Delayed Transfers of Care

(DToC) Roadshow Follow-

up

Grainne Siggins, Regional ADASS Lead and

Director of Adult Social Care, London Borough of

Newham,

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SHORT DESCRIPTION FULL COMMENT

Timely assessment • Lack of truth between professionals. Lack of good info sharing / communications . Each professional

assessing their 'bit' - differing risk aversion - differing risk and responsibility .

Multiple assessments • Causes delays -- multiple geographies - health and social car e- no trusted assessors - people

decondition .

Timely reviews • Lack of consistent staffing (sw/provider who are unable to spot deterioration due to lack of staff and no

key worker for some people for vulnerable adults.

Discharge planning in hospital • Do we know what services/care they already have? - are patients involved - lack of clarity who is

responsible - lack of recognition of baseline at home - lack of discharge co-ordination .

Information sharing • Between staff - with patients - need to gather info about the patient - centred around them - no info given

to homecare workers on discharge - people don’t take info home .

Unnecessary admission

/readmission

• Cause not always solved e.g. , cold home .

Complex Pathways • E.g. major adaptation . - variability/paperwork and process.

Input into house before admission • Adaptation

Poor knowledge of the system • Adaptation available - no cross over of expertise - fragmented system.

Commissioner Practice • Framework can destabilise the market.

Joint approach • Risk assessment.

End of life • No DNAR set up - can delay discharge to set up care at home - care worker having care planning

discussion rather than with clinician.

Crisis intervention service rather

than service that keep people well

at home

• Funding issues - lack of encouragement .

Care in community • Go into hospital with patient - difficult because different commissioner .

Issues raised

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Solutions proposed Improve the image of homecare • Led by homecare/provider - Skills for Care / or Health? With UKHCA and NHS England -

professional campaign into hospitals. Piloting new approaches to providing homecare to PR - media

around workforce - valued , support. Image - mutual request. Frailty hub - integrated care network -

single point of access.

Skilling • Skilling up carers who are caring for those with frailties / disabilities especially training post -

discharge - voluntary sector help - Skilling up carers included in commissioners guide for local care

strategy. Better carer programme.

Creative role of pharmacy • Pharmacists involved in medication on discharge - better use of medication - need to be more

involved in integration agenda - lead - CCG

National programme for

medication training

• For carer. Lead - Skills for Care and care worker - Skills for Health

More CHC budget into BCF • New assessment framework.

Build capacity to network across

acute and community

• Induction include visits to other services - co-ordinators with knowledge for patients - co -location of

services - joint or rotational posts Lead .

Career program in health and SC • Opportunities at all levels - value staff, H and W , supervision - Mechanisms to capture innovation -

Sell the lead skills for health skills for care course. New staff - understand career progression

available and recognising skills of homecare worker.

CQC rating of good /outstanding • Using existing toolkits. Lead - NHS England /CQC/DH - next - step find out which toolkits work well.

Co-location of social care and

housing and health both social

and private

• Commissioner bring together market position statements - . Lead - locally as it wont work

everywhere - Kings fund doc on commissioning talks about co-location.

Digital info sharing • Patients hold their own image helps with IG issues .

Big data technology for

commissioning

• Jointly driving behaviour change. Next step - every life tech and other to be investigated as to what is

already happening.

System wide metrics for patient

experience

• STPs should have this, Lead - NHS England. Next steps - Assurance of STPs - ensure system wide

metrics are included .

Secure email • Stop faxes in the NHS - Guidance from NHSE about good practice / option for secure email. Cultural

change program re: data protection / info sharing.

Standarised checklist • On admission - for baseline assessments - include homecare workers/ carers etc.

Take home information • Developed by patient groups - choice available

Local Solution • Community services available.

Voluntary sector into hospitals • Being involved in early discharge conversation - option available – involved in MDT board. Example

- Birmingham. Shared good practices across the system.

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Behind each number is a personal story

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• Beds are where patients wait for the

next thing to happen

• Capacity is decision making

• Everyone has a bed at home

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No correlation with 95% performance – massive

variation in counting

Medically Fit For Discharge lists are really unhelpful and

the difference between the two lists are nearly all delays

that are internal to the acute trusts in that they have not

followed due process or planned in advance

Sequential planning is the issue

Far more health than social care delays

Improvement in acute stranded patient metric has linked

to performance but is not a benchmark indicator

Time spent at home is the best outcome metric we have

seen as this takes account of time in step down beds

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Planning for discharge on admission or pre admission

for elective patients

One assessment/information gathering of function pre-

admission at handover from ambulance or as soon as

possible after.

Ask from the person/family perspective not therapy tick

boxes – discharge plan started at this point

Expected Date of Discharge with clear clinical plan with

clinical and functional criteria for discharge set within 24

– 48 hours of admission

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Daily review and decision making remove wasted days

within the hospital journey

Early in the day discharges 1 on every ward before

10.00 and 35% before midday

Review of every person in hospital over 7 days and in an

ideal world will be able to measure this at super spell

level (Camden)

This is the SAFER flow bundle

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In hospitals that implement the SAFER bundle

The number of patients in hospital over 7 days reduces –

stranded patient metric

Overall LOS reduces

Number of referrals for complex discharges reduces

Need for services outside the hospital is not increased

It appears to reduce the need for bed based services

and reduces admissions to long term care

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The overall average inpatient stay has

reduced by 3.5 days

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Early identification of people likely to require support on discharge – front

door collection of ‘how I live my life’

Set expectations on admission – welcome card/ticket home

Same notification process used as the referral mechanism for all out of

hospital services health or social care using the form that the initial

information is collected on

Sent through a joint simple/single point and streamed to a service based on

needs – need an integrated/joint intermediate tier that always says ‘YES’

Hospitals to stop telling people what they will receive and need 25% over

prescription of support required on discharge.

Do assessments of long term need wherever possible in the persons usual

place of residence.

◦ ‘Why not home’ and ‘Why not home today’

Intermediate short term support, re-ablement, rehabilitation, allow time to

recover from acute episode before long term decisions are made

Placements into long term care placements or new home care packages

from a hospital bed should be an exception

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Blame

Each partner focusing on their ‘must do’s’ in isolation

Step Down/Warehouse beds

◦ Shifts the problem

◦ Stretches the assessment capacity

◦ Unbalances the market

◦ Patients become lost in the system

Making long term decisions in hospital

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Very variable – joint vision and system leadership is vital

Have to fix all parts not one or the other – this is complex

system change

Ensure central messages don’t cut across partnership

working at local level

Joint working between TEASC/ADASS/ECIP has worked

well

Voluntary and independent sector not used to their full

potential need to be included more

Best way to achieve change is for systems to focus on

the person and their populations together

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Focus on the person – person centred

Networks of care

Easy access to services and information

Effective assessment – timely, proportionate

Avoidance of personal crisis

Easy information flow

Blurred boundaries

Continuous feedback and evaluation

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Actions to Address Delayed Transfers of Care

Work for this year builds on learning from last year…

Last winter, the Helping People Home Team (DH, DCLG, LGA, ADASS and NHS England) provided support and challenge to local systems experiencing high levels of delayed discharges.

Their work with 45 economies across England highlighted the importance of working across whole systems to ensure smooth patient ‘flow’ through health and care services. The work highlighted a number of interventions that were key to supporting improved performance.

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