South East Essex. Discharge to Assess Strategy

Transcription

1 South East Essex Discharge to Assess Strategy Version th March 2018 Document Control: Revision: Name Date: Version 2.0 Shirley Regan 12 December 2017 Version 2.1 Amendments-Paul 19 December 2017 Taylor/Sarah Baker Version 2.2. D2A Board Members-content 11 January 2018 Version 2.3 ECC & SBC Senior 15 January 2018 Management teams Version 3.0/3.1 D2A Programme Board 23/28 January 2018 revisions/reformat Version 3.2 D2A programme Board final 1 February 2018 amendments Version 3.3 SBC D2A steering group- 19 February 2018 Southend Exec version Version 3.4 SBC Senior Mgmt team amendments 27 th March

2 Ref: Contents Page: 1. Executive Summary 3 2. Introduction 5 3. D2A Strategic Vision 6 4. Drivers for Change 9 5. New D2A Delivery model D2A Performance Indicators Appendices- Implementation plans

3 1. EXECUTIVE SUMMARY 1.1. This strategy sets out the agreed vision and proposed deliverables, which are required to transform how the transfer of people from hospital to community based support will be managed from and beyond through a Discharge-to-assess approach. The strategy should be seen in the wider context of supporting health and social care transformation through the locality hub model approach Discharge to assess is the process to facilitate the assessment of care and support needs taking place outside of the hospital environment and at the right time for the person. Discharge to assess is not a means to support the rapid movement of the person out of hospital, without improving the health outcomes for the person or agreed case management plans for the next steps of the recovery pathway The joint vision of the strategic partners, alongside key principles and required outcomes contained in Section 4 for a local D2A approach, defines a systemwide commitment to: Sharing responsibility, risk and skills across organisations, leading to innovative and creative solutions; thereby achieving a seamless transfer for local residents from acute to community setting through the provision of integrated safe and effective assessment and support closer to home This vision will be realised through working together to: Improve pre-discharge planning in the hospital Invest the resources to deliver a Home first model for all transfers Establish new ways of working to deliver an integrated approach to the commissioning, delivery and co-ordination of intermediate care services in the community Review the workforce resources and skills required Build community resilience through closer partnership work with colleagues in the voluntary sector Establish a system-wide South East Essex governance structure that will oversee and ensure collective responsibility for the strategy 1.5. Both Southend and South Essex projected demographics indicate a higher proportion than the national average for those residents aged 65+.For older people we know that longer stays in hospital can lead to worse health outcomes, and increase their long-term support needs. A stay of 10 days in hospital without mobilisation has been estimated to result in the equivalent of 10 years ageing in the muscles of people over The Five Year Forward View is one of the national drivers considered in Section 4 which recognises that the traditional divide between different services in primary care, in the community and in hospitals, is increasingly a barrier to providing personalised and coordinated care for local residents. 3

4 Much work has been done to develop stronger partnerships between providers and commissioners of services to work towards networks of community based support that provide a coordinated approach to managing transfers and using resources more efficiently and effectively Fundamental to the success of the proposed new ways of working is the elimination of the blame culture that currently exists in relation to hospital discharge of patients, and a commitment to working jointly across organisational boundaries to find solutions. The redefinition of roles to reduce duplication and improve service efficiencies will require workforce engagement on new ways of working to manage the complexity of early supported discharge The delivery plans in Section 5 set out the priorities and actions required by partners across the system in the short, medium and long term over the next 2 years to achieve the vision The detail to support these priorities will be contained in local implementation and investment plans (see appendices), which are in development jointly with each authority in Southend and South Essex during February and March These will reflect the separate arrangements and service compositions in each area, but deliver against the same shared outcomes and objectives from a D2A approach to hospital discharge These developments and redesign of current local service arrangements to adapt to support the D2A principles will be overseen through the establishment of the South East Essex joint governance framework, to provide both assurance and direction to the D2A work programme. 4

