2.1 At the Collaboration Board in July, it was agreed that the 7 Day Services Team would:

Transcription

1 NWL CCGs collaboration: strategy and transformation steering group North West London Seven Day Services programme Discharge Initiative Approach & General Update Author: Rachel Tustin, 7 Day Services Lead Version: 24 September Introduction 1.1 Seven Day Services is a national quality priority. National standards in urgent and emergency care have been published for implementation NHS-wide over the next three years. Standard 9 sets out the requirement for a 7 day discharge pathway. 1.2 Based on the feedback from NWL Providers, CCGs & the Collaboration Board, the 7 Day Services team was tasked with scoping a possible piece of work on improving discharge pathways across NWL. This work was discussed with SaHF Programme Board & Clinical Board, both of which supported it. This paper reports back on each of these activities. The purpose of this paper is to agree as a Collaboration of CCGs the approach and proposed workplan for the discharge initiative detailed in the paper. 2. Background 2.1 At the Collaboration Board in July, it was agreed that the 7 Day Services Team would: carry out engagement and scoping meetings with CCGs, Hospitals, Community Services, Social Services, BCF Leads, WSIC sites etc. in order to: map current community services across NWL including referral processes, criteria & forms, opening hours, service type/ provision and availability of SPAs/SPORs (and services available through them); understand all current work on discharge to prevent duplication and ensure project is adding value; and understand appetite for the project; gather data from across the system including: cross-borough transfer numbers; and day of care audits from hospitals; design, agree and implement the governance structure of the programme of work; and

2 return to Collaboration Board to agree the scope & timeline with the CCGs. 3. Key proposals / key findings 3.1 At the July Collaboration Board, the following problem statement was agreed in principal: community Healthcare services available to support patients vary geographically by name, provision, referral criteria etc; referral / assessment forms and processes for these community services also vary across NWL depending on provider, service and geographical location. This can cause confusion for the hospital staff and GPs managing the paperwork; often, the assessment of patient need carried out by hospital staff is not trusted or accepted by community teams, who require a reassessment of the patient which can delay discharge by up to 48 hours; and these issues cause problems particularly when the discharge crosses a CCG or local authority boundary. Hospital staff are unfamiliar with services, geographical boundaries, referral processes & assessment forms for that area and community staff are less likely to rely on the hospital assessment of patient need. 3.2 Following Collaboration Board, further data has been collected and analysed as part of the agreed next steps, in order to support this assumption, with the following results: 25% of NWL non-elective admissions were to a cross-border 1 hospital within NWL in 14/15; the average length of stay for a cross-border admission within NWL is 0.7 days longer than one within a CCG boundary; and if the length of stay of all cross-border admissions within NWL could be reduced to equal that of within borough admissions, the system could release 70 beds and commissioners could save 5.16m a year 2 in excess bed day fees. 1 For tri-borough area all cross-border activity is defined as all activity excluding Imperial and Chel West. Ealing CCG s excludes Ealing Hospital, Brent CCG s excludes Northwick Park & Central Mid, Harrow CCG s excludes Northwick Park, Hounslow s excludes West Mid and Hillingdon CCG s excludes Hillingdon and Mount Vernon. 2 Based on 14/15 activity numbers and the assumption that 1 bed day saved = 200

3 3.3 Current community services that support discharge (excluding any residential services) and their referral routes have been mapped across NWL:

4 3.4 In the proposed solution, referral routes into community services that support discharge (excluding any residential services) could look as follows:

5 3.5 Proposed solution Scope: discharges of in-patients with a new or changed need for community healthcare support in their home on discharge from a hospital ward, including those that cross CCG boundaries. Proposed Solution: assessment for community discharge services focuses on the patient s current need & function; assessment of patient need and function occurs within the hospital and is carried out by the hospital MDT. However, decision-making about which community service(s) is most appropriate is undertaken by the community team; ingle points of access for all community and social services are in place in each borough in order to receive and process assessments; and this will allow the development of one single assessment form for NWL, that describes patient need rather than service referral. Excluded option Standardising services across NWL: this would also solve much of the problem statement described however would require a prohibitive amount of time. Evidence Base Birmingham Case Study Since 2013, Birmingham Community Healthcare NHS Trust has developed a model of care to enable rapid, 24-hour access to community services to support earlier discharge & reduce emergency hospital admissions. The model involves: a 24/7 single point of access for urgent and non-urgent referrals, giving professional advice and signposting to appropriate care a rapid response and advanced assessment at home within two hours for urgent referrals; multi-disciplinary teams managing non-urgent referrals for community services, with a response time between four and 48 hours; and experienced community clinicians working within acute hospitals emergency departments and on wards, preventing admissions from the front door and facilitating supported early discharges into community services. In the winter period of 2014/15, an average of 54 early discharges were supported per month. As well as being better for patients, this has generated significant cost savings: Days saved through Estimated cost per bed Estimated saving length-of-stay reductions day 3, ,600

