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North East High Impact Change Model (HICM) Event
2 October 2018, 09:30-13:00The Durham Centre, Durham
Introductions and reflections on the North East journey in respect of HICMFiona Brown - DASS, Sunderland City Council
Managing Transfers of CareA National OverviewGlasha Frank - Department of Health and Social Care Martha Dalton - Department of Health and Social Care
MC1
Slide 3
MC1 LOGOSMacGregor, Calum, 12/09/2018
Behind every Delayed Transfer of Care, there is a person, in the wrong place at the wrong time
A ‘delayed transfer of care’ occurs when a patient is ready to leave a hospital or similar care provider but is still occupying a bed.
DTOC – the story so farDTOC has been a persistent problem over many years (national reports into DTOC since early 2000s)More recently….• National Audit Office Report (2015) - Discharging older patients from hospital
– 5% muscle strength that older people can lose per day of treatment in a hospital bed – £820m gross cost to the NHS of older patients in hospital beds who are no longer in need of acute
treatment.• National Strategy to address DTOC
– Care Act (2014)• Legislation outlining LAs duty in relation to assessing people’s needs and their eligibility for
publicly funded care and support– BCF National Conditions (New condition 4 (2017)
• Requirement for Social Care to work with NHS to implement High Impact Change Model to manage delays in transfer of care (expectations published)
• iBCF monies– NHS Five Year Forward View Next Steps
• Mandate for NHS to work with Social Care to reduce DTOC– CQC Local System Reviews (interface of Health and Care)– Increased collaboration centrally between national partners
• Delayed Discharge Programme Board - Strategic (DHSC, NHSE/I, LGA, ADASS, MHCLG, CQC, BCST
• Discharge Steering Group - Operations (NHSE/I, DHSC, LGA ADASS, BCST, MHCLG)
• There has been significant improvement in DTOC over the past 18 months
– in the face of persisting challenges (workforce, finances/austerity, commissioning
complexity)
• By far, the most critical and important work has come from YOU
(frontline colleagues)
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
% o
f o
ccu
pie
d c
on
sult
an
t-ld
be
ds
Nu
mb
er
of
de
lay
ed
da
ys
Joint
Social Care
NHS
Total
Ambition
Underpinning the data are numerous examples nation-wide, of health and care
colleagues going above and beyond the call of duty, working together to ensure
patients are not delayed unnecessarily in hospital – THANK YOU!
DTOC – the story so far
Despite the significant progress…- 4500 patients still in hospital every day (who don’t need to be there)- we have to keep up the work nationally, locally and individually.Nationally - a focus now beyond DTOC to reducing delays through out the entire patient journey• Ambition to reduce DTOC to 4000 beds by the latter part
of 2018• Ambition to reduce extended length of stay• Provide support to local systems
DTOC – the story so far
National SupportProviding support to systems so that people get the right care, right place and right time and encouraging the development of home first principlesProgrammes1. Enhanced – 14 system reviews across 9 areas to really understand why transfers of care remain a challenge2. Targeted – Tailored Peer Reviews to meet the needs of the system3. Universal – HICM regional events, Learning from CQC events, Why not home, Hospital Discharge/Home First Practitioner EventsTools (Links included)• Better Care Exchange / Bulletins• LGA Guidance documents• Webinars • DTOC Improvement tool (NHS Improvement)• Quick Guides (NHS Improvement)• HICM (see next slide)
• It was developed by national partners in 2015 to promote a new approach to system resilience and year around planning for timely discharge
• The model identifies eight system changes which will have the greatest impact of reducing delayed discharge
Why refresh the HICM • To take account to new national guidance, address
persistent implementation challenges and align guidance to reducing extended length of stay, improving patient flowand early intervention and prevention agenda.
High Impact Change Model
• We are keen to understand and collect an evidence base on what works and why some areas are challenged than others.
• We know that local leadership and collaborativeworking, investment in workforce and investment do have a role to play.
