North East High Impact Change Model (HICM) Event 2 October 2018, - - PowerPoint PPT Presentation

North East High Impact Change Model (HICM) Event

2 October 2018, 09:30-13:00 The Durham Centre, Durham

Introductions and reflections on the North East journey in respect

• f HICM

Fiona Brown - DASS, Sunderland City Council

Managing Transfers of Care A National Overview

Glasha Frank - Department of Health and Social Care Martha Dalton - Department of Health and Social Care

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MacGregor, Calum, 12/09/2018

Behind every Delayed Transfer of Care, there is a person, in the wrong place at the wrong time A ‘delayed transfer of care’ occurs when a patient is ready to leave a hospital or similar care provider but is still

• ccupying a bed.

DTOC – the story so far

DTOC has been a persistent problem over many years (national reports into DTOC since early 2000s) More recently….

• National Audit Office Report (2015) - Discharging older patients from hospital

– 5% muscle strength that older people can lose per day of treatment in a hospital bed – £820m gross cost to the NHS of older patients in hospital beds who are no longer in need of acute treatment.

• National Strategy to address DTOC

– Care Act (2014)

• Legislation outlining LAs duty in relation to assessing people’s needs and their eligibility for

publicly funded care and support – BCF National Conditions (New condition 4 (2017)

• Requirement for Social Care to work with NHS to implement High Impact Change Model to

manage delays in transfer of care (expectations published)

• iBCF monies

– NHS Five Year Forward View Next Steps

• Mandate for NHS to work with Social Care to reduce DTOC

– CQC Local System Reviews (interface of Health and Care) – Increased collaboration centrally between national partners

• Delayed Discharge Programme Board - Strategic (DHSC, NHSE/I, LGA, ADASS, MHCLG,

CQC, BCST

• Discharge Steering Group - Operations (NHSE/I, DHSC, LGA ADASS, BCST, MHCLG)

• There has been significant improvement in DTOC over the past 18 months

– in the face of persisting challenges (workforce, finances/austerity, commissioning complexity)

• By far, the most critical and important work has come from YOU

(frontline colleagues)

0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 1,000 2,000 3,000 4,000 5,000 6,000 7,000

% of occupied consultant-ld beds Number of delayed days

Underpinning the data are numerous examples nation-wide, of health and care colleagues going above and beyond the call of duty, working together to ensure patients are not delayed unnecessarily in hospital – THANK YOU!

DTOC – the story so far

Despite the significant progress…

• 4500 patients still in hospital every day (who don’t need

to be there)

• we have to keep up the work nationally, locally and

individually. Nationally - a focus now beyond DTOC to reducing delays through out the entire patient journey

• Ambition to reduce DTOC to 4000 beds by the latter part
• f 2018
• Ambition to reduce extended length of stay
• Provide support to local systems

DTOC – the story so far

National Support

Providing support to systems so that people get the right care, right place and right time and encouraging the development of home first principles Programmes

• 1. Enhanced – 14 system reviews across 9 areas to really understand why

transfers of care remain a challenge

• 2. Targeted – Tailored Peer Reviews to meet the needs of the system
• 3. Universal – HICM regional events, Learning from CQC events, Why not

home, Hospital Discharge/Home First Practitioner Events Tools (Links included)

• Better Care Exchange / Bulletins
• LGA Guidance documents
• Webinars
• DTOC Improvement tool (NHS Improvement)
• Quick Guides (NHS Improvement)
• HICM (see next slide)

• It was developed by national partners in 2015 to promote a

new approach to system resilience and year around planning for timely discharge

• The model identifies eight system changes which will have

the greatest impact of reducing delayed discharge Why refresh the HICM

• To take account to new national guidance, address

persistent implementation challenges and align guidance to reducing extended length of stay, improving patient flow and early intervention and prevention agenda.

High Impact Change Model

• We are keen to understand and collect an

evidence base on what works and why some areas are challenged than others.

• We know that local leadership and collaborative

working, investment in workforce and investment do have a role to play.

• We are also keen to explore whether a

combination of national, local and regional support in this area works best

Understanding what works

Trusted Assessor – Lincolnshire Model and developing an approach to Trusted Assessment

Michele Briggs - Lead Care Home Trusted Assessor, Lincolnshire Care Association

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Trusted Assessments

Michele Briggs Lead Care Home Trusted Assessor Lincolnshire Care Association Developed with John Woods Improvement Manager (Social Care)

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Trusted Assessor Trusted Assessment A real world example Getting Going/ Checklist Myth Busting

Agenda

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What is A Trusted Assessor? What is Trusted Assessment?

• A person carrying out an assessment on

behalf of a third party

• A Trusted Assessor completes a bespoke

and agreed assessment for a specific purpose.

• Using an assessment that was designed

for one purpose to serve another.