5 2. INTRODUCTION 2.1. This strategy document sets out the local vision, principles and key deliverables in relation to implementation of discharge to assess (D2A) across South East Essex. The ambition is that from April 2018 this will drive the service transformation and new ways of working required, for the assessment of future support needs of all local residents following a period of hospital admission delivered within a D2A framework The nationally recognised definition of the term Discharge to Assess is: Where people who are clinically optimised and do not require an acute hospital bed but may still require care services, are provided with short term funded support to be discharged to their own home (where appropriate) or another community setting. Assessment for longer-term care and support needs is then undertaken in the most appropriate setting and at the right time for the person A D2A approach is not : Discharging people from hospital before their condition is clinically stable Discharging people without an assessment of risk for their safety at home or other community setting Moving people home from hospital without the right support in place, or without their consent or a best interest decision Creating an additional transfer in a person s care pathway in order to free up a hospital bed, but without adding value to their experience of care or improving outcomes for the person Moving people out of hospital early, but without indicative plans and managed processes for the next step home 1 Quick Guide to Discharge to Assess

6 3. D2A STRATEGIC VISION 3.1. The joint vision of the strategic partners for the implementation of a Discharge to assess approach is: Sharing the responsibility, risk and skills across organisations, leading to innovative and creative solutions; thereby achieving a seamless transfer for local residents from acute to community setting through the provision of integrated safe and effective assessment and support closer to home This vision will be realised through working together to: Improve pre-discharge planning in the hospital through the establishment of a fully integrated discharge team that manages patient flow from point of admission Invest the resources to deliver a Home first model for all transfers from hospital to support safe transfer out of hospital, and reducing over time the reliance on community beds Establish new ways of working to deliver an integrated approach to the commissioning, delivery and co-ordination of intermediate care services in the community, supported by flow management models to use finite resources more effectively. Review the workforce resources and skills required to meet the changing needs of a discharge to assess approach. Build community resilience through closer partnership work with colleagues in the voluntary sector to grow neighbourhood networks of support Establish a system-wide South East Essex governance structure that will oversee and ensure collective responsibility for delivery of the strategy AIMS AND OBJECTIVES 3.3. The core aim is that we will deliver the above vision for a system-wide D2A approach by making the required improvements to current processes and provision commencing from April The objectives to be achieved from these improvements include: A rapid mobilisation of integrated support and assessment services in the community, to ease transfer of care following an acute episode or prevent a hospital admission. Parity of access, approach and service delivery regardless of whether the person has physical or mental health support needs. The expectation that local residents will receive the majority of their reablement in their own home or within their local community, and are provided with information and direct access to on-going support options based on informed choice. Ensuring that community beds are used flexibly to support both recovery and admissions avoidance to maximise people s independence outside of hospital. 6

7 Identification of the joint financial investment required to manage demand, to inform the commissioning and redesign of services within the D2A implementation planning. Clear communication and engagement with system stakeholders and patients and their carers, so that people are fully aware of what D2A means and the planned changes. PEOPLE OUTCOMES 3.5. The person-centred outcomes required from an integrated health and social care D2A approach to the safe transfer of care for people from hospital to the community setting are to: Support timely hospital discharge so that people stay in hospital until their health is stabilised, and then move to the most appropriate location to continue their recovery and assessment of their future support needs; Maximise peoples capacity for independent living, increasing the number of people able to remain living at home and reducing the number of people admitted to long term care without a full assessment of needs; Complete holistic assessments working from a strength s based approach, that recognises and values community and family support systems, and builds resilience around the person; Provide enabling support in the most appropriate environment which helps people realise their rehabilitation and reablement potential, and emphasises maximising independence for the person. D2A PRINCIPLES 3.6. The following core principles will support the establishment of the D2A service model and vision: Acceptance that no patient is required to make decisions about their longterm care whilst in hospital. Any concerns regarding capacity to decide discharge planning must be dealt with appropriately and in line with the Mental Capacity Act. Agreed clinical criteria and managed discharge planning for each of the transfer pathways that starts from the point of admission to either a hospital or community bed. An integrated service approach that is staffed by the appropriate health and social care staff, whose roles and responsibilities are clear to the person and to the other stakeholders. NHS funded provision of rehabilitation/ reablement services that is free to the person following a hospital admission, regardless of ongoing care package funding arrangements. The pooling or the alignment of health and social care funding for all intermediate care services, in order to remove existing barriers and organisational boundaries to establish a seamless approach to supporting people to maintain and regain their independence. 7

