Delayed Transfers of Care (DToC) Roadshow Follow- up › wp-content › uploads › 2016 › 04 ›...
Transcript of Delayed Transfers of Care (DToC) Roadshow Follow- up › wp-content › uploads › 2016 › 04 ›...
Delayed Transfers of Care
(DToC) Roadshow Follow-
up
Grainne Siggins, Regional ADASS Lead and
Director of Adult Social Care, London Borough of
Newham,
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SHORT DESCRIPTION FULL COMMENT
Timely assessment • Lack of truth between professionals. Lack of good info sharing / communications . Each professional
assessing their 'bit' - differing risk aversion - differing risk and responsibility .
Multiple assessments • Causes delays -- multiple geographies - health and social car e- no trusted assessors - people
decondition .
Timely reviews • Lack of consistent staffing (sw/provider who are unable to spot deterioration due to lack of staff and no
key worker for some people for vulnerable adults.
Discharge planning in hospital • Do we know what services/care they already have? - are patients involved - lack of clarity who is
responsible - lack of recognition of baseline at home - lack of discharge co-ordination .
Information sharing • Between staff - with patients - need to gather info about the patient - centred around them - no info given
to homecare workers on discharge - people don’t take info home .
Unnecessary admission
/readmission
• Cause not always solved e.g. , cold home .
Complex Pathways • E.g. major adaptation . - variability/paperwork and process.
Input into house before admission • Adaptation
Poor knowledge of the system • Adaptation available - no cross over of expertise - fragmented system.
Commissioner Practice • Framework can destabilise the market.
Joint approach • Risk assessment.
End of life • No DNAR set up - can delay discharge to set up care at home - care worker having care planning
discussion rather than with clinician.
Crisis intervention service rather
than service that keep people well
at home
• Funding issues - lack of encouragement .
Care in community • Go into hospital with patient - difficult because different commissioner .
Issues raised
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Solutions proposed Improve the image of homecare • Led by homecare/provider - Skills for Care / or Health? With UKHCA and NHS England -
professional campaign into hospitals. Piloting new approaches to providing homecare to PR - media
around workforce - valued , support. Image - mutual request. Frailty hub - integrated care network -
single point of access.
Skilling • Skilling up carers who are caring for those with frailties / disabilities especially training post -
discharge - voluntary sector help - Skilling up carers included in commissioners guide for local care
strategy. Better carer programme.
Creative role of pharmacy • Pharmacists involved in medication on discharge - better use of medication - need to be more
involved in integration agenda - lead - CCG
National programme for
medication training
• For carer. Lead - Skills for Care and care worker - Skills for Health
More CHC budget into BCF • New assessment framework.
Build capacity to network across
acute and community
• Induction include visits to other services - co-ordinators with knowledge for patients - co -location of
services - joint or rotational posts Lead .
Career program in health and SC • Opportunities at all levels - value staff, H and W , supervision - Mechanisms to capture innovation -
Sell the lead skills for health skills for care course. New staff - understand career progression
available and recognising skills of homecare worker.
CQC rating of good /outstanding • Using existing toolkits. Lead - NHS England /CQC/DH - next - step find out which toolkits work well.
Co-location of social care and
housing and health both social
and private
• Commissioner bring together market position statements - . Lead - locally as it wont work
everywhere - Kings fund doc on commissioning talks about co-location.
Digital info sharing • Patients hold their own image helps with IG issues .
Big data technology for
commissioning
• Jointly driving behaviour change. Next step - every life tech and other to be investigated as to what is
already happening.
System wide metrics for patient
experience
• STPs should have this, Lead - NHS England. Next steps - Assurance of STPs - ensure system wide
metrics are included .
Secure email • Stop faxes in the NHS - Guidance from NHSE about good practice / option for secure email. Cultural
change program re: data protection / info sharing.
Standarised checklist • On admission - for baseline assessments - include homecare workers/ carers etc.
Take home information • Developed by patient groups - choice available
Local Solution • Community services available.
Voluntary sector into hospitals • Being involved in early discharge conversation - option available – involved in MDT board. Example
- Birmingham. Shared good practices across the system.
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Behind each number is a personal story
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• Beds are where patients wait for the
next thing to happen
• Capacity is decision making
• Everyone has a bed at home
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No correlation with 95% performance – massive
variation in counting
Medically Fit For Discharge lists are really unhelpful and
the difference between the two lists are nearly all delays
that are internal to the acute trusts in that they have not
followed due process or planned in advance
Sequential planning is the issue
Far more health than social care delays
Improvement in acute stranded patient metric has linked
to performance but is not a benchmark indicator
Time spent at home is the best outcome metric we have
seen as this takes account of time in step down beds
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Planning for discharge on admission or pre admission
for elective patients
One assessment/information gathering of function pre-
admission at handover from ambulance or as soon as
possible after.
Ask from the person/family perspective not therapy tick
boxes – discharge plan started at this point
Expected Date of Discharge with clear clinical plan with
clinical and functional criteria for discharge set within 24
– 48 hours of admission
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Daily review and decision making remove wasted days
within the hospital journey
Early in the day discharges 1 on every ward before
10.00 and 35% before midday
Review of every person in hospital over 7 days and in an
ideal world will be able to measure this at super spell
level (Camden)
This is the SAFER flow bundle
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In hospitals that implement the SAFER bundle
The number of patients in hospital over 7 days reduces –
stranded patient metric
Overall LOS reduces
Number of referrals for complex discharges reduces
Need for services outside the hospital is not increased
It appears to reduce the need for bed based services
and reduces admissions to long term care
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The overall average inpatient stay has
reduced by 3.5 days
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Early identification of people likely to require support on discharge – front
door collection of ‘how I live my life’
Set expectations on admission – welcome card/ticket home
Same notification process used as the referral mechanism for all out of
hospital services health or social care using the form that the initial
information is collected on
Sent through a joint simple/single point and streamed to a service based on
needs – need an integrated/joint intermediate tier that always says ‘YES’
Hospitals to stop telling people what they will receive and need 25% over
prescription of support required on discharge.
Do assessments of long term need wherever possible in the persons usual
place of residence.
◦ ‘Why not home’ and ‘Why not home today’
Intermediate short term support, re-ablement, rehabilitation, allow time to
recover from acute episode before long term decisions are made
Placements into long term care placements or new home care packages
from a hospital bed should be an exception
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Blame
Each partner focusing on their ‘must do’s’ in isolation
Step Down/Warehouse beds
◦ Shifts the problem
◦ Stretches the assessment capacity
◦ Unbalances the market
◦ Patients become lost in the system
Making long term decisions in hospital
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Very variable – joint vision and system leadership is vital
Have to fix all parts not one or the other – this is complex
system change
Ensure central messages don’t cut across partnership
working at local level
Joint working between TEASC/ADASS/ECIP has worked
well
Voluntary and independent sector not used to their full
potential need to be included more
Best way to achieve change is for systems to focus on
the person and their populations together
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Focus on the person – person centred
Networks of care
Easy access to services and information
Effective assessment – timely, proportionate
Avoidance of personal crisis
Easy information flow
Blurred boundaries
Continuous feedback and evaluation
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Actions to Address Delayed Transfers of Care
Work for this year builds on learning from last year…
Last winter, the Helping People Home Team (DH, DCLG, LGA, ADASS and NHS England) provided support and challenge to local systems experiencing high levels of delayed discharges.
Their work with 45 economies across England highlighted the importance of working across whole systems to ensure smooth patient ‘flow’ through health and care services. The work highlighted a number of interventions that were key to supporting improved performance.
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