€¦ · web viewevoc is able to play the ‘honest broker’ to ensure that best service or...

Local Opportunities for Older People:LOOPs Hospital Discharge Support Programme

Background Information:

We will be hosting a meeting to discuss this work on:

Tuesday, 8th March 2016 at 10:00 am to 12:00pm

EVOC Boardroom

14 Ashley Place, Edinburgh EH6 5PX

Introduction: What is it about?For most older people, following completion of health and social care assessments, the necessary care, support and accommodation arrangements are put in place in the community without any delay and people are appropriately discharged from hospital – families and unpaid carers play a crucial role in this – providing up to 95% of all routine care on the return home.

A delayed discharge occurs when an older person, clinically ready for discharge, cannot leave hospital because the other necessary care, support or accommodation for them is not readily accessible and/or funding is not available. This might be because family is at a distance or it has been difficult to secure a care home place.

Particularly for older people, discharge delays can result in increased dependency and a loss of confidence in a personal ability to cope, making long-term institutionalisation more likely. It also increases the incidence of depression, loss of choice and control. It raises the likelihood of an older person contracting a hospital-acquired infection and greatly increases the possibility of a stoppage or breakdown in any community supports that were in place prior to going into hospital.

The challenges around hospital discharge have been well rehearsed and, as part of what we often viewed as ‘system’ challenges, it can feel as though the individual older people who get caught up within discharge delays are overlooked. From your current work, you will be more than aware of how these system challenges impact directly upon our older citizens.

What do we want to do? NHS Lothian and City of Edinburgh Council are currently redesigning the way that services are delivered, both within the four new localities, as well as under the umbrella of the new Edinburgh Health and Social Care Partnership (also known as the Integration Joint Board (IJB)).

This funding stream is about making sure that the Third Sector, and Third Sector services and activities, culture and practice, attitudes and knowledge are integrated into these

A

Local Opportunities for Older People

changes to build a more holistic, real-world, can-do system which is able to integrate all of the community needs of older people into hospital discharge and that you are able to work with older people at the earliest possible opportunity to ensure that community supports are in place.

To achieve this, we will be recruiting local anchor organisations who will be funded to place staff within the hospital discharge hub and/or the new locality hub (further info on this below) to coordinate this work.

These staff will work with health and social care staff to assess and support local older people within the hospital environment – to begin the preparatory work around discharge, then – from the locality hub – continue to coordinate support on their return to the community and, importantly, facilitate timely interventions if things begin to go wrong.

Why is EVOC involved? Funding has now been identified though the Integrated Care Fund. EVOC has taken a lead role in this work in our capacity as a partner within the Third Sector Interface and will be working to ensure the project is delivered in an equitable way across the city.

By equitable, we mean that we need to see that each of the projects within each of the Localities is able to achieve the same level of support but also that there is impartiality within the referral routes that project staff choose. EVOC is able to play the ‘honest broker’ to ensure that best service or activity is chosen for the older person in question and that those choices are person-centred.

EVOC is also able to take a strategic role: this involves working with the widest range of providers, across localities and across sectors to ensure that the project is meeting its targets and remains relevant.

EVOC’s role will be to:

Support overall coordination of the programme. Establish overall governance and deliver financial management to the programme. Act as an interface between funded organisations and our statutory partners. Support evaluation of the programme, in partnership with Scottish Government’s

Information Services Division. Identify additional/continuation funding.

Size of the problem? Overall within the hospital system, it is estimated that approximately 10% of all beds are ‘blocked’ in some way at any given time. This figure is somewhat artificial, in that approximately 50% of those blockages are internal to the system, for example, when somebody needs to be transferred from the Western General to the Astley Ainslie hospital. Ultimately however, the remaining 50% of internal delays will most likely be the result of an external delay – such as a delay ordering a package of care.

