1. S.T.A.R.S. (Short Term Augmented Response Service) Tuesday 12th June 2007 Gail Edgar Service Manager

2. 2005 Rapid Response service Joint Partnership Agreement Skill Mix Background

3. Support earliest possible discharge Avoid unnecessary admission to hospital Rehabilitation : optimal independence Aims

4. Referrals to Service > Total number =over 2000 > Accepted = over 1800 Evidence that 410 people have avoided hospital admission Facilitated E.S.D of 614 patients > increased availability of 3072 hospital bed days > rapid assessment: early reduction in care package Statistics to date

5. New Developments Concept: Continually evolve: Identified Need E.S.D. for COPD patients Development of Generic Worker role to enhance rehabilitation & clinical skills

6. ‘Food for Thought’ March 2006 Travel Scholarship Australia Portsmouth Potential models for Dumfries & Galloway

7. Silver Chain Organisation Personal Enablement Plan Health Improvement Plan Increased support to patients at home: Generic Workers working to AHP’s.

8. Step Up/Step Down Nurse led beds in Community Units Rapid assessment > need for close observation > admission when necessary > early discharge - S.T.A.R.S. and AHP’s Supported in Community by S.T.A.R.S. > reduced hospital admissions > increased delivery of tailored rehab programme > increased potential for optimum independence

9. Presence of Discharge Team member in A&E All older people appropriately screened and assessed Discharge Team member - extensive local knowledge of community services Identification of need: discharge follow-up No additional resource PRO-ACTIVE IN-REACH PROGRAMME:A&E

10. REDUCTION IN NUMBER OF ADMISSIONS & READMISSIONS & DELAYED DISCHARGES!

11. RONA LAING ACTING SENIOR MANAGER SOCIAL WORK OLDER PEOPLE SERVICE

12. FIFE HEALTH & SOCIAL CARE PARTNERSHIP DELAYED DISCHARGE FIFE TARGET – 2005/06 REDUCE ALL DELAYS IN HOSPITAL TO 73 REDUCE ALL DELAYS IN HOSPITAL TO 73 REDUCE ALL DELAYS OVER 6 WEEKS TO 40 REDUCE ALL DELAYS OVER 6 WEEKS TO 40 REPORTED DELAYS ON 15/04/06 = 71 REPORTED DELAYS ON 15/04/06 = 71 REPORTED DELAYS OVER 6 WEEKS ON 15/04/06 = 21 REPORTED DELAYS OVER 6 WEEKS ON 15/04/06 = 21

13. FIFE HEALTH & SOCIAL CARE PARTNERSHIP FIFE TARGET 2006/07 REDUCE DELAYS OVER 6 WEEKS TO 20 REDUCE DELAYS OVER 6 WEEKS TO 20 REDUCE DELAYS IN SHORT STAY BEDS TO 1 REDUCE DELAYS IN SHORT STAY BEDS TO 1 REPORTED DELAYS ON 15/04/07 OVER 6 WEEKS = 17 REPORTED DELAYS ON 15/04/07 OVER 6 WEEKS = 17 REPORTED DELAYS ON 15/04/07 IN SHORT STAY BEDS = 0 REPORTED DELAYS ON 15/04/07 IN SHORT STAY BEDS = 0

14. FIFE HEALTH & SOCIAL CARE PARTNERSHIP

15. FIFE HEALTH & SOCIAL CARE PARTNERSHIP ACHIEVING THE TARGET MONTHLY VERIFICATION OF DATA MONTHLY VERIFICATION OF DATA WEEKLY MONITORING FOR 6 WEEKS PRIOR TO CENSUS DATE WEEKLY MONITORING FOR 6 WEEKS PRIOR TO CENSUS DATE PARTNERSHIP AGREEMENT ON CODING PARTNERSHIP AGREEMENT ON CODING ROBUST CARE MANAGEMENT AND MONITORING OF PROGRESS TO DISCHARGE ROBUST CARE MANAGEMENT AND MONITORING OF PROGRESS TO DISCHARGE

16. FIFE HEALTH & SOCIAL CARE PARTNERSHIP PROCESS IMPROVEMENT GUIDANCE ON CHOICE POLICY GUIDANCE ON CHOICE POLICY APPLICATION OF THE GUIDANCE APPLICATION OF THE GUIDANCE ROLES AND RESPONSIBILITIES ROLES AND RESPONSIBILITIES JOINT ACTION PLAN JOINT ACTION PLAN

17. FIFE HEALTH & SOCIAL CARE PARTNERSHIP RESOURCES HOSPITAL BASED ASSESSMENT AND CARE MANAGEMENT TEAMS HOSPITAL BASED ASSESSMENT AND CARE MANAGEMENT TEAMS DISCHARGE SUPPORT NURSES DISCHARGE SUPPORT NURSES SHARED I.T. SYSTEMS SHARED I.T. SYSTEMS BUSINESS & SYSTEMS SUPPORT STAFF BUSINESS & SYSTEMS SUPPORT STAFF

18. FIFE HEALTH & SOCIAL CARE PARTNERSHIP ESSENTIALS TO SUCCESS SHARED VISION/OBJECTIVES SHARED VISION/OBJECTIVES DEDICATED STAFF TEAMS DEDICATED STAFF TEAMS REGULAR COMMUNICATION REGULAR COMMUNICATION PROBLEM SOLVING APPROACH PROBLEM SOLVING APPROACH SENSE OF HUMOUR! SENSE OF HUMOUR!