8 STAKEHOLDER BENEFITS 3.7. The anticipated benefits from the planned changes to achieve a system-wide approach to delivery of a Discharge to Assess service model can be defined as: a) The removal of steps, processes and delays in the discharge process which consume valuable staff resources and do not add value to the person s experience. b) Having the right workforce capacity in the right place at the right time. This will be designed to facilitate a discharge to home as the default position for all transfers from hospital. c) The identification of health and social care conditions that have resulted in a non-elective acute admission to avoid or delay future admissions to hospital or long-term care settings d) Increased patient and family satisfaction of discharge and support planning processes e) Reduced infection and deconditioning risks associated with vulnerable patients remaining in hospital longer than required, which inhibits rehab/reablement potential f) Increased patient flow through the hospital, enabling acute service resources to be released to manage patients requiring critical care KEY ENABLERS 3.8. During the next phase of planning for D2A delivery implementation, consideration will need to be given to each of the key enablers that would support the success from new ways of working to include: Finance including the use of pooled budgets to support integration IT including single electronic data recording and mobile working for staff in the hospital and the community Workforce development in new ways of working that begins the planning earlier for discharge and reablement Integrated commissioning and brokerage for all intermediate care services to provide the basis for service quality assurance Legal and Governance arrangements to manage the shared resources across health and social care Care assessments to establish strength based approach to assessment of need across SE Essex 8

9 4. DRIVERS FOR CHANGE NATIONAL DRIVERS 4.1. A Discharge to Assess (D2A)/Home First approach has been recognised as one of the eight High Impact Changes (HIC) in relation to system processes, which can support the safe and timely transfer of care for people from a hospital to the community setting. The relevance of these eight HIC has been recognised by NHS England, and form the basis for the Better Care Fund national conditions for 2017/18 onwards This strategy also relates to the HIC in relation to Early Discharge planning, Patient flow monitoring systems and Multi-disciplinary discharge teams including the voluntary sector The NHS Five Year Forward View (5YFV) set out the need to redesign urgent and emergency care services in England for people of all ages with physical and mental health problems. It establishes the principles for the new population based models of integrated care needed to do so, moving resources into primary care. New care models such as multispecialty community provider (MCP) and primary and acute care system (PACS) are being developed by the vanguards, with the aim to bring together commissioning budgets and achieve closer integration of service delivery The NICE guidelines Intermediate Care including reablement published in September 2017, describes four service models within the definition of Intermediate Care i.e. bed-based, home-based, crisis response and reablement. From a person-centred perspective, intermediate care therefore encompasses community services which aim to: Prevent hospital admissions, Support faster recovery from illness, Support timely discharge from hospital, and Maximise independent living skills. This document deals in particular with the required changes to support timely discharge from hospital and supporting faster recovery from illness, but recognises the interdependency and relationship with the other core aspects of intermediate care Research has shown 2 that admission to hospital and delays in hospital discharge can create significant anxiety, physical and psychological deterioration, which results in a reduction of independence for the person. For older people in particular, we know that longer stays in hospital can lead to worse health outcomes and can increase their long-term support needs. A stay of 10 days in hospital without mobilisation has been estimated to result in the equivalent of 10 years ageing in the muscles of people over 80. It is therefore important that wherever appropriate, people should be supported to 2 Kings Fund