Edinburgh Voluntary Organisations' Council is a company limited by guarantee No. SC173582 and is a registered Scottish charity No. SC009944. Registered Office: 14 Ashley Place, Edinburgh EH6 5PX


Within the City of Edinburgh, as at January 2016, there were a total of 1221 people delayed in hospital. The causes of these delays are listed as:

Awaiting Community Care Assessment 30Patients waiting to go home 66Awaiting funding for care home placement -Awaiting place in care home 26Healthcare arrangements -Other -

The lengths of these delays are detailed in the graph below:

>3 days to 2 weeks

>2 to 4 weeks >4 to 6 weeks More than 6 weeks

0

5

10

15

20

25

30

35

40

45OtherHealthcare As-sessment / Ar-rangementsAwaiting funding for a care home placementPatients waiting to go homeAwaiting place availability in a care homeCommunity Care Assessment reasons

Duration of Delay 1

Num

ber o

f pat

ient

s

Delays aren’t limited to the acute hospital setting. A large number of older people leave hospital and will first be supported by a Reablement team and then provided support on a longer term basis by either Home Care or a Care at Home provider or by family and friends or other unpaid carers. Alongside these services, medical support within the community can be delivered by a range of Community NHS services including Intermediate Care, District Nursing and Allied Health Professionals (AHPs) (e.g. physio, OT).

From time to time blockages develop within these services. If there are blockages within, for example, Reablement then it might be the case that an older person will immediately move on to a package of care, delivered by a Care at Home provider. Reablement provides a crucial support to older people, who experience much better success in their return to the community if this service is taken up.

Delays will also be impacted by the destination following discharge. The table and chart below detail discharge destinations following discharge with the opening of Gylemuir indicated at December 2014 (purple line).

1 These figures exclude ‘code 9’ delays which are designated as outwith the control of the NHS Board or City of Edinburgh Council. Edinburgh Voluntary Organisations' Council is a company limited by guarantee No. SC173582 and is a registered Scottish charity No. SC009944. Registered Office: 14 Ashley Place, Edinburgh EH6 5PX


City of Edinburgh

Issue Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15

Awaiting residential care/nursing home 52 64 66 67 67 63 82 61 71 43 43 34 39 40

Awaiting domiciliary care 14 33 44 35 38 20 30 21 41 27 28 40 52 62

Delayed Discharge in Edinburgh - Action Plan - Monthly Performance

0

10

20

30

40

50

60

70

80

90

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15

Axis

Title

Delayed Discharge in Edinburgh

Awaiting residential care/nursing home

Awaiting domiciliary care

Opening of Gylemuir

Background: Within each of the new localities, the Edinburgh Health and Social Care Partnership, NHS Lothian and City of Edinburgh Council’s Department of Health and Social Care has begun the development of ‘Locality Hubs’.

The staff within the Locality Hub, paired with the Discharge Hubs within each of the Acute hospital settings, will provide additional, rapid-response support to older people within the community to ensure that people are able to get home from hospital as soon as possible and that people who experience difficulties are supported to stay in the community.

EVOC has been working closely with the Locality Managers for Health and Social Care, as well as with Senior Managers within NHS Lothian to ensure that the Third Sector is fully integrated into this new support structure.

To achieve this new work, the Integrated Care Fund Partnership has provided an investment. This will be a one-year fund, which must demonstrate clear outcomes for people by a month-nine review in order to be considered for further investment.

The LOOPs Hospital Discharge Support Programme builds upon the successes and infrastructure of the LOOPs Community Projects, which include the LOOPs Phoneline and a range of on-the-ground Community Navigation initiatives.

We believe that this work will be a first in Scotland, in that it builds a coherent single interface for the Third Sector into the hospital environment, with the support of both Health and Social Care colleagues, and which will see the delivery of an end-to-end service to improve discharge efficiency and supports for older people.

The programme will work to achieve a number of aims on a number of levels: for older people themselves, as well as for the Health and Social Care system but also takes on a range a learning outcomes



These are still in development and will be clarified by doing the work but include:

Target: Outcomes Older People: Ensure that older people stay for as short a time as possible in hospital.

Ensure that, subsequent to discharge, older people are best supported to remain in the community.

Reduce avoidable admissions. The Sector: Improve integration of Third Sector culture and activities within Statutory

services. Improve uptake and develop additional opportunities for cross-sector

partnership working. The System: Reduce levels of delays within hospital and other settings.

Improve knowledge of, and exposure to Third Sector practice. Influence the development and delivery of future services.

In addition to these practical outcomes we will need to demonstrate impacts against the following learning outcomes:

Improved understanding of Third Sector culture, practice and activities. Identify key benefits, challenges and opportunities of cross-sector working. Identify gaps in services and capitalise upon opportunities to improve access.

The work to be carried out will be additional to the work carried out by Statutory Sector colleagues, but will be delivered in very close partnership and will employ a ‘matrix management’ approach.

