Care in Crisis - the challenge

Carol Herity – Head of Partnerships

Our challenge:

“To identify what further support the Third and Not for Profit sector can offer to reduce delayed discharges.”

Scope:

• Delayed transfers of care

• Multi-disciplinary Team decision that the

patient is ready for discharge/transfer

Whole system support is needed…

• Acute & Community hospitals

• Intermediate Care Beds

• Clinical Commissioning Groups Enhanced

Assessment Beds

• Local Authority residential placements

Underlying principles:• Coordinated inter-organisational approach• In-reach model• Early identification of patient needs• Continuity of responsibility for delivery• Daily review of progress and discharge plan

update• Discharges up to 8.00pm x 7 days per week• Value for money• Agreed evaluation criteria• Sustainability

Benefits

• Increase in the number of patients referred to Third and Not for Profit Sector support each day

• Increase in the number of patients discharged each day with this support

• Daily update of the number of patients MDT fit for discharge flagged as needing the sectors support (waiting list)

• Daily update of the total number of occupied bed days since the patient was flagged as MDT fit for discharge awaiting this support

Outcomes

A reduction in:• Numbers of Medically Fit For Discharge in

any setting• Patients length of stay• Readmissions

How will we know it is working

• Review of any patients readmitted as an emergency / attending ED following discharge with Third Sector support v readmissions / ED attendances of patients not receiving Third Sector support– Within 48 hours– Within 7 days– Within 30 days

• Review of any patients readmitted as an emergency / attending ED following cessation of this timed support

Thank you

Questions?