HSJ Presentation

Report
‘Navigating the
System’
Finding early opportunities to
access Community Services‘Discharge to assess’
work stream
Bie Grobet
South Warwickshire Foundation Trust
1
2
Warwickshire North CCG challenges
• Nuneaton and Bedworth : top 1/3 most
deprived areas in England
• Warwickshire: 26/37 deprived areas are in
Nuneaton and Bedworth
• Rural North Warwickshire: 18.3% >65 years
old
3
George Eliot Hospital
• District General
Hospital
• Serves a population
of 290,000
• North Warwickshire,
South West
Leicestershire and
North Coventry
• 352 beds
4
Bed based model  Community Team model
NHS Warwickshire
Bramcote Hospital
• 41 bedded
Rehabilitation Unit
• Reduced to 20 beds
2008/09
• Option appraisal for reprovision 2010
• Closure April 2011
5
4 Principles to improve Care for
Older People (Prof. Ian Philp):
• ‘Choose to admit’ only those frail older people who have evidence
of underlying life-threatening illness or need for surgery – they
should be admitted, as an emergency, to an acute bed
• Provide early access to an old age acute care specialist, ideally
within the first 24 hours, to set up the right management plan
• ‘Discharge to assess’ as soon as the acute episode is complete, in
order to plan post-acute care in the person’s own home
• Provide comprehensive assessment and re-ablement during postacute care to determine and reduce long term care needs
6
Simplified access
Emergency Capability
Reducing variation
•
Expansion of Intermediate Care and Virtual Ward
Services- Doubling capacity and workforce
•
Service opening hours: 8.30 am till 12 Midnight
•
Development of Community Emergency Response
capability- 2 hour response
•
Simplified referral criteria – ‘Discharge to Assess’
•
Drive to improve confidence and understanding of
Community Services by Acute and GP colleagues
•
Reducing variation: 5 Daily Discharges- managing
Acute and Community flow commitment
7
‘Orange’ and ‘Green’ Flow:
Bed days for adult emergency admissions 2008/09
Source: Dr Foster Intelligence &
NHS Institute (2011)
‘5- A- Day’ Project
•
Early opportunities for 5 patients to be discharged
daily
•
2 Community Nurses navigating patients to
Community Services
•
Project Manager working across Acute and
Community
•
2 work streams: ‘Orange flow’ short stay, ‘Green flow’
ward stays
•
677 patients supported
•
Shared data collection to measure success
Community Navigators
Project Manager role
across Acute and
Community
9
•
Retraining Community Hospital
staff
•
Change of culture and approach
•
‘Hearts and minds’ presentations
Change
management
•
Senior Leadership sign up and
‘Can Do’ approach
Improving
confidence
•
Ward level engagement in
discharge planning
Whole system
sign up
•
Integrated Emergency Care Board
•
CCG and Board (x2) support
10
•
Closure of Community Hospital
savings - £2.07M:
•
£1.03 M reinvested in Intermediate
Care and Virtual Ward Services
•
£400k invested in Intermediate Care
beds in Nursing Home
•
£1M of further savings re-invested in
Acute contract
•
18 Acute beds closed
•
Winter capacity only opened
sporadically
Re-investment
Acute Trust savings
Bed Closure plan
Reduction in excess
bed days
11
•
Reduction in bed days lost due to delayed
discharges from 3 months to 4 weeks
•
Reduction in Length of Stay by 1 day for
Medicine and 0.4 day in Surgery on average
•
15% reduction in excess bed days compared
to increase by 8% in similar size Hospital with
similar demands in the area
Delayed Discharges
Length of Stay
Excess Bed days
Quarter 1
Emergency 09/ 10/11 11/12
10
ALL
6.4
5.3
5.6
Medicine
8.6
7.1
7.0
Surgery
6.9
6.0
6.7
Quarter 2
09/ 10/11 11/12
10
5.6
5.4
4.9
7.8
7.8
6.4
6.0
5.7
5.3
Quarter 3
09/1 10/11 11/12
0
5.9
6.0
5.1
8.0
8.0
6.3
6.6
7.0
6.1
Quarter 4
09/10 10/11 11/12
5.9
8.1
5.9
5.9
8.1
6.5
5.2
6.7
5.2
12
‘Discharge to Assess’
Re-admissions
Independence
•
677 patients supported in 6 months
•
30% of patients supported by the Virtual
Ward for Long Term Conditions management
•
94% of surveyed Virtual Ward patients felt
they benefitted from the service
•
87% felt more confident to manage their
Long Term Condition
•
68% of patients discharged from
Intermediate Care without ongoing support
•
0.6% of cohort re-admitted
•
16% requiring ongoing care package from
Social Care
•
85% of patients still living independently at
home 91 days post Discharge (NI 125)
13
Estimated Discharge
Dates
•
‘Right patient- Right bed’
•
Estimated Discharge Date compliance from
43% to 96%
•
Less inter-hospital transfers
•
Ahead of Deep Cleaning Programme
•
Increased Qualified Nursing levels on the
wards
•
25 Discharges a week compared to 6-7 to
bedded unit
Deep Cleaning
Reducing Variation
14
Lessons Learnt
• Project Manager role invaluable
• Consistent message regarding ‘Discharge to Assess’
at all levels (standardised presentation)
• Partnership Board and Emergency Care Board
scrutiny and endorsement
• Evaluating outcomes across organisations regularly
and early on, managing the changes in bed use
• Commissioning support regarding contracting and
performance
15
Reducing Variation: September 2011 versus January 2012
10
9
8
7
6
5
4
3
2
1
0
9
7
6
6
6
6
6
6
6
5
6
5
5
5
5
5
6
5
5
5
4
3
2
1
1
2
1
1
1
2
2
2
2
2
3
2
1
1
2
2
1
1
•Ahead of Deep Cleaning Programme
•Increased Qualified Nursing levels on the wards
No of Discharges
8
Estimated
Discharge
7
7
6
Dates
5
4
3
2
1
0
2
2
5
4
2
2
1
0
Reducing Variation
2
7
6
5
3
Deep Cleaning
Escalation Level
•25 Discharges a week compared to 6-7 to bedded
unit7
6
5
5
4
3
4
4
1
1
4
4
3
2
1
1
1
0
2
1
2
1
0
1
No of Discharges
2
1
0
1
1
0
1
0
2
2
1
0
1
0
2
2
0
Escalation Level
16
•
Electronic Common Assessment Tool
developed between Health and Social Care
•
Critical success measures openly shared
between organisations
•
Twice weekly Tele Conference between
Health and Social Care to ensure patient
flow in Community
Automating Navigation
Shared data
Community Flow
17
18

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