6 3.6 System benefits of proposed solution For Patients For Commissioners For Hospitals For Community Services Patients discharge won t be delayed because a reassessment by the community services won t be necessary, improving patient experience and reducing risks of HAIs Needs based assessments and centralized SPA will ensure that the patient receive the appropriate package of care at the right place Needs based assessments will build on the involvement of patients and carers in decision making Decision making on package of care is carried out by community teams who are best placed to understand how patients respond in their own homes. Having a centralized SPA with all the demand and supply data for community services will help commissioners in the planning and purchasing of these services Quality control and performance measurements of the community services will be easier with a simplified discharge process At a system level, efficiencies can be achieved through reduced acute LOS and improved quality of discharge could see a reduction in readmissions LoS and DTOCs will decrease as patients won t stay longer than needed waiting for a transfer of care Bed availability will improve which will have a positive impact on inhospital patient flow Paperwork pressure for hospital staff will decrease, freeing up time to care Use of a standardised needs-based assessment will allow community services to decide the package of care that is most appropriate according to the patient s needs and function Patients will be allocated to a service by community teams avoiding inappropriate discharges Use of a standardised assessment form should improve the quality of information captured as acute staff are familiar with the process 3.7 Delivery Options The scale of change required per CCG has been estimated below, based on the current state information provided to us. CCG Current State Estimated Scale of Change Estimated Implementation Timeline (Approx. & dependant on delivery option chosen) Central London West London Each of the CCGs has a SPA for CIS, Rehab & D/N. There are also plans in place to look at moving towards a single tri-borough SPA in the future. The BCF Group A scheme is looking at Low Low 2 months (to agree NWLwide assessment

7 Hammersmith earlier involvement of social care in discharge & Fulham planning and the MDT which can be built on in this work. Low form and implement) Ealing Single Point of Access in place from 1st October This is a combined referral, clinical triage, assessment and rapid response service that acts as the hub for the Ealing Home ward Service (Previously known as ICE). District nursing, falls, and enable services still have separate referral routes although this is planned to change. Medium 3-4 months (to implement SPA & implement agreed NWLwide assessment form) Hounslow (& Richmond) Single Point of Access in place for all community referrals & stakeholders supportive of moving to a needs based assessment process. Low 2 months (to agree NWLwide assessment form and implement) Brent Single Point of Access in place for STARRS services (one for Brent and one for Harrow) but separate access point for D/N & Rehab. STARRS supported discharge services are only commissioned to take patients from mainly NPH or Central Mids (and Imperial & Royal Free) so this may need to be addressed for NWL-wide system to work. Harrow Stakeholders generally supportive of a SPA & assessment-led approach. High 5-6 months (to implement SPA & extend STARRS service to accept all B&H CCG patients) High 5-6 months (to implement SPA & extend STARRS service to accept all B&H CCG patients) Hillingdon SPA in place for all community services except the hospital s Homesafe service. Low 2 months (to agree NWLwide assessment form and implement)

8 4 options for delivery of the proposed solution are outlined below, along with their resource and time implications.

9 Output Measurements 1. One Single Point of Access in place per CCG to cover (at a minimum) services provided by community health trusts in patients homes including: intermediate care, rapid response, early supported discharge, district nursing, specialist nursing, rehab, etc. 2. One common NWL needs-based assessment form (short- max. 3 pages) in place that is accepted by all of the Single Points of Access described above. 3. Patients referred and accepted into the new Single Points of Access. Outcome Measurements 3 1. Reduction in Length of Stay (and Excess Bed Days) of cross-border admissions, to equal the within-border Length of Stay. 2. Reduction in Readmission Rates for cross-border discharges vs within-border. 3. Reduction in number of patients in hospital that are not meeting acute criteria (e.g. Day of Care audit). Governance Structure We propose two options for a governance structure of this work: How do we involve SaHF Programme & Clinical Board? Reporting Progress reports by CCG would show status of deliverables (as described previously in outputs measurements) and a dashboard of key metrics (as described previously in outcome measurements). These reports would be monthly during the implementation period after which benefits tracking would be included within regular winter period monitoring. 3 We are seeking input from the AHSN on an overall evaluation framework for this initiative that combines some of the metrics listed

10 Risk to Delivery 1. On-going procurement in the system could delay progress in implementation 3.8 Proposed Next Steps: decide on a delivery option to take forward (Collaboration Board); mobilise project according to selected delivery option; and commence implementation, governance & reporting.