• A Trusted Assessment is completed for
• ne purpose but also used for a second

purpose with the agreement of both

parties.

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Examples

• Transfers from hospital to an

existing support package.

• Transfer of patients to an

interim support package e.g reablement or intermediate care.

• New admissions to residential

care & New packages of domiciliary support.

• Care Act Assessments.
• Assessments for occupational

therapy equipment.

• Anywhere else you want to

chase delays out of a process

16 |

How we do it in Lincolnshire

Care Home Trusted Assessor

(CHTA)

Working together to improve transfers from hospital to care homes

CHTA in Context

Common Problems:

Delayed Discharge Lack of Trust between acute sector and care providers Workforce capacity – skills and capacity throughout the system

ONE possible solution – Care Home Trusted Assessor

Care providers as part of the solution not the problem Simple but effective

Not the only solution

Other trusted assessment

Can be used standalone, or as part of a more compressive solution

Job Description

DOES

Undertake Care Home Pre Admission Assessment Liaise with Care Home Record/report to stakeholders

DOES NOT

Complete Statutory Assessments Choose or influence choice of Care Home

Recruitment

Person Specification

Integrity Communication Experience on both sides of the discharge

Methodology

Raise Awareness Indeed NHS Jobs Word of Mouth

Cost vv Benefits

Annual cost for 1 FTE (6+days) approx. £60K including allowance for managing

service

Allow for non-productive start (2-4 weeks) trust from care homes is essential Savings per Excel Model available

Developing the Care Home Trusted Assessor Role

Key factors of our success to date – OWNERSHIP brings TRUST

Assessor is answerable to (ideally employed by) the Care Home Sector Service is available to all, but not mandatory Care Home documentation is used where appropriate CHTA must not place individuals Independence from all parties – individual care homes can be challenged if appropriate

Recognising the importance of the information collected

Granular level information about delays Trends spotted in a timely manner (end of the week not the quarter)

Statistics per average month – 1.5 FE

80 referrals 66 Assessments Completed 64 discharges Total days saved 250 Total Savings £80K (Net)

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The way forward

• You need relationships to build trust
• Co-designing with all stakeholders can

build the relationships

• Agree a set of common/shared
• bjectives for the trusted assessment

service

• Borrow and adapt other peoples’ ideas
• Agree
• What kind of assessment will be

included in the service

• Competencies and put in place

training requirements

• How the service will be measured
• Find the funding
• Start slowly and grow

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Mythbusting

What have you heard?

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Questions

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• MicheleCHTA@linca.org.uk
• john.woods2@nhs.net / john.woods.consulting@gmail.com
• Rapid Improvement Guide
• https://improvement.nhs.uk/resources/rapid-improvement-guide-trusted-assessors/
• Trusted Assessments - Essential Elements
• https://improvement.nhs.uk/resources/developing-trusted-assessment-schemes-essential-

elements/

• Quick Guides
• https://www.nhs.uk/NHSEngland/keogh-review/Pages/quick-guides.aspx
• Better Care Exchange
• https://future.nhs.uk/connect.ti/system/login?nextURL=%2Fconnect%2Eti%2Fbettercareexch

ange%2Fview%3FobjectId%3D9820976#9820976

Further Information / Help

Putting arrangements in place for effective Discharge to Assess

Gemma Umpleby - Hambleton, Richmondshire and Whitby CCG Cara Nimmo - North Yorkshire County Council

Hambleton, Richmondshire and Whitby Integrated Discharge Pathways

Background

National Agenda

• Performance monitored as part of the HICM: Home

first/discharge to assess, Trusted Assessment

• Reduce DTOCs and LOS

Local Targets

• Consultation – ‘Transforming our Communities’ provided a

mandate to develop new models of care closer to home

• Poor performance against NHS England target of no more than

15% of DSTs undertaken in an acute trust

• Discharge to Assess for ALL patients

Patient no longer has care needs that can only be met in an acute hospital

Pathway 1 Home with Support

Pathway 2 Pathway 3

Patient needs can be safely met at home Unable to return home- Patient requires further rehabilitation/reablement Unable to return home- Patient has very complex care needs and may need continuing care Integrated Locality Team Up to 6 weeks

Community Based Beds

DTA/Nursing Home bed DST TO ESTABLISH EXPLICIT CHANGE OF FUNDING Self Fund/Self Care LA Funded Home Care Pathway 1 LA Funded Residential Care LA Funded Care CHC Funded Care Self Fund Residential Care Self Fund/ Self Care at home Self Funded Care

THE D2A Model

Transport: 365 Response

Pathway 1

Home

TA TA

FNC Including patients suffering a delirium episode

So for everyone…

• Pathway 1
• Pathway 2
• Pathway 3

Trusted Assessment = One referral process One Form One assessment

TRUSTED ASSESSMENT

Intermediate care & NYCC complete assessment. Patient discharged home Pathway 1 Home with support Intermediate care & NYCC to deliver support for limited period

