south west adass · dtoc –the story so far dtoc has been a persistent problem over many years...

South West ADASS/ NHSe and

Local Government Association

Implementing the High Impact Change

Model workshop – 16th October 2018

Taunton Racecourse

Managing Transfers of Care

A National OverviewHigh Impact Change Model Events

Autumn 2018

MC1

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%

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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 principles

Programmes

1. Enhanced – 14 system reviews across 9 areas to really understand why

transfers of care remain a challenge

2. Targeted – Tailored Peer Reviews to meet the needs of the system

3. Universal – HICM regional events, Learning from CQC events, Why not home,

Hospital Discharge/Home First Practitioner Events

Tools

• 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 flow and 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 collaborative

working, 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

South West – Good Practice

Task – 15 minutes

• Within your health and care communities

identify on the flip charts which elements of

the 8 HCMI model are working well for you

and require further development

• You can identify something that is working

well ands requires further development

• Can you provide the lead for the HCMI activity

Longer Length of Stay Patients

What? So What? Now What?

Emergency Care Intensive Support Team (ECIST)

Vanessa Williams, Improvement Manager

Contents

• What is a Longer Length of Stay Patient?

• When does a patient become stranded?

An Example Patient Journey…Need for Change

Anecdote Anecdote

Evidence Anecdote

• Understand and take ownership of the situation

• Look at the data

• Site diagnostics

Work on facts not assumptions!

Where to start?

https://www.youtube.com/watch?v=RZWf2_2L2

v8

Beds aren’t capacity

‘Beds are where patients wait for the next thing to happen’

Look at the Data: Delays

Proportion of beds for……..

Delayed transfers of care 4.37%

Super stranded patients 15.89%

Stranded patients 48.96%

Length of Stay No. Beds No. Patients

<3 5 1418

3-5 8 815

6-7 5 607

8-14 88 1094

15-21 25 503

22-28 21 303

>29 80 546

Total 232 5,286

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Date Report Run

Number of Over 14 Day Stay Patients

Geriatric MedicineStranded Patients Mean (Ave) Lower Control Limit Upper Control Limit

Significant reduction in number of patients with a

length of stay of over 14 days.

Evidence of early success with stranded patient

reviews.

• What is the situation at ward level?

• Does this correlate with the data?

• How does this compare with best practice guidance?

Useful approaches:

- Acute walk-through

- Length of stay review

- Discharge events

- Patient journeys

Site Diagnostics

The Start

• Ownership of the problem

• Review the data

• Site Diagnostics

• Building trust

The Middle

• Executive sponsorship

• Motivating staff

• Creating work streams

• PDSA cycles of change

The (Never) End

• What worked?

• What could be improved?

• What didn’t work?

• Sustainability

The Improvement Journey

27 |

• A practical approach to review and reduce the number of long stay patients (length of stay 21 days plus). The approach is based on the recently published NHSI ‘Guide to reducing long hospital stays’ (see page 29).

Approach

#longstaywednesday

28 |

• A practical approach to review and reduce the number of long stay patients (length of stay 21 days plus). The approach is based on the recently published NHSI ‘Guide to reducing long hospital stays’ (see page 29).

• Agree an initial date (a Wednesday) to test the process on a number of wards.• Run a preparation session with everyone who will be involved with the process the

day before.• Every Wednesday (#longstaywednesday) a dedicated team visits agreed inpatient

wards to review all long stay patients (21 days plus).• One of the advantages is doing the review on the ward (close to the patients) so

members of the MDT can contribute and ward teams don’t need to leave the clinical area.

• Each ward manager should know that the #longstaywednesday team will be visiting their ward at an approximate time every Wednesday so they can be prepared.

• After a number of weeks, if the approach is standardised, ward teams will become increasingly proactive to tackle delays and ensure there is a robust plan for each patient that includes clinical and functional criteria for discharge. They will also be clear about the process to escalate actions they cannot resolve.

Approach

#longstaywednesday

30 |

• For each patient with a length of stay exceeding 20 days, ask ‘what is the plan’? This is about the entire clinical plan, not just the discharge plan.

• Ideally there should be a clear clinical plan with a diagnosis, clinical and functional criteria for discharge. Clearly establish what the patient is waiting for – ‘medically unfit’ is not an acceptable response. A probing question to ask is, ‘What is the next thing that needs to happen to progress this patient’s discharge?’

• Once it has been established if the person is medically optimised/fit/stable/not fit, the team administrator should record an appropriate code for each patient (The ECIST codes are attached (word document) codes – the visiting team members should have a copy of this, so copies will need to be pre-printed) into the attached excel spreadsheet.

Each individual patient review after practice shoul d take about 2 -3 mins (initially it will take longer):

#longstaywednesday

‘SAFER’ at home?

• Marginal gains- never underestimate the value of small and simple

• QI methodology

• Meet weekly as and MDT- communicate, communicate, communicate

• Don’t pass the baton of blame, look for solutions

• Senior decision maker is essential

• Can do transformation and quality changes without any new money

• Have a clear focus and embrace the evidence

The (Never) End

Thank-you for listening

Questions or Comments?