• We are also keen to explore whether a combination of national, local and regional support in this area works best
Understanding what works
Trusted Assessor –Lincolnshire Model and developing an approach to Trusted Assessment
Michele Briggs - Lead Care Home Trusted Assessor, Lincolnshire Care Association
MC1
Slide 11
MC1 LOGOSMacGregor, Calum, 12/09/2018
Trusted Assessments
Michele Briggs
Lead Care Home Trusted Assessor
Lincolnshire Care Association
Developed with John Woods Improvement Manager (Social Care)
13 |
Trusted Assessor Trusted Assessment
A real world example
Getting Going/ Checklist
Myth Busting
Agenda
14 |
What is A
Trusted
Assessor?
What is
Trusted
Assessment?
• A person carrying out an assessment on behalf of a third party
• A Trusted Assessor completes a bespoke and agreed assessment for a specific purpose.
• Using an assessment that was designed for one purpose to serve another.
• A Trusted Assessment is completed for one purpose but also used for a second purpose with the agreement of both parties.
15 |
Examples
• Transfers from hospital to an existing support package.
• Transfer of patients to an interim support package e.g reablement or intermediate care.
• New admissions to residential care & New packages of domiciliary support.
• Care Act Assessments.
• Assessments for occupational therapy equipment.
• Anywhere else you want to chase delays out of a process
16 |
How we do it in Lincolnshire
Care Home Trusted Assessor(CHTA)
Working together to improve transfers from hospital to care homes
CHTA in Context
� Common Problems:
� Delayed Discharge
� Lack of Trust between acute sector and care providers
� Workforce capacity – skills and capacity throughout the system
� ONE possible solution – Care Home Trusted Assessor
� Care providers as part of the solution not the problem
� Simple but effective
� Not the only solution
� Other trusted assessment
� Can be used standalone, or as part of a more compressive solution
Job Description
� DOES
� Undertake Care Home Pre Admission Assessment
� Liaise with Care Home
� Record/report to stakeholders
� DOES NOT
� Complete Statutory Assessments
� Choose or influence choice of Care Home
Recruitment
� Person Specification
� Integrity
� Communication
� Experience on both sides of the discharge
� Methodology
� Raise Awareness
� Indeed
� NHS Jobs
� Word of Mouth
Cost vv Benefits
� Annual cost for 1 FTE (6+days) approx. £60K including allowance for managing
service
� Allow for non-productive start (2-4 weeks) trust from care homes is essential
� Savings per
� Excel Model available
Developing the Care Home Trusted Assessor Role
Key factors of our success to date – OWNERSHIP brings TRUST
� Assessor is answerable to (ideally employed by) the Care Home Sector
� Service is available to all, but not mandatory
� Care Home documentation is used where appropriate
� CHTA must not place individuals
� Independence from all parties – individual care homes can be challenged if
appropriate
Recognising the importance of the information collected � Granular level information about delays
� Trends spotted in a timely manner (end of the week not the quarter)
Statistics per average month – 1.5 FE
80 referrals
66
Assessments Completed
64 discharges
Total days saved 250
Total Savings
£80K (Net)
24 |
The way
forward
• You need relationships to build trust
• Co-designing with all stakeholders can build the relationships
• Agree a set of common/shared objectives for the trusted assessment service
• Borrow and adapt other peoples’ ideas
• Agree• What kind of assessment will be
included in the service • Competencies and put in place
training requirements • How the service will be measured
• Find the funding
• Start slowly and grow
25 |
Mythbusting
What have you heard?
