Adult Social Care Record (MODS): Adult Social Care Record (MODS) Implementation Guidance

Teams responsible for hospital admissions and discharges understand the existing care plans and ensure that they communicate the requisite care details to care providers upon a patient's discharge.

Scenario:

James (Subject of care) has a learning disability (Reasonable adjustment, Impairment, Needs) and lives in supported living (Accommodation status). James (Subject of care) has not been well and was admitted to hospital for 48 hours (Admission details). When James (Subject of care) arrived with his care worker (Care worker), they explained to the nurse in A&E that he had a learning disability (Reasonable adjustment) and would need information explained to him clearly (Need) and any documents would need to be in an easy read format (Need). They did not bring along a copy of James' (Care and support plan) which explains the support he needs with dressing and going to the bathroom etc. When James (Subject of care) was admitted to the ward, his care worker (Care worker) explained to the ward nurse (Care worker) that he had a learning disability and would need additional support (Need). His care worker then had to leave. During his stay at hospital James (Subject of care) struggled to understand what the doctors and nurses were explaining to him and found it difficult to ask for help. When James was discharged (Discharge details), a different care worker (Care worker) came to collect him, James (Subject of care) was very distressed (Outcome). The nurse (Care worker) gave James' care worker (Care worker) a copy of his discharge papers (Discharge details) and explained the extra support (Need) and medication (Medication) James (Subject of care) would need over the next week. When they arrived home, James' care worker (Care worker) showed the manager (Care worker) his discharge papers (Discharge details) and they were filed but the information about James' (Subject of care) additional support (Need) and medication (Medication) this week were not shared with the rest of the team.

Goal:

Everyone who cares for James in hospital is able to access a digital copy of his care plan so they are aware of his needs and able to provide him with the correct level of support. When he is discharged from hospital, his after care is incorporated into his care plan and the necessary information from his hospital stay is shared with his family carers and care provider staff.

Assumptions:

As James has a learning disability, he may struggle to understand some of the information provided at the hospital, need extra support and a copy of his care plan should be shared with hospital staff. The Red Bag Scheme could be beneficial in this scenario. Details of additional support needs noted by nurses - but unable to access a digital copy of care plan, no paper copy provided Paper copy of the documents filed by the care provider but not shared with all staff who may support James over the next week By having a clear digital shared care record with James's care and support needs available to all NHS staff would enable them to support James better. When he is discharged, the additional support needs from his hospital stay could be added to this digital record and then this could be accessed by all care staff at James' supported living accommodation. This would ensure consistent care and support in both settings.

Process breakdown

Hospital admission (Admission details) Additional support needs noted by nurses (Needs, Care and support plan) Hospital records maintained and shared (Needs, Medication) Discharge papers provided to care worker (Discharge details)