Trusted Assessment

Patient medically optimised for discharge Home from hospital Service – Provided By AGE UK

Pilot November 2018: MOU Agreement NYCC and Trust Risk Analysis Regular Communications Culture change – “the in-perfect package”

Pathway 2

Patient discharged to SUSD Bed Support from ILT 7 days a week and in house care team, goal to reach functional

• ptimum

Reviewed weekly Week 3 If no progress made or deterioration – consider need to complete DST checklist Week 3 (and progress made) Social Care Assessment to inform Discharge planning Pathway 1 Home FNC Not eligible for CHC – social care package Self-fund (support family ref next steps)

DST Outcome Funding

DST/ Social Care Assessment to determine

• nward funding responsibility

6 Weeks Health Funding Monitoring in place

Patient medically optimised for discharge Social care assessment /DST if req’d Fully funded CHC Discharge plan

Trusted Assessment

Discharge Home if appropriate DST Checklist

Pathway 3

Friary

(2 ring- fenced beds, all beds can be considered)

Community Team receive TA to trigger visit within 48 hours. Community team to deliver Rehab/ reablement plan with goal to reach functional

• ptimum .

Requirement for a CHC Checklist as part of weekly reviews if not already completed. Patient medically optimised for discharge

Utilise pre booked DST Slots

Discharge plan agreed through MDT & Family informed of discharge destination to D2A Bed

Patient/ Family Leaflet

Benkhill

Whitby Hospital

CCG informed by Discharge Facilitator

• f

placement and Patient transferred to Discharge to Assess Bed.

Discharge Facilitator identifies provider

Trusted Assessment (SPoR Referral Form)

DST completed (within 28 days of CHC checklist)

CCG notified

• f

funding

• utcome

& date

• f DST

Ward team deliver Rehab/ reablement plan with goal to reach functional optimum . Requirement for a DST Checklist as part of weekly reviews.

Community Bed Base Step Up/ Step Down Beds (Referral to Coordination Service)

8

Non – Commissioned Services Patient identified as unsuitable for community bed (justification documented) Patients NHS Number and justification sent to CCG

CCG considers Spot Purchase Placement & approves if appropriate (CHC approved provider list only)

CHC Checklist completed in Acute Setting prior to transfer

CCG confirm date NHS funding ceases (maximum

• f 5 working

days post DST assessment)

All transferred Patients to be discussed on the weekly conference call Tuesdays 12pm (Minimum representation : NYCC, CHC, SPoR, CCG) CCG to receive completed monitoring requirements from each agency each Tuesday following the call DST completed within 28 days

• f CHC

checklist.

DST Assessments

• Since the introduction of D2A (mid August 2017) the average number of referrals for DST’s have reduced

by 30%.

• The outcomes of DST assessments has changed ( monthly averages):

– 14% reduction in fully funded patients – 37% reduction in patients awarded Full Nursing Care – 100% reduction in patients fast tracked following assessment – 38% reduction in patients identified as not eligible for funding once assessed

1 2 3 4 5 6 7 8 9 10 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Fully Funded FNC Fast Track Not Eligible

Outcomes of DSTs

• Enables a period of recuperation within a homelike environment
• Reduced level of need for long term funding
• Fewer patients are going through the CHC assessment process
• Patients who are transferred to a Spot Purchase bed are high need patients who require

complex care packages - 85% of patients qualified for funding

• Packages brokered through North Yorkshire County Council on behalf of health
• Savings to the whole system
• Reduced Delayed Transfers of Care
• 0% DST in acute setting

Pathway 3 – End of Year Review

Mrs Swale is an 83 year old lady who lives alone in Reeth all her family live down South. Usually she is fully independent and is still driving. The neighbours are concerned that she had not been seen around the village and had entered her house to find her on the sofa. She said that she had been suffering from diarrhoea for three days and was clearly dehydrated. When they attempted to walk her she was too weak to

• stand. Paramedic complete initial assessment Patient admitted to CDU.

‘Off Legs’

Ward complete a Trusted Assessment Pathway 1: Referral to Social Care requesting a 48 hour response and Home from Hospital Support A community health assessment requested by Fast Response within 24 hours.

MAMS Meeting

Home from Hospital Service visit patient within 24 hours; check family/ neighbours support in place for the next 24 hours Social Care assessment within 48 hours

Mrs Swale is an 83 year old lady who lives alone in Reeth all her family live down South. Usually she is fully independent and is still driving. Paramedics were called as the neighbours were concerned that she had not been seen around the village and had entered her house to find her on the sofa. She said that she had been suffering from diarrhoea for three days and was clearly dehydrated. When they attempted to walk her she was too weak to

• stand. Paramedic complete initial assessment. Patient admitted to CDU –

Patient requires therapy assessment and is anxious.

