1. ‘DELAYED DISCHARGE – A WICKED, BUT RESOLVABLE PROBLEM’
Dr Sheena MacDonald
Medical Director NHS Borders and
Mr Eddie Fraser...

2. The challenge remains….
Some patients are in our hospital system that could be managed out of hospital and not admitted at all
AND
Some patients are delayed in our hospital system that could be managed out of hospital

3. Reshaping Care Pathway
A programme for change

4. THE DD EXPERT GROUP
A culture and behaviour change is required so that any delay for a day longer than is necessary is deemed unacceptable and that the norm should be discharge within hours and days rather than weeks.
A perception should be promoted that 2-3 days be considered a reasonable period for someone to return home.
Patients should not have their long term care needs assessed in an acute bed unless unavoidable and appropriate due to the clear levels of future care required.
July 2012

5. The default position should be that the patient is discharged to the accommodation they occupied prior to admission. Only if this is not possible should alternatives be investigated.
Patient should not be admitted directly from an acute setting to a long-term stay in a care home, unless unavoidable and appropriate.
Leadership of the delayed discharge agenda should be improved at several levels.
The code 9 cases needed more robust challenging and should be kept under regular review with much more focus.
Alternatives to hospital admission must be developed and accessible to GPs

6. Full use should be made of appropriate step-up facilities including community hospitals to avoid admission to acute hospitals.
A ‘gatekeeping’ function should be established at A&E with the ethos of ‘decide to admit’ rather than ‘admit to decide’. This could be primary care based teams with a knowledge of community options that could triage and manage risk.
Better use should be made of Day Hospitals and 23 hour beds.
Links should be improved between acute hospitals, NHS24 and SAS.
Risk prediction and case / care management should be further developed.
Intermediate care options, including ‘virtual wards’ and specialist integrated community teams should be explored.
The use and sharing of Anticipatory Care Plans should be expanded.
Early application of frailty screening criteria should prompt early flow to specialist geriatric teams when required.

7. Estimated Date of Discharge (EDD) should be routinely set.
Although ultimately for the clinician in charge, clinical readiness for discharge should be a MDT decision.
Where appropriate a form of self-assessment should be introduced.
An interim, quick and easy, assessment should be developed that can be undertaken by any appropriate member of the MDT.
Where a local partnership has identified a local need for residential intermediate care, dedicated care homes could be identified and developed as hubs to provide this. This might provide everyone with the opportunity for recovery, rehabilitation and reablement before confirming long-term care home requirement.
Avoid inappropriate care home placements by improving enhanced home care, improved rapid response services, equipment and adaptation provision.
Adopt a reablement approach and start this within hospital.
Agree local timescales for cancellation of existing care packages,

8. There should be local agreement on direct purchase of home care by ward staff withset timelines and built in review process.
Better engagement with housing is needed
The choice policy should be reinvigorated at a local level with senior ownership among health and social care executives and medical practitioners.
A national message that a patient does not have the right to remain indefinitely in hospital would be helpful.
In cases of disagreement, the patient should be discharged while resolution is sought.
Improve use of intermediate care as step-down.
A dedicated group be established to look at where the blockages in the guardianship process are occurring and work with colleagues in health, social care and the justice system to improve the situation.
Partnerships experiencing difficulties with AwI to invite support through the Joint Improvement Team

9. So how did we do?

10. Bed days occupied by delayed discharge patients; All ages; Trend
There were 148,000 (148,079) bed days occupied by delayed discharge patients during the quarter of January – March This is an increase of 10% from the previous quarter and an increase of 18% from the corresponding quarter in 2013.
Compared to 134,978 in Oct – Dec 2013 (an increase of 10%)
Compared to 125,410 in Jan – Mar 2013 (an increase of 18%)
This is the highest recorded number of occupied beddays since data collection began and the second consecutive quarter this has happened
For 2013/14 just over half a million bed days were occupied by delayed discharge patients (532,499)
80% of bed days occupied are attributable to standard delay reasons.
Source: ISD Scotland

11. Latest published data as at April 2014; Delayed Discharges by Length of Delay and LA
This chart shows the latest published data as at April 2014 by LA area and indicates the number of delays by length.
Over 90% of Glasgow City delays are under 4 weeks compared to just over 40% for Aberdeen City.
Of the 107 delays over 6 weeks (31% were over 3 months)
Source: ISD Scotland

14. And more older people live at home

15. Latest Census Management Data as at June 2014: Delayed Discharges (> 6 week target)

16. DELAYED DISCHARGE SUMMIT AND TASKFORCE 2014
Cross sector multidisciplinary lock in !
Tasked to say what should be done now , by 15/16 and what should be highlightes to strategic commissioning

17. Using technology and local assets
Now:
In test sites begin to build cross sector collaborations with action learning and evaluation :
Third sector and housing links in discharge hubs to connect to local assets - ? role for ALISS
Map and scope potential to pool local care workforce to improve cover out of hours, reduce duplication, improve efficiency and personalisation
Deep dive on housing delays and available lets Connect Intermediate Care Teams with local Third Sector and housing with care providers

18. 15/16:
Use Integrated Care Fund and national funding to spread above beyond tests sites
Improve processes for (re)allocation of available adapted properties
Use Technology enabled care to manage risk and connect with family / unpaid carers
Simple narrative to increase staff / public / family awareness of new models
Develop volunteer home from hospital support using experienced retired public sector staff
Develop hub / cluster models for housing support; day care; care at home
Strategic Commissioning:
Living wage
Market facilitation
Involve local HEIs in recruiting to care sector

19. Supporting Choice and improving quality of care sector
Now:
Identify true cost of care and costs to build a quality workforce
Invest in workforce training and developing relationships with the care sector
Cross sector partnership working and make better use of third sector
Share good practice across areas and sectors
15/16:
Influence care inspections to be asset based and outcome focused
Involve geriatricians and nurse practitioners in supporting the care sector
Strategic Commissioning:
Build community capacity including Third sector, family networks, community support
Develop new models to support more people to remain at home / in the community

20. WORKFORCE DEVELOPMENT AND CULTURE
Now:
Challenge health senior leadership team (MD, DoNMAHP, DPH, Chief Exec ) to deliver:
Home First / discharge to assess ethos
Delegated criterion led discharge from hospital
Practice where clinicians do not prescribe care packages
National summary of key messages about harmful consequences of delays - increased mortality and decreasing independence – and challenge view of hospital as place of safety
Statement regarding valuing the workforce - terms and conditions and standards
15/16
Flexible use of workforce – HCSW, Generic support worker; Rehab assistants
Further spread of re-ablement
Ensure senior decision making is not risk averse
Strategic Commissioning:
Workforce development plans
Revisit IRF to inform strategic plan and scrutinise variation

21. ASSESMENT AND FUNDING
Now:
Make return Home the default position
Simplify and fast-track risk assessments that enable early discharge to assess at home
Ensure timely reviews of all care packages to recycle resources
15/16:
Person centred discharge assessment and care planning that also involves the family
Shift resources ( funding and workforce ) from acute to community integrated care teams
Start integrated discharge planning at point of admission to hospital ( or pre-assessment clinic )
Ensure early assessment of capacity
Embed telecare and telehealth within the integrated assessment
Strategic Commissioning:
Aggregate assessed needs to inform strategic commissioning - including housing fit for the future

22. INTEGRATION OUTCOMES