Mid Highland CHP
Governance Committee
23 April 2010
DELAYED DISCHARGES – REPORT TO MID HIGHLAND CHP
GOVERNANCE COMMITTEE
APRIL 2010
1
CURRENT POSITION
As at 5 April across the whole of the CHP there are 14 patients experiencing delays, of which 5
are breaching 42 days (4 complex care patients, 1 awaiting social care arrangements for
specialist housing provision) The total number is broken down as follows:
7 patients in CCHI (1 awaiting commencement of assessment, 1 awaiting completion
of assessment, 1 awaiting placement, 4 complex care).
2 patients in RMH (1 awaiting commencement of assessment, 1 awaiting social care
arrangements for specialist housing provision)
2 patients in Lochaber (1 awaiting commencement of assessment, 1 complex care)
3 patients in Skye (2 awaiting commencement of assessment, 1 exercising choice)
The overall figure reflects a decrease since the last report in February (18 patients). However
the number of complex case patients experiencing delay has risen from 1 to 5.
No patients are currently awaiting funding.
2
ACTION PLANS TO ADDRESS

A virtual ward round is being held weekly with Martin Wilson, Consultant, Medicine for
the Elderly. Looking in detail at patients most likely to be admitted from the community,
i.e. those being case managed and those involving ACAH. This facilitates early
identification and prevention of hospital admission and ultimately any discharge issues

There are plans in place to ensure continuity of CHP representation at the Raigmore bed
meetings to facilitate timely and appropriate transfer and discharge.

The Community Mental Health Teams continue to work with the day hospital based in
Fyrish ward to support people with dementia type illness to remain at home for as long
as possible.

Work is ongoing to identify the position and address inappropriate admission of patients
who are referred because their social situation has broken down.

The multi disciplinary teams continue to meet weekly to discuss and plan all discharges
in all the hospital wards in this area. Estimated dates for discharge are set as quickly as
possible following admission and used as the benchmark for discharge planning. Again,
anticipatory care plans are being developed to minimise unnecessary readmission.

Monthly meetings continue to take place with Social Work team leaders and ward
charge nurses to facilitate escalation/resolution of difficult issues. These include
facilitation of the appointment of care managers and problem solving in relation to care
at home issues. This is in addition to the weekly MDT meeting at ward level which
involve all the parties involved in patient care. Ward staff are now routinely phoning the
emergency social work number if requests are taking place for admission to hospital for
apparently ‘social’ reasons.
3

The use of anticipatory care plans, SPARRA and the roll out of case management
across the localities in 2010 will also contribute to the reduction in admission and delays
in discharge.

Following on from the workshop held in September to understand length of stay in the
Ross Memorial, work is being carried out to revisit referral processes and admission
criteria for the hospitals.
EXPECTED IMPACT OF ACTIONS ON PERFORMANCE
Reduction in length of stay and proactive management of long term conditions using
anticipatory care plans.
Prevention of avoidable hospital admissions.
4
FORECAST OF RETURN TO PLANNED PERFORMANCE (ie Trajectory)
Realistically, in the current Highland Council financial climate this could be challenging.
Forecast is therefore difficult.
Ongoing collaboration and co-operation between health and social work services at all levels is
required to ensure success.