26 |
Questions
27 |
• [email protected] / [email protected]
• Rapid Improvement Guide• https://improvement.nhs.uk/resources/rapid-improvement-guide-trusted-assessors/
• Trusted Assessments - Essential Elements• https://improvement.nhs.uk/resources/developing-trusted-assessment-schemes-essential-
elements/
• Quick Guides• https://www.nhs.uk/NHSEngland/keogh-review/Pages/quick-guides.aspx
• Better Care Exchange• https://future.nhs.uk/connect.ti/system/login?nextURL=%2Fconnect%2Eti%2Fbettercareexch
ange%2Fview%3FobjectId%3D9820976#9820976
Further Information / Help
Putting arrangements in place for effective Discharge to Assess
Gemma Umpleby - Hambleton, Richmondshire and Whitby CCGCara Nimmo - North Yorkshire County Council
Hambleton, Richmondshire and Whitby
Integrated Discharge Pathways
Background
National Agenda
• Performance monitored as part of the HICM: Home first/discharge to assess, Trusted Assessment
• Reduce DTOCs and LOS
Local Targets
• Consultation – ‘Transforming our Communities’ provided a mandate to develop new models of care closer to home
• Poor performance against NHS England target of no more than 15% of DSTs undertaken in an acute trust
• Discharge to Assess for ALL patients
Patient no longer has care needs that can only be
met in an acute hospital
Pathway 1 Home
with Support Pathway 2 Pathway 3
Patient needs can be
safely met at home
Unable to return home-
Patient requires further
rehabilitation/reablement
Unable to return home-
Patient has very complex
care needs and may need
continuing care
Integrated Locality Team
Up to 6 weeksCommunity Based Beds DTA/Nursing Home bed
DST TO ESTABLISH EXPLICIT CHANGE OF FUNDING
Self
Fund/Self
Care
LA Funded
Home Care
Pathway 1 LA Funded
Residential
Care
LA Funded
Care
CHC
Funded
Care
Self Fund
Residential
Care
Self Fund/
Self Care at
home
Self
Funded
Care
THE D2A
Model
Tra
nsp
ort
: 3
65
Re
spo
nse
Pathway 1 Home
TATA
FNC
Including
patients
suffering a
delirium
episode
So for everyone…
• Pathway 1
• Pathway 2
• Pathway 3
Trusted Assessment = One referral process
One Form
One assessment
TRUSTED
ASSESSMENT
Intermediate care &
NYCC complete
assessment.
Patient discharged
home
Pathway 1 Home with support
Intermediate care &
NYCC to deliver
support for limited
period
Trusted
Assessment
Pa
tie
nt
me
dic
all
y o
pti
mis
ed
fo
r d
isch
arg
e
Home from
hospital Service –
Provided By AGE UK
Pilot November 2018:
MOU Agreement NYCC and Trust
Risk Analysis
Regular Communications
Culture change – “the in-perfect package”
Pathway 2
Patient
discharged
to SUSD Bed
Support from
ILT 7 days a
week and in
house care
team, goal to
reach
functional
optimum
Reviewed
weekly
Week 3
If no progress
made or
deterioration –
consider need to
complete DST
checklist
Week 3 (and
progress made)
Social Care
Assessment to
inform Discharge
planning
Pathway 1
Home
FNC
Not eligible
for CHC –
social care
package
Self-fund
(support
family ref
next steps)
DST
Outcome
Funding
DST/ Social Care Assessment to determine
onward funding responsibility6 Weeks Health Funding
Monitoring in place
Pa
tie
nt
me
dic
all
y o
pti
mis
ed
fo
r d
isch
arg
e
Social care
assessment
/DST if req’d
Fully
funded CHC
Discharge
plan
Trusted
Assessment
Discharge Home if
appropriate
DST
Ch
eck
list
Pathway 3
Friary (2 ring-
fenced
beds, all
beds can be
considered)
Community
Team receive
TA to trigger
visit within 48
hours.
Community
team to
deliver Rehab/
reablement
plan with goal
to reach
functional
optimum .
Requirement
for a CHC
Checklist as
part of
weekly
reviews if not
already
completed.
Pa
tie
nt
me
dic
all
y o
pti
mis
ed
fo
r d
isch
arg
e
Utilise pre booked DST Slots
Discharge plan
agreed through
MDT & Family
informed of
discharge
destination to
D2A Bed
Patient/
Family Leaflet
Benkhill
Whitby
Hospital
CCG
informed by
Discharge
Facilitator
of
placement
and Patient
transferred
to
Discharge
to Assess
Bed.
Dis
cha
rge
Fa
cili
tato
r
i
de
nti
fie
s p
rov
ide
rTrusted
Assessment
(SPoR
Referral
Form)
DST
completed
(within 28
days of CHC
checklist)
CCG
notified
of
funding
outcome
& date
of DST
Ward team deliver Rehab/
reablement plan with goal to
reach functional optimum .
