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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
Slide 2
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 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
16
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
0
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No
. o
f P
ati
en
ts
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
High Impact Change Model
South – West Good Practice
South – West Good Practice
Somerset County Council
South – West Good Practice
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
South – West Good Practice
Swindon Council
PRACTITIONERS LEAD THE WAY TO
SIMPLER STRONGER SOCIAL CARE
A STORY OF CULTURAL CHANGE
SWINDON BOROUGH COUNCIK
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
Apr
17
May
17
Jun
17
Jul
17
Aug
17
Sep
17
Oct
17
Nov
17
Dec
17
Jan
18
Feb
18
Mar
18
Apr
18
May
18
47
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
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
Apr
17
May
17
Jun
17
Jul
17
Aug
17
Sep
17
Oct
17
Nov
17
Dec
17
Jan
18
Feb
18
Mar
18
Apr
18
May
18
48
STARTING THE CHANGE
PRACTITIONERS LEAD THE WAY TO SIMPLER STRONGER SOCIAL CARE: A STORY OF CULTURAL CHANGE
LOCAL GOVERNMENT STRATEGY FORUM – 16TH MAY 2018
FEAFEAFEAFEA
RRRR
59
%NOT
IDEAL
30
%COULD
HAVE
GONE
HOME
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
Apr
17
May
17
Jun
17
Jul
17
Aug
17
Sep
17
Oct
17
Nov
17
Dec
17
Jan
18
Feb
18
Mar
18
Apr
18
May
18
TIME
MO
RALE/PRO
DU
CTIV
ITY
49
THE CHANGE CURVE
PRACTITIONERS LEAD THE WAY TO SIMPLER STRONGER SOCIAL CARE: A STORY OF CULTURAL CHANGE
LOCAL GOVERNMENT STRATEGY FORUM – 16TH MAY 2018
AWARENESS
DESIRE
MOTIVATION
ACHIEVE
EXCEL
KNOWLEDGE
PRACTITIONERS
AWARE OF THE
JOURNEY AHEAD
PLANNING FOR THE
DIP IN MOTIVATION
TAKING
RESPONSIBILITY FOR
THEIR OWN PLANS
Oct
16
Nov
16
Dec
16
Jan 17
17
Feb 17
17
Mar
17
Apr 17
17
May
17
Jun 17
17
Jul 17
17
Aug
17
Sep
17
Oct 17
17
Nov
17
Dec
17
Jan 18
18
Feb
18
Mar
18
Apr
18
May
18
50
DESIGNING THE SOLUTIONS
PRACTITIONERS LEAD THE WAY TO SIMPLER STRONGER SOCIAL CARE: A STORY OF CULTURAL CHANGE
LOCAL GOVERNMENT STRATEGY FORUM – 16TH MAY 2018
DESIGN
TESTANALYSE
DRIVE &
PACE
0
1
2
3
4
PLACEMENTS PER
WEEK
0%
5%
10%
15%
20%
REASONS THAT THE IDEAL
OUTCOME WAS NOT
ACHIEVED
Oct
16
Nov
16
Dec
16Jan 17 Feb 17
Mar
17Apr 17
May
17Jun 17 Jul 17
Aug
17
Sep
17Oct 17
Nov
17
Dec
17Jan 18
Feb
18
Mar
18
Apr
18
May
18
51
DESIGNING THE SOLUTIONS
PRACTITIONERS LEAD THE WAY TO SIMPLER STRONGER SOCIAL CARE: A STORY OF CULTURAL CHANGE
LOCAL GOVERNMENT STRATEGY FORUM – 16TH MAY 2018
“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?”
Oct
16
Nov
16
Dec
16Jan 17 Feb 17
Mar
17Apr 17
May
17Jun 17 Jul 17
Aug
17
Sep
17Oct 17
Nov
17
Dec
17Jan 18
Feb
18
Mar
18
Apr
18
May
18
TIME
MO
RA
LE
/PR
OD
UC
TIV
ITY
52
IMPLEMENTING THE SOLUTIONS
PRACTITIONERS LEAD THE WAY TO SIMPLER STRONGER SOCIAL CARE: A STORY OF CULTURAL CHANGE
LOCAL GOVERNMENT STRATEGY FORUM – 16TH MAY 2018
DToC
Oct
16
Nov
16
Dec
16Jan 17 Feb 17
Mar
17Apr 17
May
17Jun 17 Jul 17
Aug
17
Sep
17Oct 17
Nov
17
Dec
17Jan 18
Feb
18
Mar
18
Apr
18
May
18
53
IMPLEMENTING THE SOLUTIONS
PRACTITIONERS LEAD THE WAY TO SIMPLER STRONGER SOCIAL CARE: A STORY OF CULTURAL CHANGE
LOCAL GOVERNMENT STRATEGY FORUM – 16TH MAY 2018
PRODUCTCONTINUOUS
IMPROVEMENT
Oct
16
Nov
16
Dec
16Jan 17 Feb 17
Mar
17Apr 17
May
17Jun 17 Jul 17
Aug
17
Sep
17Oct 17
Nov
17
Dec
17Jan 18
Feb
18
Mar
18
Apr
18
May
18
54
IMPLEMENTING THE SOLUTIONS
PRACTITIONERS LEAD THE WAY TO SIMPLER STRONGER SOCIAL CARE: A STORY OF CULTURAL CHANGE
LOCAL GOVERNMENT STRATEGY FORUM – 16TH MAY 2018
0
100
200
300
400
500
600
SOCIAL CARE DToC DAYS PER MONTH
99DISCHARGED
TO
RESI/NURSIN
G
<2
5DISCHARGED
TO
RESI/NURSIN
G
Oct
16
Nov
16
Dec
16Jan 17 Feb 17
Mar
17Apr 17
May
17Jun 17 Jul 17
Aug
17
Sep
17Oct 17
Nov
17
Dec
17Jan 18
Feb
18
Mar
18
Apr
18
May
18
55
MAKING IT STICK
PRACTITIONERS LEAD THE WAY TO SIMPLER STRONGER SOCIAL CARE: A STORY OF CULTURAL CHANGE
LOCAL GOVERNMENT STRATEGY FORUM – 16TH MAY 2018
Oct
16
Nov
16
Dec
16Jan 17 Feb 17
Mar
17Apr 17
May
17Jun 17 Jul 17
Aug
17
Sep
17Oct 17
Nov
17
Dec
17Jan 18
Feb
18
Mar
18
Apr
18
May
18
56
THE IMPACT
PRACTITIONERS LEAD THE WAY TO SIMPLER STRONGER SOCIAL CARE: A STORY OF CULTURAL CHANGE
LOCAL GOVERNMENT STRATEGY FORUM – 16TH MAY 2018
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
South – West Good Practice
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