MEDWAY

8 WEEKS Setting the scene.. Acute trust in special measures Focus on three areas of improvement Discharge to Assess pilot - September 2015 Other models explored 8 WEEKS

Quotes that made an impact Home First Principle (Ian Sturgess) No patient should ever enter hospital and never return to see their home ever again (Liz Sergeant) Understand and successfully operate the existing business – Alignment (Ian Sturgess) Need to remove barriers and perverse incentives created by contracts and organisational boundaries via planning and working collaboratively (Ian Sturgess) 3

OUR AIM

Our aim was to speed up hospital discharge times and improve patient outcomes   We pledged that we would support patients who might need assistance at home by providing assessment of needs in the patients own home; setting goals and providing any necessary support; promoting independence and reducing the need for ongoing long term care in the future 5

A multi-agency partnership initiative working across the whole health and social care system to reduce unnecessarily prolonged lengths of stay in an acute hospital.   Facilitating more timely and effective hospital discharges, achieved by the community providing holistic assessment, equipment and on-going enablement and support in the patient’s own home or intermediate care facility instead of in the hospital. Facilitating up to 35 discharges onto Pathway One per week, including weekends. 6

Designated Lead Pathways

Pathway 0 Pathway 1 Pathway 2 Pathway 3 Pathways – The Medway model designed four pathways to get people out of the hospital quicker: Pathway 0 The patient no longer has any additional needs Pathway 1 The patient has some additional needs that can be safely met at home Pathway 2 The patient is unable to return home immediately. The discharge may need more planning due to complex needs OR the patient may need an intermediate care bed for a short period of time The patient has complex needs and is unable to return home Pathway 3

Pathway One The Ward contact community single point of contact Triage completed over the telephone: If transport is required a slot will be booked Any previous community support & enablement will be reinstated A timed visit will be made for an OT to assess Any health service referrals will be made In the community the patient will be visited by an OT within two hours of arriving home. The OT will:- - Perform a holistic assessment of needs Establish enablement goals Instigate an independence program (inc therapy & personal care for up to 6 weeks) Order / provide equipment within next two hours

Designate a lead – supported by a core group Pathways – keep it simple Single Point of Access (SPA) – one call does it all Staffing – flex resource across the whole system Enablement agency support – free care for all Board rounds – trusting decisions Equipment provision – quick access Transport - reliable Wrap around support – substitute for care visits Comms – spread the message and the vision Contingency and escalation plans – it may not be perfect but it can be good enough Branding

Themes & Issues No EDN’s Wards not calling to inform us the patient had left the ward Patients not ready to leave by 3pm Backlogs & ‘roll overs’ Numbers and trends Bypassing of the systems in place Some complex needs required more planning before discharge Creation of new/alternative pathways

What has been achieved so far.. Time… Discharges under Home First… Reduction in stranded patient numbers… Reduction in DTOC Change in culture… Reduction in long term care reliance… Improved patient flow… Recognition… Great working relationships…

Challenges (acute) Delayed/aborted discharges due to: EDN’s TTO’s Waits for a decision by a senior doctor Increased temporary nursing staff on the wards, unfamiliar with patients and processes. Poor uptake at the weekends (zero referrals on Sundays)

Criteria led discharge (CLD) Patients identified on board rounds who would be candidates for home first when medically optimised EDD’s Clear criteria and parameters to be met for discharge entered onto the electronic bed management system (BMS) Patients/families included in the discharge planning Proactive completion of EDN Bleep holder support for junior staff out of hours Clear escalation processes

What’s new? Day before referrals Transport booked the day before discharge Increased numbers discharged via this pathway Proactive not reactive Increased numbers of patients discharged before 10am Improved weekend discharges Improved performance

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