20. Delayed Discharge Warts and All…. Emerging Themes From The 2004/5; 2005/6 & 2006/7 Census

21. Life is like a bowl of….

22. Two Ways of Managing a Census…. Quarterly or annually Quarterly or annually Debate the definitions Debate the definitions Robust management (shouting and/or weeping) Robust management (shouting and/or weeping) Throw money at the list Throw money at the list Weekly Weekly Clear understanding of reasons for delay allows… Clear understanding of reasons for delay allows… Constant management and… Constant management and… Consistent funding decisions Consistent funding decisions

23. The Census Day 2004/5 Success is….. Target 43 Target 43 Census minus one week 78 Census minus one week 78 0900hrs 39 0900hrs 39 1200hrs 46 1200hrs 46 1700hrs 37 1700hrs 37

24. What was going on?

25. Accurate; Current.. “The List” The SW List informed the… The SW List informed the… The NHS List which was bigger than above… The NHS List which was bigger than above… The Joint List ….had decayed The Joint List ….had decayed The Lists not regular, but collected for census The Lists not regular, but collected for census Managers didn’t hold and monitor the lists. Managers didn’t hold and monitor the lists.

26. Anomolies The “Long Term” DD who is not reviewed The “Long Term” DD who is not reviewed The “compassionate” DD The “compassionate” DD The DD with no discharge date The DD with no discharge date “Predictable Incapax” at point of discharge “Predictable Incapax” at point of discharge Hidden DD’s and backdating Hidden DD’s and backdating Virtual DD’s Virtual DD’s

27. ….So For 2005/6 Agreed Definitions Agreed Definitions “Amnesty” and senior sign off of local agreement of lists “Amnesty” and senior sign off of local agreement of lists Named local managers/collators Named local managers/collators Changed focus for DD Action Team Changed focus for DD Action Team Real time management information including value of codes Real time management information including value of codes Management, not administration Management, not administration

28. 2005/6…Success Is….. Increasing by 200+%..... Increasing by 200+%..... ….then receiving “support and encouragement” ….then receiving “support and encouragement”

29. Delayed Discharge 2006/7

30. Differential Impact on Hospitals

31. Comparative Delayed Discharge At End Of 2005/6 2004/05 Performance Target 39 Actual 37 Target 39 Actual 37 264 patients; 27,629 bed days 264 patients; 27,629 bed days 2005/06 Performance Target 34; Actual 10 Target 34; Actual 10 Six Week Target 19; Actual 3 Six Week Target 19; Actual 3 Acute Target 5; Actual 2 Acute Target 5; Actual 2 Max Wait 56 days Max Wait 56 days 384 patients……29,582 bed days 384 patients……29,582 bed days ….the wrong targets? ….the wrong targets?

32. Performance Issues 2006/7 Knowledge, awareness & late starters Knowledge, awareness & late starters Systems and responses Systems and responses NHS/SW relationships and engagement & pushing responsibility down NHS/SW relationships and engagement & pushing responsibility down Targeting of patients Targeting of patients Managing now, not future ideas Managing now, not future ideas Achieved…….. Achieved……..

33. Delayed Discharge 2006/7 Target 28 Actual 24 Target 28 Actual 24 Short stay 9 Actual 7 Short stay 9 Actual 7 Six Weeks 11 Actual 9 Six Weeks 11 Actual 9

34. Success is…… 136% increase on last year??? OR 136% increase on last year??? OR Actual reduction of Occupied Bed Days 15k…47%..£3.1m !!!!! Actual reduction of Occupied Bed Days 15k…47%..£3.1m !!!!!

35. A Journey Through Delayed Discharge Performance …..A Reality Check Disengagement Disengagement Monitoring a deteriorating situation Monitoring a deteriorating situation Actively managing Actively managing Performing & delivering Performing & delivering Eye goes off ball… Eye goes off ball… …and is brought back by weekly reporting regime. …and is brought back by weekly reporting regime.

36. But…. The system is now moving too fast…. The system is now moving too fast…. Implications for balance of care Implications for balance of care Anticipatory Care? Anticipatory Care?

37. A Final Thought.. No pudding till you finish your greens?

38. Delayed Discharge Warts and All…. Emerging Themes From The 2004/5; 2005/6 & 2006/7 Census