[email protected]

High Impact Change Model

South – West Good Practice


Somerset County Council


Plymouth Council

Improving System Flow

Home First

High Impact Changes

In the Beginning

• A system under pressure!

• LoS and DTOC’s too high! We were not delivering the service we want for people!

• People were Assessed for Discharge To Assess!

• Care needs were planned in hospital environment

• Delays in assessment and brokerage increasing LoS

• Over reliance on bed based care following acute admission

• Health staff had a lack of confidence in home discharge if person had ongoing needs

Key Principles

• Home is ALWAYS the 1st Option considered– People want to go Home!

• Hospital is NOT the best place to determine someone's needs when living home– We will use capacity more effectively

• Ring-fenced Reablement Capacity

• People discharged and visited within 2 hours– Discharges and booked into planned timeslots!

• Co-Location - “One Team”– Reabelment provider hosting assessment staff

Evidence its working…

• Delayed Transfers of Care: ASCOF Indicator 2C(2)

• What is the evidence to support why the

work-steam is working well

Evidence its working…

• 35 patients per week discharged with Home

First

• 75-80% independent after Reablement

• At point of discharge hours per person

reduced from 11 hours pw to 9 hours pw

– 20% more effective use of capacity

Learning & Tips

• Listen to peoples experiences

• Co-Design and oversight

• Regular and rapid feedback

– Feedback the positive news too!

– Use your principles to overcome your challenges…..

• Innovative communication & feedback

– Ask Tina, Home First Ambassadors, Intranet

– Wards, community staff and Senior Leaders

Learning & Tips

• Determination


Swindon Council

PRACTITIONERS LEAD THE WAY TO

SIMPLER STRONGER SOCIAL CARE

A STORY OF CULTURAL CHANGE

SWINDON BOROUGH COUNCIK

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THE BEGINNING

PRACTITIONERS LEAD THE WAY TO SIMPLER STRONGER SOCIAL CARE: A STORY OF CULTURAL CHANGE

LOCAL GOVERNMENT STRATEGY FORUM – 16TH MAY 2018

REABLEMENTVOLUME & EFFECTIVENESS

ACUTE

DISCHARGEBETTER PATHWAYS

FRONT DOOROPERATION FAST-TRACK

COMMUNITYBEATING THE BACKLOG

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STARTING THE CHANGE



FEAFEAFEAFEA

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HOME

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THE CHANGE CURVE



AWARENESS

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PRACTITIONERS

AWARE OF THE

JOURNEY AHEAD

PLANNING FOR THE

DIP IN MOTIVATION

TAKING

RESPONSIBILITY FOR

THEIR OWN PLANS

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DESIGNING THE SOLUTIONS



DESIGN

TESTANALYSE

DRIVE &

PACE

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DESIGNING THE SOLUTIONS



“WE HAVE A PROBLEM AND ITS THEIR FAULT, WHAT ARE YOU

GOING TO DO ABOUT IT?”“WE HAVE A PROBLEM, I’VE

SPOKEN TO REABLEMENT AND THIS IS THE ACTION WE’VE TAKEN, IS

THAT GOING TO WORK FOR EVERYONE ELSE?”

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IMPLEMENTING THE SOLUTIONS



DToC

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PRODUCTCONTINUOUS

IMPROVEMENT

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0

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SOCIAL CARE DToC DAYS PER MONTH

99DISCHARGED

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MAKING IT STICK



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THE IMPACT



BEFORE NOW

PERMANENT ANNUAL ADMISSIONS TO RESIDENTIAL &

NURSING210 166

PEOPLE RECEIVING HOME BASED OR RESIDENTIAL

REABLEMENT600 1200

LENGTH OF STAY IN RESIDENTIAL REABLEMENT 58 days 22 days

FRONT DOOR WAITING LIST > 3 months < 6 weeks

MONTHLY DTOC > 500 days < 30 days

£2.7

MSAVINGS

TARGET

£3.3

MSAVINGS

ACHIEVED


Task - Identify good practice on the HICM – 35 minutes

• Discuss the key principles of the good practice

• What is the learning for the care and health system

• What are the key improved outcomes - for people and care and health system

• What are the 2/3 top tips that were key in the development and /or delivery of the good practice - this could be a commissioning/ integration or operational top tip

South – West Areas for Further

Improvement

Task – Identify areas in the HCMI model that need

further development – 40 minutes

• Discuss the improvements that could be made

and the actions needed to bring about these

improvements.

• How will you monitor the impact of these actions

• How can SW ADASS / LGA provide support and

assistance on the HICM and other areas of work

around discharge planning

Refreshing the HICM

June 2018 – April 2019

• 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

• 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 1

Spend 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 2

Spend 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

south west adass · dtoc –the story so far dtoc has been a persistent problem over many years...

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