Assessment Service North Mersey(ICRAS) Integrated ...€¦ · North Mersey(ICRAS) Integrated Community Reablement and Assessment Service Service Intensive Community Care Service CCG

d:\moderngov\data\agendaitemdocs\0\0\2\ai00041200\$1vdm2j5y.docxPrint date: 26 September 2017

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North Mersey Integrated Community Reablement and

Assessment Service (ICRAS)

Developed byMel Wright, South Sefton CCG/Southport and Formby CCG

Mark Waterhouse/Tina Wilkins, Sefton CouncilChris Ferns, Liverpool City Council

Jacqui Campbell, Liverpool CCGJohn Williams, Knowsley Council/Knowsley CCG

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Document name: v:\workstreams\intermediate care\north mersey approach\nm intensive community ra scheme v7 (post consult)).docxVersion 7: post consultation draft

Print date: 26 September 2017


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Contents

1. Purpose of this paper..................................................................................................32. Approval process ........................................................................................................43. Purpose of the service ................................................................................................44. Definitions ...................................................................................................................55. Clinical Governance....................................................................................................66. Governance ................................................................................................................67. Operational Management ...........................................................................................68. ICRAS Construct.........................................................................................................69. What is the ICRAS? ....................................................................................................710. Workforce/Staff Training .............................................................................................811. Aims ...........................................................................................................................812. Principles ....................................................................................................................913. Key Operational Features/Care Pathway ...................................................................914. Episode of Care ........................................................................................................1115. Outcome and Performance Measures ......................................................................1116. Appendices ...............................................................................................................12


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Consultation draft North Mersey

Integrated Community Reablement and Assessment Service (ICRAS)

Service Intensive Community Care Service

CCG Leads Melanie Wright (NHS South Sefton CCG)Jacqui Campbell (NHS Liverpool CCG)John Williams (NHS Knowsley CCG)

LA Leads Tina Wilkins/Mark Waterhouse (Sefton Council) Chris Ferns (Liverpool Council)John Williams (Knowsley Council)

Date of Review March 2017

1. Purpose of this paper The purpose of this paper is to explain the form and function of an Integrated Community Reablement and Assessment Service (ICRAS) in response to the need for aligned community services in Sefton, Liverpool and Knowsley for the delivery of step-up (admission avoidance) and step-down care (transition from hospital or other urgent care setting) for those with support needs.

This model has been developed as part of the work across the North Mersey Local Delivery System (LDS) Demand Management workstream which, in turn, forms part of the Cheshire and Merseyside Sustainability and Transformation Plan (STP).

This is an ambitious project which has the potential to deliver much needed systemic change across North Mersey; but it will require a high level of sustained commitment from all Delivery Board members. It will also require practical support, such as a dedicated project manager, to ensure delivery.


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2. Approval process In order to approve the development of the service and processes described herein this paper, it will be necessary to adopt the following process.

Step Timescale(1) Circulation internally only (CCGs/Local Authorities) for comment 20 January 2017

(2) Stakeholder consultation – initial meeting re model 28 February 2017

(3) Stakeholder consultation – A&E Delivery Board March 2017|3. Purpose of the service The provider of this service will be responsible for the holistic care of patients throughout the duration of their care episode.

The Integrated Community Reablement and Assessment Team (ICRAS) is integral to the delivery of responsive 24/7 urgent community health and care services. The ICRAS comprises a range of intermediate health and social care services, which includes:

a intermediate care/assessment bed base(s) delivered via locality hubs; multi-disciplinary care in a person’s usual place of residence; or reablement support.

This model is predicated on the ‘lanes’ approach (see figure 1) to hospital discharge and the hospital having less social workers based at the hospital, the majority of which will become community-based .

Figure 1

Lanes ExamplesLane 1 – simple discharge Patient goes straight homeLane 2 – supported discharge Restart package of care

District nurse referralTreatment room referralOutpatient appointment requiredPermanent provider reassessment (res/nursing home)RepatriationHomeless

Lane 3 – intensive supported discharge

ICB referral for LiverpoolEquipment for local areaFast track dischargeNew/increased package of careEarly Supported Discharge

Lane 4 – complex discharge Upgrade to nursing careAny out of area discharge pathway Complex Rehab NetworkNew placementCHC reviewDSTRapid EOL discharge


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4. Definitions “D2A” Discharge to Assess

“Neighbourhood” In Liverpool (only), this means a group of GP practices within a geographical area, around which community services are wrapped (see figure 1)