10 return to their home environment for rehabilitation and assessment as soon as possible Evidence demonstrates that multidisciplinary services that focus on rehabilitation/reablement can support people to recover, regain independence, and return to or remain at home, and removes or reduces the need for long-term care and support. 3 The best results show that up to 62% of reablement users no longer need a service after 6 12 weeks intervention, and that a further 26% had a reduced requirement for long term home care support Closer collaboration in both the commissioning and delivery of services between health and care locally, is therefore vital to ensure sufficient parity and quality of service, and joint agreement on how best to allocate resources and funds whilst facing significant financial challenges in future years. LOCAL DRIVERS 4.8. Across South East Essex, we have an increasing ageing population, and ongoing hospital capacity pressures through an increased demand and complexity of health conditions. The update of JSNA profiles identified the following population demographics. Southend 4.9. Southend has a population close to 178,000, with a higher proportion than national average population aged 65+ of 18.9% (33,600) set to increase to 21.2%by 2025 (40,700) Deprivation in Southend is higher than the England average and the regional average. In 2015, 25.8% (45,840 people) of Southend residents lived within areas classified as being in the 20% most deprived in England Southend also has a higher proportion of people who have 3 or more longer term conditions (12.9%) compared to the England 10.5%.It also has a higher prevalence of people over 65 diagnosed with dementia being 4.7%, compared with the England average of 4.3% There is also a health inequality around life expectancy across Southend. Life expectancy is 10.3 years lower for men and 9.5 years lower for women in the most deprived areas of Southend-on-Sea compared to the least deprived areas People living in the area with a serious mental illness have mortality rates 2-3 times higher than the total population. This is known to be largely due to 3 NICE Guidelines Intermediate Care including Reablement Sept SCIE Southend JSNA Feb Southend on Sea Profile, PHE; Sept

11 undiagnosed or untreated physical illness because the medical focus had been on the mental illness The Southend BCF plan sets out how Southend s senior leaders in health and social care will continue to prioritise the health and wellbeing of local residents. These plans include: Implementing a locality approach to the delivery of community services, Commissioning a complex care co-ordination service to case manage residents that are high users of health and social care services, and Ensuring continued engagement with the STP developments. South Essex In Castle Point 7 between 2015 and 2025: The total population will increase from 89,110 to 93,440 - an increase of 5% or 4,330 more people Over 65s will increase from 22,300 to 26,500 - an increase of 19% (4,200) and will represent 28% of the total population in the district 1,410 people aged over 65 are thought to have dementia and this number is expected to rise by 70% to 2,390 by The life expectancy rates are higher than the national average for both male and females. This was 79.8% and 83.3% respectively, compared to national figures78.9% and 82.8% In 2014/15, 61% of those adults in Castle Point who had accessed reablement services during the year, left as self-carers i.e. being able to live independently. This is considerably below the 71% average in the whole county Rochford 8 is the third smallest district in Essex in terms of total population numbers, accounting for 5.9% of the total population in Essex. It has a slightly lower proportion of over 65s compared to the county as a whole Between 2015 and 2025: The total population in Rochford will increase from 84,815 to 89,494: an increase of 5.5% or 4,679 more people. Over 65s will increase from 19,187 to 22,866: an increase of 19.2% (3,679) and will represent 25.6% of the total population in the district The prevalence of hospital admissions due to hip fractures in the over 65s in 2014/15 was higher than the previous year and at 644 was above the England average of 571 per 100,000 population. 7 Essex JSNA Castle Point profile May Essex JSNA Rochford Profile May

12 WHAT NEEDS TO CHANGE? All of these drivers require a change in organisational culture and ways of working to provide a more planned and proactive approach to discharge planning, and achieve a seamless transfer for the person between home and hospital when required It is recognised that the current hospital discharge process has been driven by a focus on the need to rapidly free-up acute hospital beds in order to manage delayed transfers of care (DToC). Therefore moving a person from hospital to another bed has become the current default position for reducing delays in complex discharge transfers Out of hospital services have therefore largely evolved in response to both national and local influence to meet the needs of the system discharge targets, rather than maximising outcomes for the person. This has resulted in numerous individual services operating within separate structural and organisational constraints Therefore it is now widely accepted by system partners that the current fragmentation of services fails to meet the needs of the population as a whole and that greater integration can improve the person s experience, through providing more equitable access to provision and improved outcomes achieved through more efficient use of resources Fundamental to the success of the proposed new ways of working is the elimination of the blame culture that currently exists in relation to hospital discharge, and a commitment to work jointly across organisational boundaries to find solutions. The redefinition of roles to reduce duplication of effort and deliver service efficiencies will require workforce engagement in new ways of working, in order to manage the complexity of early supported discharge The planned joint development of an integrated model of community based assessment and support based around the four GP localities/neighbourhoods in each local authority area, also aims to deliver the principles of care closer to home. This will provide a network of multi-disciplinary care and support in each community to deliver the allocation of resources to manage assessment of recovery support needs closer to home, as well as offering early intervention to facilitate admissions avoidance Within both social care and health there is an increased focus on a strength based approach to assessment of need. This recognises and promotes the community and personal assets to support recovery and independence that have been previously underutilised in support planning and facilitates the increased involvement of community partners in supporting residents to live in their own home. 9 Community Investment plan Dec