Requirement for a DST
Checklist as part of weekly
reviews.
Community
Bed Base
Step Up/
Step Down
Beds
(Referral to
Coordination
Service)8
Non –
Commissioned
Services
Patient
identified as
unsuitable for
community bed
(justification
documented)
Patients NHS
Number and
justification
sent to CCG
CCG considers
Spot Purchase
Placement &
approves if
appropriate
(CHC approved
provider list only)
CHC Checklist
completed in
Acute Setting
prior to transfer
CCG confirm
date NHS
funding
ceases
(maximum
of 5 working
days post
DST
assessment)
All transferred Patients to be discussed on
the weekly conference call Tuesdays 12pm
(Minimum representation : NYCC, CHC,
SPoR, CCG)
CCG to receive completed monitoring requirements
from each agency each Tuesday following the call
DST completed
within 28 days
of CHC
checklist.
DST Assessments
• Since the introduction of D2A (mid August 2017) the average number of referrals for DST’s have reduced
by 30%.
• The outcomes of DST assessments has changed ( monthly averages):
– 14% reduction in fully funded patients
– 37% reduction in patients awarded Full Nursing Care
– 100% reduction in patients fast tracked following assessment
– 38% reduction in patients identified as not eligible for funding once assessed
0
1
2
3
4
5
6
7
8
9
10
Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18
Fully
Funded
FNC
Fast Track
Not
Eligible
Outcomes of DSTs
• Enables a period of recuperation within a homelike environment
• Reduced level of need for long term funding
• Fewer patients are going through the CHC assessment process
• Patients who are transferred to a Spot Purchase bed are high need patients who require complex care packages - 85% of patients qualified for funding
• Packages brokered through North Yorkshire County Council on behalf of health
• Savings to the whole system
• Reduced Delayed Transfers of Care
• 0% DST in acute setting
Pathway 3 – End of Year Review
Mrs Swale is an 83 year old lady who lives alone in Reeth all her
family live down South. Usually she is fully independent and is still
driving.
The neighbours are concerned that she had not been seen around the
village and had entered her house to find her on the sofa.
She said that she had been suffering from diarrhoea for three days and was
clearly dehydrated. When they attempted to walk her she was too weak to
stand. Paramedic complete initial assessment Patient admitted to CDU.
‘Off Legs’
Ward complete a Trusted Assessment
Pathway 1: Referral to Social Care
requesting a 48 hour response and Home
from Hospital Support
A community health assessment requested
by Fast Response within 24 hours.
MAMS
Meeting
Home from Hospital Service visit
patient within 24 hours; check
family/ neighbours support in place
for the next 24 hours
Social Care
assessment
within 48 hours
Mrs Swale is an 83 year old lady who lives alone in Reeth all her
family live down South. Usually she is fully independent and is still
driving.
Paramedics were called as the neighbours were concerned that she
had not been seen around the village and had entered her house to
find her on the sofa.
She said that she had been suffering from diarrhoea for three days and was
clearly dehydrated. When they attempted to walk her she was too weak to
stand. Paramedic complete initial assessment. Patient admitted to CDU –
Patient requires therapy assessment and is anxious.
‘Off Legs’
MAMS
Meeting to
deliver
Patient
Discharge
Plan
Ward complete a Trusted Assessment
Pathway 2: Referral to Step Down Bed.
Patient transferred to Step
Down Bed within their locality.
10 hours personal care
provided per week.
Therapy
Assessment
Completed by
Community Team
Social Care
assessment
Patient stay 2
week : weekly
Therapy support.
Mrs Wensley is an 83 year old lady who lives in West Witton she has moderate
dementia. She receives BD carers who help with washing and dressing. Mrs
Wensley has a background of type two diabetes and hypertension. She takes,
Ramipril, bendroflumethside, metformin and gliclazide.
Mrs Wensley is admitted to the Friarage where she stays for a period of 4 days creating a level of
confusion preventing her from going home or to a step down bed. It is felt further observation is required
to understand her long term needs
One of the carers witnessed Mrs Wensley
collapsing and call a paramedic.
