Health and Social Care in Partnership Doncaster Integrated Discharge Team Health and Social Care in Partnership

Strategic Lead Integrated Discharge Pathway Debra Everton Strategic Lead Integrated Discharge Pathway

In Doncaster we have changed the way we manage Hospital Discharges and in doing so reduced unnecessary delays. Through a four year programme of transformation we have delivered significant efficiency savings across the whole health and health economy. So how have we don’t this

Social Care & Health professionals working in partnership have taken integration beyond co-location and by working together as an Integrated Discharge Team we have created a whole system that works for the benefit of patients and organisations I am going to show you how we have done this

Where we were - January 2011 Purple Alert 57 estimated delays Working from 4 lists of patients 76 medical sleepers out 126 cancelled operations Staff working in blame culture So why did we change? We had no option

Issues with the discharge process Social Care and Continuing Care Assessments completed in an acute bed Inaccurate outcomes of assessments Outlier for admissions to 24 hour care and CHC funding Patients remaining in hospital too long Delays in system Permanent residential care as a matter of course Duplication in assessment Blame culture Silo working. Poor Communication. Only Monday to Friday These are the issues

How we changed it Worked with CCG to develop and agree new ways of working Utilised BCF to provide additional resource in the team including an integrated lead Developed a Culture of Trust and removed section 2’s and section 5’s (as was) Allowed wards to own simple discharge planning Made IDT centre of complex discharge planning and provided proactive management of potential delays in the patient journey through IDT Introduced a front door admission avoidance team Developed an innovative transfer to assess model Introduced Trusted Assessors Worked over 7 days Lots of differences to get over, terms and conditions flexi, home working, meetings, journeys continue outside for SC

Doncaster Integrated Discharge Pathway Ward identify patient is over acute stage of their illness and is either: Able to go home alone Discharge arrange, Home from hospital considered Able to go home with support Discharge arranged through SPOC Unable to go home with support at this time Referral made to IDT Fact Find completed and MDT agreement to one of pathways below Transfer to assess options available Positive Step Social Care Assessment unit Dementia beds 22 None dementia beds 11 Complex Assessment Pathway 26 independent home beds 10 Dementia nursing beds None dementia nursing Intermediate care beds Community NHS trust Mexborough Rehabilitation Centre Social Care staff provide discharge support to all the units, DNs support to Mexborough and soon to cover CAP

Simple discharges If the ward feel that the patient is a simple discharge they refer to rebalement through SPOC Patient must have no ongoing care package Assessment at home within 2 hours of discharge, Support packages put in place same day SPOC has reduced the time that the nursing staff spend on simple discharges by the use of one call These discharges do not come through IDT

Complex Discharges/Transfer to assess model IDT staff do board rounds each day on the wards and jointly identify patients ready for discharge planning-’medically stable and fit for transfer’ and referral made to IDT, as early as possible Fact finding assessment undertaken by a member of IDT, nurse or Social Worker who decide which pathway is most appropriate (Trusted Assessor), the recommendation is discussed and agreed by IDT If for Complex Assessment Pathway, Patient referred to geriatrician for their authorisations as Patient remains under care of the geriatrician who provides support and weekly ward round in CAP bed Social care staff in units are made aware of transfer of care and continue with case until discharged from unit We have a lot of discharge pathways and soe poeel may say too many as the more beds you have the more you want. CCG have jjust completed an academically sound IMCA where they have looked at 100 cases to see if the placements in bed base services were right and some of the early outcomes are that we shodu be sending more people homea/ and wrap services around them there

Rapid Assessment Program Team Admission avoidance Front door, comprehensive assessment of need - ED, Assessment Units Multi-professional team…therapists, social care, nurses 7-day service Follow -up visits…equipment provision… further assessment/signposting Follow-up telephone contact…24 hours 76% of patients turned round - discharge home/step-up bed Education/training…appropriate referrals…RAPT App

PERFORMANCE INFORMATION – 13/14 ASCOF 2Ci Delayed transfers of care from hospital (attributable to adult social care) has improved from 6.7 (2012/13) to 2.3 (2013/14). 3327 Acute Beds Saved which delivered cost savings of £793,264 A 5% reduction of direct placements into permanent care 41% of people supported by an IDT assessor, returned home with support from our reablement services

Average length of stay within the assessment units - 28 Days Positive outcomes for people receiving reablement service; 65.6% of people were discharge home with or without support ASCOF 2B Number of People still at Home 91 Days has improved from 59.6% (2012/13) to 67.5% (2013/14).   The above data sets continue to be performance managed through 2013/14; it appears the trend continues to improve across the system.

Where We Are Now Fully integrated Discharge Team Minimal delays in the system 7 day working across the team Innovative transfer to assess model DST’s not undertaken in hospital Developed a competency based Trusted Assessor programme 2015 winners of the NHS Leadership recognition award for outstanding collaborative leadership

Strategic lead Integrated Discharge Pathway Contact details Debra Everton Strategic lead Integrated Discharge Pathway Debra.everton@doncaster.gov.uk 01302 647095