To achieve this EVOC, will be working with local providers to begin a process of identifying organisations who would be in a position to develop elements of the project within each of the localities and to work with local partners to develop expedited, local referral pathways.

Scope: The project will take on two initial core roles:

Acute Care Settings: Within each of the Acute Hospital settings there will be a Third Sector Hospital Liaison Worker. Based at the Discharge Hub, this individual will work with older people while they remain in hospital to provide initial support, build individual capacity and knowledge as well as ensuring that discussions are taking place about referrals to existing Third Sector supports within that older person’s local community. Referrals will be made to The Carer’s Hospital Discharge Service.

This role will additionally work with other local providers to expedite the practical elements of that journey home through the development of a ‘Hospital 2 Home’ service. This will work by ensuring that milk and basic food items are in stock, heating has been turned on and by making sure the person has a supported way to get home.



We have funding for 1.3 FTE staff for this role for the first year. These will be located as follows:

0.5FTE Western General Hospital (working within the Discharge Hub) 0.5FTE Royal Infirmary Edinburgh 0.3FTE

(floating)Royal Edinburgh Hospital St. Johns Hospital

We are currently recruiting organisations to deliver this work. Please see below for management and application arrangements.

Community Settings: Within each of the Locality Hubs there will be a Discharge Support Development Worker. This individual will work with people once they have left the hospital environment to coordinate on-going support focussed on remaining well within the community.

They will also work within the wider Multi Disciplinary Team within the Locality Hub and the Third Sector Hospital Liaison Workers, to ‘pull’ people out of hospital by ensuring that community supports are put in place as early as possible.

At each of the Locality Hubs, at 9am, there will be a Multi Disciplinary Team Huddle of community staff located within or working alongside the Locality Hub. This meeting will be a fast-paced opportunity to input Third Sector solutions to hospital discharge challenges and to gather referrals which will need to be handled in an expedited fashion.

By building this social bridge alongside the medical/social care bridge, we believe that we can both significantly improve the quality and speed of discharges for older people, as well as demonstrate the value of Third Sector interventions that will stand your organisations in good stead for the future.

In addition to this direct work with older people, it will be the responsibility of Discharge Support Development Workers to develop clear, coherent and expedited pathways into existing Third Sector services within the community. This will support earlier discharges.

These pathways will include (for example):

Falls, Reablement and Exercise. Individual Long Term Conditions (e.g. COPD), Wellness and Self Management. Day Care services and lunch clubs. In-home community based service delivery (e.g. Library Link). Social Re-ablement (e.g. Community Connecting). Befriending and Social Support. Advice and Information (e.g. benefits, pensions and housing support). Legal Information (e.g. Power of Attorney). Strengthening Local Social Supports.



We have funding for 4 FTE staff for this role for the first year. These will be located as follows:

1FTE North East: Leith Community Treatment Centre1FTE South East: Royal Infirmary Edinburgh1FTE South West: Wester Hailes Healthy Living Centre 1FTE North West: North Neighbourhood Office (W. Pilton Gdns.)

We are currently recruiting organisations to deliver this work. Please see below for management and application arrangements.

Management Arrangements: It is crucial that we will are able to demonstrate the value of this work within the 2016/17 financial year and that we are able to maintain oversight of the whole project – including remaining flexible to the on-going changes that will take place within this project as a test of change.

To ensure equal delivery across the city the work will be coordinated as a single team using a matrix management approach and delivered as an collective of providers.

This reduces duplication of effort, overall costs and will strengthen continuity of care while ensuring that local intelligence and know-how is included within the development and delivery of the service.

To achieve this, we are recruiting local organisations who would be able to support the following structure:

The LOOPs Steering Group will provide overall governance and will be answerable to the Older People’s Executive Redesign Group and through that group to The Integrated Care Fund Core Group.

An Operational Group will be assembled from providers’ management to support the Team Leader alongside input from EVOC’s existing Development Worker (Reshaping Care for Older People (RCOP)).

The Team Leader will deliver fortnightly team meetings for front-line staff which will form the team’s connection to the governance of the project.

Clinical Management will be coordinated in partnership with City of Edinburgh’s Dept. of Health and Social Care, EVOC and local providers.

Matrix Management:

The diagram below shows the matrix management approach.



Development: To ensure that we are able to get an early start on this work and to develop the management and information systems for this project, EVOC will be recruiting the Team Leader post within the next weeks.

