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 peopleDecreasing populationArea of high deprivation

• Hospital Model - Pre 2009/2010Ninewells Hospital serves the acute requirements of the population of Dundee City and Angus5 MfE Assessment and Rehabilitation wards in Royal Victoria HospitalNo Community Hospital Model

• Social Care/Social Work Model – Pre 2009/2010Establish Early Supported Discharge but targeted at specific wardsSocial Work Teams chasing services for discharge Separate Adult Services/Older People hospital Teams – different referral /assessment proceduresHigh number of people admitted directly to care home from hospital

• Reactive ResponsesFocussing on patients delayed longest in systemProblem solving at point of trigger (ie pre census date)

• Culture of Acceptance of DelaysFamilies and staff ‘expected’ to be delayed for up to 6 months in hospitalUse 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

At Risk SupportVirtual Ward - multi agency team approach.Care ManagementCase ManagementCare HomesHospital Care

Universal ServicesHealth Leisure & CommunitiesHousingVoluntary SectorPrivate Sector

Mainstream Extra SupportSocial Work ServicesCommunity RehabilitationEnablementIndependent Living & Equipment CentreSheltered Housing

Targeted Extra SupportComprehensive Geriatric AssessmentDay ServicesDay HospitalIntermediate CareIntensive Home CareVery Sheltered Housing

Pipeline ApproachThe 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.

Integrated Assessment FrameworkSingle Shared AssessmentIntegrated Care RecordEnd of Life Pathway

Self Determined

Physical & Mental Health Decline

Life Crisis

Significant Illness

Palliative Care

“AS IS”

Self Care/Self ManagementDirect AccessAnticipatory CareHealthy Communities

Mainstream Extra SupportEnablement Approach for AllRehabilitation at HomeTele-health Tele-care

Targeted Extra SupportIntermediate Care - step-upDay HospitalCommunity Geriatric Care

At Risk SupportVirtual Ward approach across city.Assessment in Appropriate Setting

“TO BE”

Complex Needs

Targeted Multi-agency

Care

Mainstream Additional Support

Universal Services and Self-Care

Dundee Integrated Care Model for Older People

Liv

ing

In

dep

end

entl

y

User & Satisfaction

Faster Access

Support for Carers

Quality of Assessment

& Care Planning

IdentifyingThose at Risk

Moving Services Closer to

Users/Patient

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 agreedOutcomes –• 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 rateChallenges –• 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 ManagerOutcomes – • 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 teamsChallenges – • 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 Current model

Patient referred to SWD

Patient assessed

0 days

10 days

Care manager arranges package 10 days

Patient dischargedFrom hospital

20 daystotal

Patient continues on Long term package

No time limit

Patient referred to SWD

Patient assessment reduced to identify

core needs

Care manager Contacts enablement

Patient dischargedFrom hospital

Patient progressesThrough enablement

programme

0 days

5 days

2 days

7 daystotal

42 daysmax

49 daysPatient allocated long term package

Patient discharged on no services

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 SettingOutcomes - • 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 ModelChallenges - • 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.