“Locality” Liverpool A group of four neighbourhoods

Sefton

Knowsley

A group of GP practices within a geographical locality, around which community services are wrappedA group of GP practices within a geographical locality, around which community services are wrapped (currently under development)

“LCC” Liverpool City Council

“SMBC” Sefton Council

“KMBC” Knowsley Metropolitan Borough Council

“LCCG” Liverpool Clinical Commissioning Group

“SSCCG” South Sefton Clinical Commissioning Group

“KCCG” Knowsley Clinical Commissioning Group

“ICRAS” Intensive Community Reablement and Assessment Service

“Reablement Services” Liverpool LCC and independent sector providers

Sefton Sefton New Directions

Knowsley [ KMBC Reablement Service]

MDT Multi-disciplinary team (a combined team of health and social care professionals)

Primary Screen Primary Screen Member of the ICRAS who undertakes the screen role either within the acute hospital setting or within the community setting.

As development of ICRAS continues, it will be important to determine a standard approach to language and terminology, to support a single approach and understanding.


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Figure 1 – Neighbourhood and Locality Model

5. Clinical Governance

Clinical governance rests with the providers.

6. Governance

The governance framework can be seen at Appendix 2.

7. Operational Management

All aspects of service provision will be managed by the ICRAS, with ultimate operational responsibility resting with the Operational Systems Manager.

8. ICRAS Construct

The ICRAS will be created by the merger of a number of community teams across the current community services provider1, as follows:

South Sefton Liverpool Knowsley Southport and Formby2

Urgent CareCommunity Intermediate

CareRehab at Home

Discharge PlanningWard 35

Some hospital-based Social Workers

Home FirstEmergency Response

TeamIntensive Community Care

TeamOutreach

Hospital Social Work TeamLOOS

Bed BrokerageCare Placement

Knowsley Urgent Response Team

Knowsley Hospital Discharge Team (Social Worker and Therapists)Knowsley Reablement

ServiceKnowsley Intermediate

Care Service

CERTDischarge Planning

Some hospital-based Social Workers

↓ ↓ ↓ ↓South Sefton ICRAS Liverpool ICRAS Knowsley ICRAS S&F ICRAS

The ICRAS will work in partnership and as a single service with a single point of access, along with colleagues in the Local Authority Adult Social Care and Reablement Services, which will coordinate all admissions and discharges to and from the service (whether bedded or in a patient’s normal place of residence), overseeing patients’ care and providing medical input by way of a GP or Community Geriatrician.

The ICRAS will therefore be an MDT which, via a ‘screen’ role (or trusted assessment) provides both an in-reach or ‘pull’ approach to hospital discharge and also acts as an admission avoidance scheme for patients with frailty who may need additional support to remain at their normal place of

1 Subject to the Liverpool Community Health Services NHS Trust acquisition process2 Part of a separate transition process to South Sefton, Liverpool and Knowsley, but included for the purposes of completeness


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residence. The ICRAS will also deliver a proactive short-term approach to optimising health to delay the impact of frailty.

Closely aligned to other community services and as the urgent care element of the community service locality/neighbourhood model of care (see Definitions), ICRAS will support delivery of a 24/7 urgent response to patients and carers in a health or social care crisis to avoid an acute admission and to deliver care closer to home.

ICRAS will be linked to the North West Ambulance Service in relation to admission avoidance, with the aim of applying the ‘lanes’ system before hospital admission and divert people to a more appropriate care setting on a 24/7 basis. This may require change and flexibility within both community and bed based reablement / intermediate care services.

Single Point of Access

ICRAS will also act as a single point of access for all community rehabilitation referrals to ensure that patients are treated by the right service at the right time, stabilising patient need/risk and transferring patients to other community rehabilitation services when appropriate to ensure optimal outcomes for patient rehabilitation.

9. What is the ICRAS?

Upon any of the following:

a request for assessment from either a social worker/GP/other community care provider; or the acute hospital contacting the SPA; or a hospital-based Primary Screen who forms part of the hospital’s own MDTs;

a Primary Screen will attend (if not already on-site, as is the case for the hospital-based Primary Screen) and ‘screen’ person to understand how they can best be supported to remain or return to their usual place of residence. This Primary Screen will have access to a range of integrated services on a ‘sliding’ scale so a personalised choice can be made for each patient.

