Transcript HSJ Presentation

‘Navigating the
System’
Finding early opportunities to
access Community Services‘Discharge to assess’
work stream
Bie Grobet
South Warwickshire Foundation Trust
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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
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George Eliot Hospital
• District General
Hospital
• Serves a population
of 290,000
• North Warwickshire,
South West
Leicestershire and
North Coventry
• 352 beds
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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
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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
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Simplified access
Emergency Capability
Reducing variation
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Expansion of Intermediate Care and Virtual Ward
Services- Doubling capacity and workforce
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Service opening hours: 8.30 am till 12 Midnight
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Development of Community Emergency Response
capability- 2 hour response
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Simplified referral criteria – ‘Discharge to Assess’
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Drive to improve confidence and understanding of
Community Services by Acute and GP colleagues
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Reducing variation: 5 Daily Discharges- managing
Acute and Community flow commitment
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‘Orange’ and ‘Green’ Flow:
Bed days for adult emergency admissions 2008/09
Source: Dr Foster Intelligence &
NHS Institute (2011)
‘5- A- Day’ Project
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Early opportunities for 5 patients to be discharged
daily
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2 Community Nurses navigating patients to
Community Services
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Project Manager working across Acute and
Community
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2 work streams: ‘Orange flow’ short stay, ‘Green flow’
ward stays
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677 patients supported
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Shared data collection to measure success
Community Navigators
Project Manager role
across Acute and
Community
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•
Retraining Community Hospital
staff
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Change of culture and approach
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‘Hearts and minds’ presentations
Change
management
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Senior Leadership sign up and
‘Can Do’ approach
Improving
confidence
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Ward level engagement in
discharge planning
Whole system
sign up
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Integrated Emergency Care Board
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CCG and Board (x2) support
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•
Closure of Community Hospital
savings - £2.07M:
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£1.03 M reinvested in Intermediate
Care and Virtual Ward Services
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£400k invested in Intermediate Care
beds in Nursing Home
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£1M of further savings re-invested in
Acute contract
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18 Acute beds closed
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Winter capacity only opened
sporadically
Re-investment
Acute Trust savings
Bed Closure plan
Reduction in excess
bed days
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Reduction in bed days lost due to delayed
discharges from 3 months to 4 weeks
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Reduction in Length of Stay by 1 day for
Medicine and 0.4 day in Surgery on average
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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
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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
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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
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‘Discharge to Assess’
Re-admissions
Independence
•
677 patients supported in 6 months
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30% of patients supported by the Virtual
Ward for Long Term Conditions management
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94% of surveyed Virtual Ward patients felt
they benefitted from the service
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87% felt more confident to manage their
Long Term Condition
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68% of patients discharged from
Intermediate Care without ongoing support
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0.6% of cohort re-admitted
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16% requiring ongoing care package from
Social Care
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85% of patients still living independently at
home 91 days post Discharge (NI 125)
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Estimated Discharge
Dates
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‘Right patient- Right bed’
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Estimated Discharge Date compliance from
43% to 96%
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Less inter-hospital transfers
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Ahead of Deep Cleaning Programme
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Increased Qualified Nursing levels on the
wards
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25 Discharges a week compared to 6-7 to
bedded unit
Deep Cleaning
Reducing Variation
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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
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Reducing Variation: September 2011 versus January 2012
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7
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5
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3
2
1
0
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5
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2
1
1
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1
1
1
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2
2
2
2
3
2
1
1
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2
1
1
•Ahead of Deep Cleaning Programme
•Increased Qualified Nursing levels on the wards
No of Discharges
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Estimated
Discharge
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7
6
Dates
5
4
3
2
1
0
2
2
5
4
2
2
1
0
Reducing Variation
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7
6
5
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Deep Cleaning
Escalation Level
•25 Discharges a week compared to 6-7 to bedded
unit7
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5
5
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1
1
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4
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2
1
1
1
0
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1
2
1
0
1
No of Discharges
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1
0
1
1
0
1
0
2
2
1
0
1
0
2
2
0
Escalation Level
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Electronic Common Assessment Tool
developed between Health and Social Care
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Critical success measures openly shared
between organisations
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Twice weekly Tele Conference between
Health and Social Care to ensure patient
flow in Community
Automating Navigation
Shared data
Community Flow
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