11 Appendix 1 Stakeholder List The following people have been involved in the scoping and discussions around a NWL-wide Discharge Improvement project. Inner CCGs Louise Proctor, Managing Director, West London CCG; Paul O Brien, WSIC Lead, West London CCG; Katie Beach, Whole Systems Programme Lead, West London CCG; Toby Hyde, Head of Strategy, Hammersmith & Fulham CCG; Holly Manktelow, Urgent Care Lead, Hammersmith & Fulham CCG; Jenny Platt, Strategic Lead for Integrated Care and Joint Commissioning, Hammersmith & Fulham CCG; Jo Nguyen, BCF Group A Discharge Lead, Triborough CCGs and local authorities; and Mohini Parmar, Chair, Ealing CCG. Outer CCGs Bernard Quinn, Director Delivery & Performance, Brent, Harrow, Hillingdon CCG's; Ceri Jacob, Managing Director, Hillingdon CCG; Kamran Bhatti, Planned Care and 7 Day Services Lead, Hillingdon CCG; Sarah Mansuralli, Interim COO, Brent CCG; Philip Vining, Urgent Care Lead, Brent CCG; Anne Elgeti, Deputy Director of Contracts, Brent CCG; Helen Woodland, BCF Lead, Brent; Lucy Hall, BCF Scheme 3 (Discharge) Lead, Brent; and Sarah McDonnell, WSIC Lead, Brent CCG, Acute Trusts Alison Kingston, Divisional Director of Operations, Chelsea & Westminster NHS Foundation Trust; Dominic Conlin, Director of Strategy & Integration, Chelsea & Westminster NHS Foundation Trust; Max Carter, Head of Service Improvement, Chelsea & Westminster NHS Foundation Trust; Julie Wright, Director of Integrated Care, Hillingdon Hospital; James Hall, Service Improvement Lead, LNWH NHS Trust; Dr Bill Oldfield, Deputy Medical Director, Imperial College Healthcare NHS Trust; and Cathy Hill, Deputy General Manager Clinical Support Services & Surgery, West Middlesex University Hospital NHS Trust. Community Providers Jen Allen, Divisional Director of Operations, CLCH;

12 Sarah Brice, Chief of Service for CIS, Imperial NHS Trust as lead provider; Natasha Porter, Inreach, CIS; Gill Dickinson, Head of Adult Services, CNWL (Hillingdon); Indpal Nawaz, Community Matron, clinical lead IRCS, Hounslow and Richmond Community Healthcare; Jo Manley, Operations manager, Hounslow and Richmond Community Healthcare; Dawn Karim, Head of Community Nursing Ealing West, London North West Healthcare Trust; Elizabeth Doyle, Head of Community Nursing Ealing East, London North West Healthcare Trust; Kris Walecki, ENable Service Manager, Ealing Community Services, London North West Healthcare Trust; Bhupender Sethi, Head of Falls Service, London North West Healthcare Trust; Penolope Johnson, Head of ICE service, London North West Healthcare Trust; Vince Baxter, General Manager, Community Services Brent, London North West Healthcare Trust (Acute Services); Nipa Shah, Head of Service, STARRS, London North West Healthcare Trust (Acute Services); Edgar Swart, Clinical Head Nurse, Starrs London North West Healthcare Trust; Patrick Laffey, General Manager, London North West Healthcare Trust; Jeanne Davey, Head of Community nursing, LNWH (Community services); and Rachel Sandi, Lead Integrated Care Co-Ordination Service, LNWH (Community services). Boards & Committees 7 Day Services Delivery Group; Collaboration Board; SaHF Programme Board; SaHF Clinical Board; Ealing CCG Executive & Innovation Committee; Lay Partners Advisory Group; and Brent & Harrow Systems Resilience Group.