13 4.28. The D2A developments will also contribute to the wider transformation and integration plans in South East Essex that seek to ensure: 7 days a week services Single point of access and referral Single assessment process and care planning Holistic directory of community services Integrated information and data sharing New developments will need to include digital and education solutions that can support each person with self-management of their health and well-being and maintain their independence from statutory services. SOUTH & MID ESSEX SUSTAINABILITY AND TRANSFORMATION PLAN Plans for the South and Mid Essex STP are in development with a focus on the reconfiguration and financial stability for acute services. For the STP to succeed, system leaders have agreed the need for the STP to be aligned with the plans to integrate health and social care within each community Health and care organisations have published a high-level plan to invest in innovation and expertise, integrate service delivery to provide more care closer to where people live, and re-design our hospitals to meet rising demands The D2A planning will reflect this wider development and has identified service gaps that because of economy of scale may be better considered across the STP footprint e.g. discharge rehab placements for bariatric and neuro-rehab patients. 13

14 5. NEW D2A DELIVERY MODEL 5.1. The D2A task & finish groups identified common themes and enablers across each of the discharge stages, (pre-discharge and D2A pathways) which together would provide the framework to establish a sustainable basis for the delivery of a system-wide Discharge to assess approach across South East Essex These high-level themes have been considered in relation to immediate (spring / summer 2018/19) medium (Summer / Autumn 2018/19) and long term (during 2019/20) actions, to achieve new ways of working to improve and manage the assessment of health and social care needs of local residents The detailed activity and level of investment that will be required to deliver against each of these themes and objectives will be determined within the local D2A Implementation Plans (see appendices) to be worked up with all stakeholders in each area during spring 2018 prior to the phased D2A implementation. PRE-DISCHARGE PLANNING INTEGRATED DISCHARGE TEAM 5.4. The current arrangements are an alignment of the different multi-disciplinary professionals working together to support timely discharge of patients. The majority of discharge planning is delayed until MFD status is verified including preparation of TTA s. This creates an avoidable delay in patient flow for the hospital. Key deliverables 5.5. The actions as defined in Annex 1 have been identified to deliver the D2A service model, with any associated strategic partner responsibilities. D2A CARE PATHWAYS 5.6. The current discharge pathway arrangements for patients from Southend Hospital were analysed in 2016 by the Boston Consulting Group, where at least 12 different discharge routes were identified. This complexity of options in the absence of a single co-ordination of approach, leads to confusion for practitioners and the person being discharged with a number of handovers between services. Key deliverables 5.7. The proposed D2A model for implementation across South East Essex is largely based on the Warwickshire model. This reduces the flow from hospital to one of 3 main pathway routes as outlined in the diagram below. 14

15 5.8. In addition, in recognition that the majority of hospital patients should be able to return home without any additional support from health and social services, there will be a low level Pathway 0. This is for those people where there has been no significant change to their daily living skills since admission and who can go home from hospital with no additional assessment for support, or just with a continuation of their previous packages of care and informal support. This pathway should be made available as soon as the patient is medically stable and ready for transfer home. Consideration of signposting to community support links may be appropriate, where levels of frailty may indicate future risk of deterioration An individual s progress towards the agreed outcomes through Pathways 1-3, will be assertively managed by the appropriate MDT within the agreed care pathway with shared records of care plans and review dates. The focus will be on working towards the patient s transfer to or maintenance at home, with the expectation that the maximum length of any intermediate care/reablement service provision will be between 2 to 6 weeks. Pathway 1: For those people who can return to their original home with rehabilitation support to regain functional and daily living skills The future planning assumption is that the majority of people should be provided with the right package of support for up to 6 weeks to enable them return to their own home for a period of rehabilitation/reablement. This will become the default pathway for all complex transfers from hospital from May The person once transferred home, will be provided with support and therapy by the community team in order to support the patient s recovery to independence. During this time, the patient will be supported to achieve the 15