‘Off Legs’

MAMS Meeting to deliver Patient Discharge Plan Ward complete a Trusted Assessment Pathway 2: Referral to Step Down Bed. Patient transferred to Step Down Bed within their locality. 10 hours personal care provided per week. Therapy Assessment Completed by Community Team Social Care assessment Patient stay 2 week : weekly Therapy support.

Mrs Wensley is an 83 year old lady who lives in West Witton she has moderate

• dementia. She receives BD carers who help with washing and dressing. Mrs

Wensley has a background of type two diabetes and hypertension. She takes, Ramipril, bendroflumethside, metformin and gliclazide. Mrs Wensley is admitted to the Friarage where she stays for a period of 4 days creating a level of confusion preventing her from going home or to a step down bed. It is felt further observation is required to understand her long term needs

One of the carers witnessed Mrs Wensley collapsing and call a paramedic. Patient spends 4 days in the bed for observation. Following which it is decided a CHC checklist is not required.

Patient returns home MAMS Meeting

Patient transferred to a commissioned Discharge to Assess bed pathway 3.

Social Care assessment

Pathway 3

Patient Outcomes:

• Home First at the soonest possibility
• Proportionate support in at the right time
• Utilising existing systems and support already in place
• Identifying the right pathway for the individual patient
• Clear pathway home
• Continued reablement and support in the right setting
• Utilising commissioned beds
• Assessment in the right setting

Learning

• Requires good working relationships
• Pragmatic approach
• Clear clinical leadership
• Wide ranging and ongoing engagement as a

system

Pathway 1 Home

For patients on a hospital ward who can return home.

• Patient discharged through the Age Uk ‘ Home from Hospital’ service.
• They receive a Patient Centred Care Plan to support their continued

independence and self-care management. For patients on a hospital ward who can return home with additional support from their local Integrated Locality Team.

• Patient discharged through the Age Uk ‘ Home from Hospital’ service.
• They receive ongoing support at home and stay on the pathway for up to six

weeks.

• The ward multidisciplinary team completes a single Trusted Assessment for
• ngoing care needs in the patient’s home, which is shared between social care

and community health teams (trusted assessment). Intermediate Care Team or the reablement service provides care and therapy at home to support patients’ recovery to independence. The intensity of the service depends on patients’ needs: they can be seen up to four times a day.

• Daily review process required

Pathway 2

For patients who cannot be discharged home directly but could return there with additional rehabilitation and reablement

• Patients are discharged to a community bed or temporary residential care via trusted

assessment for up to 6 weeks.

• The local Integrated Locality Team manage the discharge home during the 6 week

temporary placement.

• Daily assessments
• All packages identified via Local Authority Brokerage System

Pathway 3

For patients likely to need ongoing care in a Care Home or Residential setting, who may be eligible for continuing healthcare funding.

• The hospital-based team has assessed these patients as having complex care needs and

likely to require daily care at a higher level than pathway 2.

• Patients suffering a delirium episode and require daily care until they are fit for

assessment.

Refreshing the HICM June 2018 – April 2019

Glasha Frank - Department of Health and Social Care Martha Dalton - Department of Health and Social Care

• HICM was introduced in 2015 as a

improvement toolkit to help health and social care systems consider a implementing a series of Changes in order to reduce DTOC and improve patient flow.

• This year, there is a ambition to refresh the

model to better links with emerging national agendas on improved patient flow, community support and reducing length of stay.

Introduction

HICM Refresh Questionnaire

• Below is a link for the HICM refresh

questionnaire, This is a further opportunity for you to provide feedback as a means of informing the refresh of the HICM. It should take around 10 mins to complete.

• For reference the HICM can be found here

http://survey.euro.confirmit.com/wix/p1866998059.aspx

• To find out how you use the model and your views on how

this could be improved?

• To find out what has been most useful / least useful when

implementing the model and considering the impact it has had

• To find out what you what you think the gaps are in the

current model and how you think it should be improved and why The views from this workshop will directly feed into collecting the evidence base for revising the current HICM.

Purpose of the workshop

Stage 1

Spend 20 minutes considering the following questions

• Q1. How do you use the HICM and what is missing?
• Q2. What Change has had the most / least useful in

improving patient flow and why? Use prompt questions provided that are on the tables

Stage 2

Spend 20 minutes considering the following questions

• Q3. How do you think the HICM could be

improved? Please make use of the prompt questions for this question provided on each table.

Next Steps

• Understanding the key themes from each of the

nine HICM refresh workshop

• Set up of a National Reference Group of

practitioners to act as a sounding board for the development of the refreshed HICM.

• Aim is to publish refreshed model by April 2019

Reflections on the morning / What next

Fiona Brown - DASS, Sunderland City Council

Thank you for attending!

An Evaluation will be emailed round, please could you ensure you take the time to fill this in.