The range of services can be described as:

Level Description – possible support needed Setting

(a) Home First/ Reablement

Home First/Reablement: can function at a safe level in usual place of residence – service aims to restore confidence and support return to activities of daily living – feeding, washing self etc

Usual place of residence

(b) Home First with intermediate care

Rest, rehabilitation – low level therapy or nursing intervention

Usual place of residence

(c) Assessment/ intermediate care bed

Person’s care cannot be managed at levels 1 and 2 Assessment/ intermediate care bed

A patient can step-up and down the level of need without need for further referral between services.


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Leadership, Workforce and Staff Training Key to delivery of this project is the right people involved in terms of project management to drive further development of ICRAS, appropriate leadership and support across the system and the ability to ensure staff are appropriately skilled to enable people to take informed risks and the ability to make an informed judgement. Further, people utilising the service can be supported to manage their own level of risk accordingly.

It will be important to ensure a clear and cohesive engagement plan, which is repeated regularly, across all providers and stakeholders in relation to development and mobilisation of the service and this should be built into the project plan for the implementation of ICRAS.

The challenge to drive this project should be not be under estimated, particularly in terms of delivering the necessary cultural change and understanding regarding the principles of trusted assessment. Appropriate staff training should therefore be included as part of the project plan.

10. Aims 6.1 To provide a holistic multi-disciplinary, outcome-focussed rehabilitation or further

assessment service to support people in the community to avoid hospital admission or people who, following a stay in hospital or other urgent care setting, have a new or increased level of care.

6.2 To facilitate the seamless transfer of patients from hospital to a more appropriate level of care.

6.3 To maintain or promote a return to independent living.

6.4 To assist the health economy in improving overall urgent care performance.

6.5 To reduce delayed discharge and complications associated with delayed discharge from hospital.

6.6 To move the assessment process to a more appropriate setting and reduce the number of patients entering into long term care placements.

6.7 To support an increased number of patients reaching their optimum level of functioning post-medical discharge, including carer support where appropriate.

6.8 To provide a single point of access for community rehabilitation referrals and hospital discharges.

6.9 To support a 24/7 urgent community services response in close alignment with other out of hours community nursing services.

6.10 To provide comprehensive discharge care plans ensuring patients and their carers are aware of:

- when and how to access services as required to ensure fast access to community services to minimise the impact of future deterioration;

- encouraged to self-care/access further support to self-care;

- appropriate services including voluntary and community assets to further support patient / carer need.


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11. Principles

7.1 ICRAS is not a new or additional service, but will rather be delivered through a collaborative arrangement between health and social care providers.

7.2 ICRAS will be available on a 7-days a week basis, 365 days a year, inclusive of bank holidays with a service response to crisis available 24/7.

7.3 There will be no requirement to issue Assessment or Discharge notifications (previously known as section 2 and 5) for people entering the ICRAS. No DTOC fines (on any patients) will be levied once ICRAS is operational.

7.4 ICRAS will apply the principle of the ‘Discharge to Assess’ model as widely as possible.

7.5 The role of Primary Screen will be developed collaboratively as part of ICRAS.

7.6 In as far as practical and consistent with the delivery timetable, the interface between the acute hospital and ICRAS will be standardised across Liverpool, Sefton and Knowsley.

7.7 ICRAS will maximise the use of assistive health and social care technology.

7.8 ICRAS will also maximise the rich plethora of resources within the community, voluntary and faith sectors in terms of both early intervention and post-discharge support.

12. Key Operational Features/Care Pathway

General

8.1 It is envisaged that ICRAS will be age neutral (ie, any patient registered with a North Mersey GP, or living in Sefton, Knowsley or Liverpool, over the age of 18, and consenting) when fully operational. However, in the early stages of development, it may focus on specific cohorts of people across the community and acute sector. It may also, where the operational exigencies of the service dictate, start operations linked to acute trusts and extend other care groups in due course e.g. mental health patients with long term conditions.

8.2 A copy of the Care Pathway can be located at Appendix 1.

Hospital discharge – critical steps

8.3 This model is predicated on the ‘lanes’ approach (see figure 1) to hospital discharge and the hospital having less social workers based at the hospital, the majority of which will become community-based .

8.4 It is envisaged that while simple care package restarts can be actioned within the acute setting the ICRAS will respond where the level of care within home care package has increased or is new.

8.5 Within 24 hours of hospital admission patients should be set an Expected Date of Discharge (EDD), along with commencing discharge planning, utilising the ‘Lanes System’ contained in the ICRAS model. The EDDs of people in lane 3 will be notified to the ICRAS.