This staff member will initially be working in the South East Locality Hub and will carry out much of the early development work. During this time EVOC will be recruiting additional organisations to deliver the work in the South West, North West and South East Locality Hubs and the Acute Hospital settings.

Once these organisations are recruited, the Team Leader will move to begin the development role in the North East, with a second organisation taking on the developed work in the South East.

The Locality Hubs and other arrangements in the various localities are at different stages of development. The first Locality Hub is currently being tested within the South East, so it is here that the work will begin, the rest of the work will follow from this development with the South West likely to be next.

With development taking place within the South East and South West of the City, while we will be recruiting for all parts of the work, there may need to be some phasing of the start dates of the projects. During this time we will split the city into two parts: East and West.

The EVOC Team Leader will work across the East of the City until the beginning of the development within the North East which will see the recruitment of an organisation to deliver the work in the South East locality.

In the first instance we are looking for applications from geographically relevant providers



within the locality and/or who have demonstrable experience of delivering a locality based project, at pace, on time and within budget.

Role Details: The roles of the first two posts to be recruited have various elements that must be achieved, many of these take place on a daily or weekly basis.

Both within these tasks, in the detail of how the tasks/outcomes are delivered and outside these tasks, in terms of additional work to achieve the overall outcomes of the project, there is scope for individual providers to carry out their work in their own ways.

We want to be sure that the work will be well supported and that it has opportunity for innovation and experimentation: through this innovation we expect to see that there are differences within and between localities.

We will require that this innovation and the learning from both successes and failures be recorded and shared at team meetings.

Acute Setting: Within the Acute setting the Third Sector Hospital Liaison Worker will work with relevant staff within the ward and will be based within the Discharge Hub as part of City of Edinburgh Council’s Health and Social Care Team.

The general outline for this work is still in development and will remain subject to review throughout the project as part of the test of change. However, the general tasks will involve working with people to expedite a confident return to the community and to work with the Hospital Discharge Support Worker to consolidate these gains. This will include referrals to relevant providers, support to prepare for the return home and coordination of any relevant hospital to home services.

The people with whom your project would work will, mostly, be those people who have been identified during the 9am Huddle at the Locality Hub and communicated via the Discharge Support Development Worker.

Alongside these hands on tasks, we will be asking staff across the project to participate in an awareness raising and training programme to improve knowledge of the Third Sector across our statutory partners.

Community Setting: Within the Locality Hub, the morning will largely be taken up with the detail of the Huddle meeting which takes place at 9am and making appropriate referrals to local agencies. The afternoon will be devoted to ensuring that previously discharged patients are getting their needs met within the community using a loose case-management approach.

Much of this work will be able to take place by telephone but there will be an amount of visiting involved with the role. Edinburgh Voluntary Organisations' Council is a company limited by guarantee No. SC173582 and is a registered Scottish charity No. SC009944. Registered Office: 14 Ashley Place, Edinburgh EH6 5PX


TIME: TASK: PURPOSE: 8am9am LOCALITY HUDDLE (daily, compulsory) Identify suitable referrals.10am Contacting local providers about this morning’s cases

(compulsory) 11am12am1pm2pm3pm4pm5pm

Outwith this allocated time in the mornings, which is crucial to coordination, the Development Worker’s time will be available to:

Visit existing clients: workers will approach this role in a loose case-management method. We are keen to see that there is frequent follow-up with clients to ensure that any problems are picked up early and handled quickly.

Development Work: the development work involved within the project is included below but includes delivery of in-service training and awareness raising about Third Sector provision, development of a volunteer Hospital 2 Home service and development of local expedited referral pathways.

Admin, Support and Supervision, Team Meetings.

Governance: With a project of this kind, which works closely with vulnerable adults, and for which we need to deliver at pace in order to demonstrate the value of this kind of work, we need to maintain strong governance.

Ultimately the project will be responsible to the Older People’s Executive Redesign Group and the Integrated Care Fund Core Group, though the following structure:

Governance Structure Integrated Care Fund Core Group

Older People’s Executive Redesign Group Locality Hub Steering Group Locality Hub Operational Group

LOOPS Steering GroupEVOC RCOP Development Worker

LOOPs Hospital Discharge Operational Coordination Group EVOC Hospital Discharge Team Leader (North East)

SW Team NW Team SE Team RIE Acute WGH Acute REH/SJH Acute

Evaluation and Learning:



With a project of this kind, with a focus on testing change, it is crucial that we are able to maintain retain excellent evaluation and monitoring data about what goes well, but we will also need to know what hasn’t gone so well.

