Reflecting on the presentations:
• Share experiences from your own Health Board
area / locality / site in relation to the part of the
patients’ flow discussed:
• What works well in your area / locality / site?
• What and who have been the drivers for this?
• What could work better?
• Who needs to be engaged?
• Where local practice could be improved,
consider how to utilise the evidence / learning
from the workshop to influence change.
Arranging Effective Discharge
Karen Anderson
Diane McCulloch
Content
•
Dundee Position
•
Challenges Facing the System and
Partnership
•
Improvement Steps
•
Future Challenges
Dundee
•
Demographics
Increasing number of very old people
Decreasing population
Area of high deprivation
•
Hospital Model - Pre 2009/2010
Ninewells Hospital serves the acute requirements of the population of Dundee City and Angus
5 MfE Assessment and Rehabilitation wards in Royal Victoria Hospital
No Community Hospital Model
•
Social Care/Social Work Model – Pre 2009/2010
Establish Early Supported Discharge but targeted at specific wards
Social Work Teams chasing services for discharge
Separate Adult Services/Older People hospital Teams – different referral /assessment procedures
High number of people admitted directly to care home from hospital
•
Reactive Responses
Focussing on patients delayed longest in system
Problem solving at point of trigger (ie pre census date)
•
Culture of Acceptance of Delays
Families and staff ‘expected’ to be delayed for up to 6 months in hospital
Use of ‘CHOICE’ as last option, seen as punitive not supportive
Challenges
• High number of delayed discharges
• Number of Unallocated Social Work
Assessments
• Long waiting list for placement
• No step down facility
• Resources limited
Dundee Integrated Care Model for Older People
“AS IS”
“TO BE”
At Risk Support
At Risk Support
Living Independently
User &
Satisfaction
Virtual Ward - multi agency team
approach.
Care Management
Case Management
Care Homes
Hospital Care
Complex
Needs
Targeted Extra Support
Faster
Access
Support for
Carers
Quality of
Assessment
& Care
Planning
Comprehensive Geriatric Assessment
Day Services
Day Hospital
Intermediate Care
Intensive Home Care
Very Sheltered Housing
Targeted
Multi-agency
Care
Virtual Ward approach
across city.
Assessment in Appropriate
Setting
Targeted Extra Support
Intermediate Care - step-up
Day Hospital
Community Geriatric Care
Mainstream Extra Support
Social Work Services
Community Rehabilitation
Enablement
Independent Living & Equipment
Centre
Sheltered Housing
Mainstream Extra Support
Mainstream Additional Support
Enablement Approach for All
Rehabilitation at Home
Tele-health
Tele-care
Self Care/Self
Management
Universal Services
Identifying
Those at Risk
Moving
Services
Closer to
Users/Patient
Health
Leisure & Communities
Housing
Voluntary Sector
Private Sector
Direct Access
Anticipatory Care
Healthy Communities
Universal Services and Self-Care
Pipeline Approach
The main statutory
agencies will assess
every older person at
key milestones with
the aim of enabling the
person to regain/retain
as independent a
lifestyle as possible.
Service providers will
then have a clear
outcome to achieve.
Self
Determined
Physical
& Mental
Health
Decline
Life
Crisis
Significant
Illness
Integrated Assessment Framework
Single Shared Assessment
Integrated Care Record
End of Life Pathway
Palliative
Care
Improvement Step –
Use of Edison
• Tayside was one of the original pilots for EDISON, well supported by
IT (Joe Donnelly)
• Developed a Weekly Update Spreadsheet
• Originally only used by ESDS and Care Management Team Leaders
• Expanded to include SCNs, HoPCN (Heads of patient Care and
Nursing)
• Twice Weekly Email Distribution System
• Updated by Ward and Care Management Staff on Weekly Basis
• Used by HoPCNs for Tracking Flow in Wards
• Used by Partnership to Track and Manage Patients’ Pathway
• Triggers for ‘CHOICE’ – Collaborative Approach
• All Delayed Patients are Actively Monitored and Managed
• Clinical and Care Management Staff are Responsible for Action
Planning
• Improved Communication BUT still a Challenge
Improvement Step –
Review of Hospital Social Work Model
Model
•
Analysed referral, allocation and assessment processes.
•
Amalgamated OP care Management Teams and Hospital intake Team into one service with single
line manager.
•
Redesigned referral process with new documentation and reintroduced telephone referrals.
•
Introduced single process across all hospital sites.
Outcome
•
Simpler referral processes.
•
Quicker assessments resulting in quicker discharges.
•
Reduction in duplication of assessment.
