For Children. are you sharing the right information in the right way? 8. Is there a statutory duty or court order to share the information? 6. Is the information confidential? 4. If consent is refused or there are good reasons not to seek consent.Principles Of Information Sharing Before releasing information. If so.Annexes Annex 1 Privacy Concerns . Young People And Families “. Does the information enable a person to be identified? 3. do you have consent to share? Has the client/ client‟s parent or guardian sign a consent form? 5. Change for Children.

age. needs. … … 3. and their preferences are accommodated (where possible). The client‟s strengths. The roles of all persons involved to achieve the goals are stated. physical status and mental state.Annex 2 Table 1: Care Plan Checklist Care Plan Checklist 1. The client and caregivers are consulted. … … 7. The care plan is dated and signed. … … 20 . Yes … No … 2. … … 4. The goals are “SMART” – specific. … … 8. realistic and time-bound. abilities and preferences (SNAP) are documented and considered. … … 6. The plan is appropriate to the client‟s culture. There is a date set for review. … … 5. measurable. There is an interpretive summary. and the care plan modified accordingly. actionable.

… … 8. Contact details of a staff from the discharging organisation has been given to client and caregiver. The likely post-discharge needs and issues are identified and conveyed to client and caregiver. … … 3. such as pamphlets of community-based services. The client‟s strengths. … … 5. respite services and other community resources. A designated staff had been assigned to follow-up with the client and caregiver. … … 4. if any. and informed with other resources available. Yes … No … 2. where necessary. needs. within a specified time-frame. abilities and preferences (SNAP) at the point prior to discharge are documented. … … 7.) had been given to client and caregiver. Caregivers are briefed on client needs. coping skills for caregivers. or goals achieved are documented. including caregiver support groups. The gains from participating in the programme. etc. Information resources. nutrition or diet.Table 2: Discharge Plan Checklist Discharge Plan Checklist 1. … … 21 . Referral to other agencies for post-discharge needs are made. health-related information (disease prevention. … … 6.

Annex 3 TEMPLATE OF A CARE AND DISCHARGE PLAN Agencies can modify the care plan to suit unique programme needs Referral Source: Section 1: Referral Information (E.: Date of Referral: Date of Receipt: Name of referrer/ Designation: Contact Numbers (Office. Mobile. Hospital. (Home. Email) Address: Religion Gender Preferred Language/Dialect Ethnicity Date of Birth Age Section 3: Caregiver’s Information Has Primary Caregiver Relationship to client : Yes … No … 22 . etc) External Referral No. Email:) Current Location of Client: Section 2: Client’s Particulars Case Reference Name NRIC Contact nos.g. CDC. FSC. Mobile.

No. others. Mental Health Issues. Learning Disability. of needs met If accepted Reason for acceptance & date: Referred to: If not accepted Name of Organisation Name of Receiving Staff/ Designation 23 . Financial Issues. Care Arrangement/ Shelter. Psycho-emotional issues. Substance Abuse. Marital Issues. Addiction. Family Issues.g. Interpersonal Issues. Mobile. Health Issues.Name of Caregiver/Guardian/ Next of Kin Occupation: Address Contact Numbers (Home. Caregiving Issues. Immigration Issues. of needs E. Elderly Issues. Sexual Issues. Office. Employment Issues. Email) Nationality Marital Status Section 4: Intake Assessment Presenting Problem Underlying Problem No. Suicide. Abuse/Neglect. Housing Issues.

Family Means Test Information . preparing meals. place of medical follow up. irregular employment. toileting. large family.g. grocery shopping. grooming. unemployment.Charges and Fees. drug addiction. certified permanently incapacitated.Remarks Section 5: Needs Assessment (if necessary by a multi-disciplinary team) Date created Review date Name and Designation Staff in charge Other staff involved Name and Designation Functional Assessment Include ability to perform Activities of Daily Living such as feeding. poor budgeting. doing housework and laundry). RAF status. level and general academic performance for students. Instrumental Activities of Daily Living (using the telephone.Financial Assistance (if any) . imprisonment (prison/DRC). for e. . Assessed by: (Name & Designation) Date: Medical History Include nursing needs. Assessed by: (Name & Designation) Date: 24 . Include highest qualification and work history for adults. including transport fees if any. dressing. in debt or bankruptcy. mobility. etc Assessed by: (Name & Designation) Date: Financial Profile Include reasons for financial difficulties. Assessed by: (Name & Designation) Date: Educational Background & Career History Include name of school. gambling.alcoholism. chronic illness. physical/intellectual disability. etc. non-contribution from other wage earners. others. family relationship problems. bathing. low wages. irregular/not receiving maintenance.

violent behaviour. non-substance abuse. aggression. Include observation of behaviour for e.g. risk or history of abscondence. as well as information on formal and informal support network. substance abuse. repetitive behaviour etc. hobbies)/ Stated or Known Preferences Assessed by: (Name & Designation) Date: Section 6: Interpretive Summary Caseworker‟s Diagnosis Assessed by: (Name & Designation) Date: 25 . medical.g. Psychological Profile misconduct.g. Assessed by: (Name & Designation) Date: Social History Include information of next of kin and caregivers. suicidal attempt. task. others.Section 5: Needs Assessment (continued) Include general assessment for e. anxiety. Assessed by: (Name & Designation) Date: Strengths/Abilities Assessed by: (Name & Designation) Date: Interests (e.

3.Section 7: Care Plan Description (Aim) Goals and Measures Goal Type (Longterm/ short-term) Date set Review Outcome date Date set Review Outcome date 1. 4. Action Plan/Strategies Progress Notes Note changes in client needs and circumstances and changes to care plan. Achieved Partially Achieved Not Achieved Partially Achieved Not Achieved Partially Achieved Not achieved Achieved Partially Achieved Not 2. 26 .

Section 8: Discharge Plan Include role of client. other agencies and resources Date of closure Initiated by: Reason for closure Goals achieved Completion of Goals Caregiver satisfaction survey Is Survey Conducted. family. Date) 27 . Level of Caregiver Satisfaction/ Comments Duration of stay (days) Organisation referred for follow-up Staff responsible for follow-up Date of planned followup Name of staff and contact details given to client Tel: Email: Client‟s signature/ Date Case manager‟s signature/ Date Approved by: (Name. community. Designation and Signature.

uk/_files/59881E141B8023DD062CB83E19 0F5AF5. Individualised Care Planning Training Manual (2006). Knowing When To Share in „Making It Happen.References Guides/Manuals 1. http://www. Articles 5. Social Service Training Institute. Guide on Intake and Assessment (2006). Young People And Families‟ Pal Abhimanyau. Patrice L. National Council of Social Services. Is Your Discharge Planning Effective? (2003) Brown-Spath & Associates. Singapore 4.everychildmatters. 2.pdf 28 . (2002). Singapore. Commission on Accreditation of Rehabilitation Facilities. A Guidebook on Dementia Day Care Singapore. Ministry of Health. Spath.htm 6. 3. http://www. CARF Behavioural Health Standards Manual 2006. Working Together For Children. United States of America.