8.6 Although a member of the ICRAS, the Primary Screen will operate within the acute trust and will proactively attend wards, inpatient areas and AED, liaising with the responsible


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nurse to identify patients who are medically suitable for the ICRAS and which the level of care is likely to be most beneficial for the patient. The Primary Screen may also attend board rounds to provide an active ‘pull’ mechanism and identify patients suitable for ICRAS. Ward staff do not need to undertake a full functional assessment before a person is discharged onto the ICRAS pathway. Patients going on the ICRAS pathway will also no longer need a ward-based social care assessment, this will also be undertaken in a community setting.

8.7 Having identified the patient, the Primary Screen screens the patient for care management in a community setting, then makes an individualised offer of care/support to the patient. Upon acceptance by the patient, Primary Screen then arranges transfer of the patient accordingly to either:

(1) the patient’s usual place of residence and for the patient to be met at home by a member of ICRAS within [timescale?]; or

(2) if not able to return to their usual place of residence, transfer to an assessment/ intermediate care bed;

8.8 Once transferred, the person will have an assessment of reablement health and/or social care needs.

Admission avoidance – critical steps

8.9 Referral can be made by any health or social care professional following a face-to-face assessment within the previous 24 hours and with the patient’s consent to the Single Point of Access. (The service will also consider self-referrals from patients and carers already known to the service in consultation with the patient’s GP.)

8.10 Upon referral, the Primary Screen will attend the patient’s usual place of residence within 2 hours of a referral and will identify the patient’s needs in order to provide alternative delivery of care to a hospital admission.

8.11 In the event of a patient requiring stepped-up care to an intermediate care bed following a crisis, the Primary Screen will arrange this.

8.12 At a later stage of development, it it is envisaged that NWAS transfers of care will be accepted.

Once on the pathway

8.13 Although the maximum stay on the ICRAS pathway is up to 6 weeks/42 days, it should be clearly communicated to patients in terms of managing expectations that they may be assessed as suitable to leave the pathway at any point between day 1 to 42 following assessment of functional, clinical and social needs.

8.14 A full assessment regarding social care needs will be undertaken as soon as there is any indication that a longer term care package might be necessary. Working as part of the integrated team, Reablement Services will be kept informed of people on the ICRAS pathway who may need their services so they can plan accordingly and be ready to take on people at the earliest appropriate time. There will be no need for Reablement Services’ independent assessors to attend hospital and screen in a ward setting; this will be undertaken by the Primary Screen, with Reablement Services’ functional assessment taking place in the person’s usual place of residence. A person will have their outcomes identified and a plan created, which will then be subject to regular review. Once they


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achieve the outcomes, they will either be discharged or assessed further if they still have needs.

8.15 Discharged/transferred from service.

13. Episode of Care

During their time being supported by ICRAS, patients will also receive:

a programme of therapy and care that will maximise physical, psychological, and social functions and independence;

a continuous assessment of needs with patients and carers that will facilitate decisions regarding future care when the acute phase of illness has subsided;

the ability to ‘slide’ up and down the spectrum of available care within the scheme without the necessity of further referrals;

a collaborative approach to assess care needs with patients and their carers and facilitate decisions regarding future self-management and care;

a timely, responsive and appropriate assessment / transfer of care and discharge pathways for patients with on-going needs;

automatic enrolment of frail elderly / patients with Long Term Conditions into Chronic Care Pathway on discharge from the Team;

where appropriate, direct access to the Frail Elderly Clinic with Consultant Geriatrician;

a comprehensive discharge care plan to ensure patients and carers:

- are aware of when and how to access services as required to ensure fast access to community services to minimise the impact of future deterioration;

- encouraged to self-care/access further support to self-care;

- are aware and, where appropriate, referred directly to appropriate services (including voluntary and community assets) to further support patient/carer need;

where appropriate, carers will also receive an assessment by the service providing a carers care plan/risk assessment to ensure optimal outcomes for the patient and provide the carer with access to additional appropriate support to promote patients remaining at home / preventing admission to long term care placement.

14. Outcome and Performance Measures

ICRAS’ objectives are:

to have 95% of eligible patients discharged onto the pathway within 48 hours of being declared medically fit and / or ready for discharge;

to contribute to the overall reduction of formally reported DTOC for both NHS and non-NHS delays; and

to reduce the current estimated conversion rates into longer term packages of care to 50% or below within one year of inception.


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15. Appendices

Appendix 1 Care PathwayAppendix 2 Operational Governance Framework


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Appendix 1 - Care Pathway


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Appendix 2

Documents

Assessment Service North Mersey(ICRAS) Integrated ...€¦ · North Mersey(ICRAS) Integrated Community Reablement and Assessment Service Service Intensive Community Care Service CCG