Patient spends 4 days in the
bed for observation. Following
which it is decided a CHC
checklist is not required.
Patient returns home
MAMS
Meeting
Patient transferred to a
commissioned Discharge to
Assess bed pathway 3.
Social Care
assessment
Pathway 3
Patient Outcomes:
• Home First at the soonest possibility
• Proportionate support in at the right time
• Utilising existing systems and support already in place
• Identifying the right pathway for the individual patient
• Clear pathway home
• Continued reablement and support in the right setting
• Utilising commissioned beds
• Assessment in the right setting
Learning
• Requires good working relationships
• Pragmatic approach
• Clear clinical leadership
• Wide ranging and ongoing engagement as a
system
Pathway 1 Home
For patients on a hospital ward who can return home.
• Patient discharged through the Age Uk ‘ Home from Hospital’ service.
• They receive a Patient Centred Care Plan to support their continued independence and self-care management.
For patients on a hospital ward who can return home with additional support from their local Integrated Locality Team.
• Patient discharged through the Age Uk ‘ Home from Hospital’ service.
• They receive ongoing support at home and stay on the pathway for up to six weeks.
• The ward multidisciplinary team completes a single Trusted Assessment for ongoing care needs in the patient’s home, which is shared between social care and community health teams (trusted assessment). Intermediate Care Team or the reablement service provides care and therapy at home to support patients’ recovery to independence. The intensity of the service depends on patients’ needs: they can be seen up to four times a day.
• Daily review process required
Pathway 2
For patients who cannot be discharged home directly but could return there with additional
rehabilitation and reablement
• Patients are discharged to a community bed or temporary residential care via trusted
assessment for up to 6 weeks.
• The local Integrated Locality Team manage the discharge home during the 6 week
temporary placement.
• Daily assessments
• All packages identified via Local Authority Brokerage System
Pathway 3
For patients likely to need ongoing care in a Care Home or Residential setting, who may be
eligible for continuing healthcare funding.
• The hospital-based team has assessed these patients as having complex care needs and
likely to require daily care at a higher level than pathway 2.
• Patients suffering a delirium episode and require daily care until they are fit for
assessment.
Refreshing the HICMJune 2018 – April 2019
Glasha Frank - Department of Health and Social Care Martha Dalton - Department of Health and Social Care
• HICM was introduced in 2015 as a improvement toolkit to help health and social care systems consider a implementing a series of Changes in order to reduce DTOC and improve patient flow.
• This year, there is a ambition to refresh the model to better links with emerging national agendas on improved patient flow, community support and reducing length of stay.
Introduction
HICM Refresh Questionnaire • Below is a link for the HICM refresh
questionnaire, This is a further opportunity for you to provide feedback as a means of informing the refresh of the HICM. It should take around 10 mins to complete.
• For reference the HICM can be found here
http://survey.euro.confirmit.com/wix/p1866998059.aspx
• To find out how you use the model and your views on how this could be improved?
• To find out what has been most useful / least useful when implementing the model and considering the impact it has had
• To find out what you what you think the gaps are in the current model and how you think it should be improved and why
The views from this workshop will directly feed into collecting the evidence base for revising the current HICM.
Purpose of the workshop
Stage 1Spend 20 minutes considering the following questions
Q1. How do you use the HICM and what is missing?
Q2. What Change has had the most / least useful in improving patient flow and why?
Use prompt questions provided that are on the tables
Stage 2Spend 20 minutes considering the following questions
Q3. How do you think the HICM could be improved?
Please make use of the prompt questions for this question provided on each table.
Next Steps• Understanding the key themes from each of the
nine HICM refresh workshop
• Set up of a National Reference Group of practitioners to act as a sounding board for the development of the refreshed HICM.
• Aim is to publish refreshed model by April 2019
Reflections on the morning / What next
Fiona Brown - DASS, Sunderland City Council
Thank you for attending!
An Evaluation will be emailed round, please could you
ensure you take the time to fill this in.