Evaluation will be led by EVOC, in partnership with ISD. This information will be used to ensure that the project stays on track but also that we are able to produce a key learning document/tool kit for providers elsewhere in Scotland.

We will be able to discuss this further at the meeting on Tuesday, 8th March 2016.


Milestones:

Task

Jan. 16

Feb. 16

Mar. 16

Apr. 16

May 16

June 16

July 16

Aug. 16

Sept. 16

Oct. 16

Nov. 16

Dec. 16

Jan. 17

Feb. 17

Mar. 17

Provider

Ow

ner

Initial Funding: EVOC SM/IBInitial Development: EVOC SM/IBDevelop Evaluation Procedures: EVOC SM/IB/TL*Funding Event: 8/3 EVOC SM/IB

Application Period: 22/2 21/3 EVOC SM/IBLOOPs Steering Group: EVOC SM/IBDevelop Internal Systems: EVOC SM/TL*Develop Shared Systems: EVOC SM/TL*Funding Offers: EVOC SM/IB

SE Test of Change Start: Launch 1/4 IJB KMcW/NC

EVOC East Project: Development (Launch 1/4) Implementation EVOC SM

SW Locality Hub Start: ? ? IJB DW/EHRecruitment of Project Staff PROJ. ?Develop Local Pathways: Development Implementation EVOC TL*

Develop H2H Service: Development Implementation EVOC TL*

Develop Workforce Development: Development Implementation EVOC TL*

NW Locality Hub Start: ? ? IJB MG/MG

NE Locality Hub Start: ? ? IJB AG/EB

Additional Project Staff in Post: Assumed PROJ. ?

Project Review: 30/6 30/10 PROJ. ?

Project Reporting: 1/1 EVOC SM/TL*

Integrated Care Fund Core Group: ? IJB RMcGExit or continuation funding: Investigate additional funding SG SM/IB

TL = EVOC North East (East) Team Leader.SG = LOOPS Steering Group


Further information:

Localities:

As of April 16, Health, Social Care, Police and other services will begin to work toward the new Locality structure which has been agreed through the Edinburgh Health and Social Care Partnership in line with legislation related to the development of more integrated services.

To find out more about Integration or hospital discharge, please see the following pages. Transform Edinburgh:http://www.edinburgh.gov.uk/transformedinburgh/site/index.php

Scottish Government Integration of Health and Social Care: http://www.gov.scot/Topics/Health/Policy/Adult-Health-SocialCare-Integration

Information Services Division:http://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Publications/data-tables.asp?id=1604#1604

Audit Scotland, Moving On? An overview of delayed discharges in Scotland, June 2005: http://www.audit-scotland.gov.uk/docs/health/2005/nr_050623_delayed_discharges.pdf

Scottish Government: Delayed Discharge. http://www.gov.scot/Topics/Health/Quality-Improvement-Performance/NHS-Performance-Targets/Delayed-Discharge


http://www.gov.scot/Topics/Health/Quality-Improvement-Performance/NHS-Performance-Targets/Delayed-Discharge

http://www.gov.scot/Topics/Health/Quality-Improvement-Performance/NHS-Performance-Targets/Delayed-Discharge

http://www.audit-scotland.gov.uk/docs/health/2005/nr_050623_delayed_discharges.pdf

http://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Publications/data-tables.asp?id=1604#1604

http://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Publications/data-tables.asp?id=1604#1604

http://www.gov.scot/Topics/Health/Policy/Adult-Health-SocialCare-Integration

http://www.edinburgh.gov.uk/transformedinburgh/site/index.php


British Medical Journal:http://www.bmj.com/content/326/7395/927.full

For further information about this funding stream and the work to be carried out, please contact:

Stefan Milenkovic Development Worker (Reshaping Care for Older People (RCOP))

EDINBURGH VOLUNTARY ORGANISATIONS’ COUNCIL 14 Ashley Place

EDINBURGH, EH6 5PX 0131 555 9100

[email protected]


mailto:[email protected]

http://www.bmj.com/content/326/7395/927.full

€¦ · web viewevoc is able to play the ‘honest broker’ to ensure that best service or...

Documents