Dr Sheena MacDonald Medical Director NHS Borders and

Mr Eddie Fraser...

‘DELAYED DISCHARGE – A WICKED, BUT RESOLVABLE

PROBLEM’

The challenge remains….

Some patients are in our hospital system that could be managed out of hospital and not admitted at all

ANDSome patients are delayed in our hospital system that could be managed out of hospital

Reshaping Care Pathway

THE DD EXPERT GROUP

• A culture and behaviour change is required so that any delay for a day longer than is necessary is deemed unacceptable and that the norm should be discharge within hours and days rather than weeks.

• A perception should be promoted that 2-3 days be considered a reasonable period for someone to return home.

• Patients should not have their long term care needs assessed in an acute bed unless unavoidable and appropriate due to the clear levels of future care required.

•The default position should be that the patient is discharged to the accommodation they occupied prior to admission. Only if this is not possible should alternatives be investigated.•Patient should not be admitted directly from an acute setting to a long-term stay in a care home, unless unavoidable and appropriate.•Leadership of the delayed discharge agenda should be improved at several levels.•The code 9 cases needed more robust challenging and should be kept under regular review with much more focus.•Alternatives to hospital admission must be developed and accessible to GPs

•Full use should be made of appropriate step-up facilities including community hospitals to avoid admission to acute hospitals.•A ‘gatekeeping’ function should be established at A&E with the ethos of ‘decide to admit’ rather than ‘admit to decide’. This could be primary care based teams with a knowledge of community options that could triage and manage risk.•Better use should be made of Day Hospitals and 23 hour beds.•Links should be improved between acute hospitals, NHS24 and SAS.•Risk prediction and case / care management should be further developed.•Intermediate care options, including ‘virtual wards’ and specialist integrated community teams should be explored.•The use and sharing of Anticipatory Care Plans should be expanded.•Early application of frailty screening criteria should prompt early flow to specialist geriatric teams when required.

•Estimated Date of Discharge (EDD) should be routinely set.•Although ultimately for the clinician in charge, clinical readiness for discharge should be a MDT decision.•Where appropriate a form of self-assessment should be introduced.•An interim, quick and easy, assessment should be developed that can be undertaken by any appropriate member of the MDT.•Where a local partnership has identified a local need for residential intermediate care, dedicated care homes could be identified and developed as hubs to provide this. This might provide everyone with the opportunity for recovery, rehabilitation and reablement before confirming long-term care home requirement. •Avoid inappropriate care home placements by improving enhanced home care, improved rapid response services, equipment and adaptation provision.•Adopt a reablement approach and start this within hospital.•Agree local timescales for cancellation of existing care packages,

•There should be local agreement on direct purchase of home care by ward staff withset timelines and built in review process.•Better engagement with housing is neededThe choice policy should be reinvigorated at a local level with senior ownership among health and social care executives and medical practitioners.A national message that a patient does not have the right to remain indefinitely in hospital would be helpful.In cases of disagreement, the patient should be discharged while resolution is sought.Improve use of intermediate care as step-down.A dedicated group be established to look at where the blockages in the guardianship process are occurring and work with colleagues in health, social care and the justice system to improve the situation.Partnerships experiencing difficulties with AwI to invite support through the Joint Improvement Team

So how did we do?

Bed days occupied by delayed discharge patients; All ages; Trend

Source: ISD Scotland

Latest published data as at April 2014;Delayed Discharges by Length of Delay and LA

Source: ISD Scotland

And more older people live at home

Latest Census Management Data as at June 2014: Delayed Discharges (> 6 week target)

DELAYED DISCHARGE SUMMIT AND TASKFORCE 2014• Cross sector multidisciplinary

lock in !

Using technology and local assets

• Now:• In test sites begin to build cross sector

collaborations with action learning and evaluation :

• Third sector and housing links in discharge hubs to connect to local assets - ? role for ALISS

• Map and scope potential to pool local care workforce to improve cover out of hours, reduce duplication, improve efficiency and personalisation

• Deep dive on housing delays and available lets Connect Intermediate Care Teams with local Third Sector and housing with care providers

•

15/16:Use Integrated Care Fund and national funding to spread above beyond tests sites Improve processes for (re)allocation of available adapted propertiesUse Technology enabled care to manage risk and connect with family / unpaid carers Simple narrative to increase staff / public / family awareness of new models Develop volunteer home from hospital support using experienced retired public sector staff Develop hub / cluster models for housing support; day care; care at home Strategic Commissioning:Living wageMarket facilitationInvolve local HEIs in recruiting to care sector

Supporting Choice and improving quality of care sectorNow: Identify true cost of care and costs to build a quality workforce Invest in workforce training and developing relationships with the care

sector Cross sector partnership working and make better use of third sector Share good practice across areas and sectors15/16: Influence care inspections to be asset based and outcome focused Involve geriatricians and nurse practitioners in supporting the care

sector Strategic Commissioning: Build community capacity including Third sector, family networks,

community support Develop new models to support more people to remain at home / in

the community

WORKFORCE DEVELOPMENT AND CULTURENow: Challenge health senior leadership team (MD, DoNMAHP, DPH, Chief Exec

) to deliver:o Home First / discharge to assess ethos o Delegated criterion led discharge from hospitalo Practice where clinicians do not prescribe care packages

National summary of key messages about harmful consequences of delays - increased mortality and decreasing independence – and challenge view of hospital as place of safety

Statement regarding valuing the workforce - terms and conditions and standards

15/16 Flexible use of workforce – HCSW, Generic support worker; Rehab

assistants Further spread of re-ablement Ensure senior decision making is not risk averse Strategic Commissioning: Workforce development plans Revisit IRF to inform strategic plan and scrutinise variation

ASSESMENT AND FUNDING

Now: Make return Home the default position Simplify and fast-track risk assessments that enable early

discharge to assess at home Ensure timely reviews of all care packages to recycle resources15/16: Person centred discharge assessment and care planning that

also involves the family Shift resources ( funding and workforce ) from acute to

community integrated care teams Start integrated discharge planning at point of admission to

hospital ( or pre-assessment clinic ) Ensure early assessment of capacity Embed telecare and telehealth within the integrated

assessmentStrategic Commissioning: Aggregate assessed needs to inform strategic commissioning -

including housing fit for the future

INTEGRATION OUTCOMES