•
Equal service across all hospital sites.
•
Improved communication between hospital and social work staff.
Challenges
•
Size of teams – very large for single manager
•
Skill mix in teams to be reviewed.
•
Impact of other changes impacting on the end point of assessment.
Improvement Step –
Priority Allocation Meeting
Model • Moved from a Fortnightly Schedule to Weekly (mid week)
• Led by OP Service manager, group includes all team leaders across city and admin
for updating IT systems
• Health Colleagues included in group membership (DD lead, POA, ESDS)
• Allocation process considered on level of need (urgency), breach status and
availability of placement choice
• EDISON spreadsheet updated and individual cases discussed
• CHOICE process agreed
Outcomes –
• Improved communication between health and Social work
• Action plan implemented for individual cases
• Placements for Community and Hospital patients agreed on priority – fair system
• Improved placement activity and rate
Challenges –
• Availability of suitable placements
• Managing perceived bias towards hospital breach patients
• Balancing competing needs with resource availability
Improvement Steps
– Enablement
Model • In 2009 Moved from a Mixed Model of Teams to a Single Enablement Model
• Step 1 - All Patients Discharged from a Hospital Setting Accessed the
Enablement Team in First Instance
• SCO Staff Development Supported by Health and Social Work OT and Health
PT Staff
• Single System Approach to Documentation
• People Requiring Long term Packages – Cases are Submitted to Weekly
Resource Allocation Meeting, led by OP Service Manager
Outcomes –
• No Delays Incurred for Patients being Discharged with a Home Care Package
Within 6 Months of Commencement
• 703 people have been discharged through the Enablement teams
Challenges –
• Ensuring and Sustaining that Staff are in Receipt of the Right Training and
Support
• Access to Community Based Rehabilitation Staff
• Breaking Down Traditional Barriers
• Public Expectation
Old model
Patient referred to SWD
Current model
0 days
Patient assessed
10 days
Care manager
arranges package
10 days
Patient discharged
From hospital
20 days
total
Patient continues on
Long term package
No time
limit
Patient referred to SWD
0 days
Patient assessment
reduced to identify
core needs
5 days
Care manager
Contacts enablement
2 days
Patient discharged
From hospital
7 days
total
Patient progresses
Through enablement
programme
42 days
max
Patient discharged
on no services
Patient allocated
long term package
49 days
Improvement Steps
– Intermediate Care
Model • Introduced in 2008 providing a step down facility for older people in Dundee – 2 Year
Project
• 23 Bedded Unit Within a Private Care Home
• MfE Consultant Led, Screening for Admission by ESDS team
• NHS Staffing – Nurse Team Leader, Pharmacy, OT, PT and N&D
• Dedicated Input of Care Manager from Hospital Team
• Ethos of Slow Stream Rehabilitation and Enablement with Aim of Discharging
Patients Back to Home Setting
Outcomes • Average LOS 22 days
• Progressed to Include Step-Up from Community
• Approval to Continue with Bed Based Model April 2011 for Further 2 Years, Moving to
GP LES and AHP/Nurse Led Model
Challenges • Provision for people with dementia
• Earlier Identification of Patients in their Journey
• Working with an External Provider
• Culture and Expectations of Local Population and Staff
Improvement Step –
Moving Assessment
Model
•
Assessment started by social work staff on site in hospital.
•
Assessment continued through discharge route – Enablement, PICU prior to final outcomes
determined.
•
Targeted community resources for people who will potentially require residential care.
•
Planned increased service provision – tele-care, overnight care, social care and respite.
Outcome
•
Better outcomes for people.
•
Better and more accurate assessments.
•
Older people are not waiting in hospital for care with all the associated risks of lengthy stays.
•
Initial patients identified as requiring residential care have returned home safely and no longer
deemed as requiring residential care.
Challenges
•
Very early stages.
•
Public expectations.
•
Changing the culture within hospital – no early decision making!
•
Political buy in for the policy change.
•
Will not work if we cannot improve carer supports.
Future Challenges
• Widening the culture change in Health and Social Care
• Utilising technology creatively
• Rethinking services to meet the needs of people who have
dementia.
• Under 65 provision
• Public expectations
• Freeing up resources for future change
• Engendering a Person Focussed Approach to discharge and
independence
Reflecting on the presentations:
• Share experiences from your own Health Board
area / locality / site in relation to the part of the
patients’ flow discussed:
• What works well in your area / locality / site?
• What and who have been the drivers for this?
• What could work better?
• Who needs to be engaged?
• Where local practice could be improved,
consider how to utilise the evidence / learning
from the workshop to influence change.