16 identified goals to increase independence and be assessed with regards the most appropriate ongoing care. The patient upon discharge from the reablement service will either move under their GP/MDT s care, self-funded care, local authority funded care or funded Continuing Health care, according to the outcome of the full assessment. Current Service offer The current range of services and level of investment available to support D2A pathway 1 are being collated. This data will be used to inform future commissioning plans as of April Key deliverables The actions as defined within Annex 2 have been identified to deliver the D2A Pathway 1 service model, with any associated strategic partner responsibilities The availability of third sector resources is not currently fully considered in terms of utilising community facilities to support a person s independence. It is recognised that the sector is often best placed in tackling social isolation through befriending, and alerting health and social services when there are signs of deterioration in wellbeing to enable avoidance of hospital admission. There is the therefore the opportunity to build this service offer into the discharge to assess care planning framework from April Pathway 2: For those people who could potentially return home after a period of additional rehabilitation/reablement but also require 24/7 supervision In pathway 2, the patient is discharged to an interim placement in residential care/rehab care facility/community hospital/ supported accommodation setting for two -six weeks and is provided with an intensive therapy programme in this setting. An assessment of their long-term support needs is conducted during their stay and onward referrals made as appropriate. Current service offer The current range of services and level of investment available to support D2A pathway 2 are being collated. This data will be used to inform future commissioning plans as of April 2018 Key deliverables The actions as defined within Annex 3 have been identified to deliver the D2A Pathway 2 service model, with any associated strategic partner responsibilities National evidence from areas where a D2A model has already been successfully implemented has shown there to be a reduced need for this pathway over time, and that rehabilitation and reablement deliver the best longterm outcomes when they are delivered in the person s own home. The future 16

17 capacity required will be defined during 2018/19 to reflect any required increased capacity in home based rehabilitation/reablement services. Pathway 3: For those people (Adult & Children) who are unable to live independently even with support, and are likely to need ongoing care in a residential setting The patient is referred to a nursing or care home facility with support for full recovery, and for a comprehensive assessment of care needs. This will include those where it is already known that the person needs full time care especially as part of frailty or end of life care pathways. Current service offer The person-centred nature of the service needs means that placements are generally purchased on a spot purchase arrangement. Without a centralised allocation, this has resulted in local competition for places across health and social care, and lack of quality assurance of placement in some instances where urgent transfers from hospital are actioned. Key deliverables The Trusted Assessor model in development in both council areas will support the seamless and safe transfer of people between the care home and hospital ward, with designated discharge co-ordinators acting as the link between the two locations A shared brokerage function is required to manage the referral and market performance management aspects across the strategic partners. This centralisation of the identification and quality assurance of placement would enable the market to develop in partnership to meet future service needs and capacity for D2A Consideration will be given to a new model of nursing intermediate care provision at home that would aim to reduce the need for transfer to alternative accommodation. 6. D2A QUALITY / PERFORMANCE INDICATORS 6.1. The following indicators are reported through statutory and regulator required reporting across the health and social care systems, and can be utilised for measuring the impact and success of the Discharge to Assess model from point of implementation. Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services. [ASCOF 2B(1)] Delayed transfers of care from hospital (people) which are attributable to Health and Social Care, per 100,000 population. [ASCOF 2C(1)] 17

18 Delayed transfers of care (people) from hospital which are attributable to social care, per 100,000 population Delayed transfers of care (people) from hospital which are attributable to health, per 100,000 population 6.2. The NICE quality standards for Intermediate care are due to be released in Spring Once available these will be used to benchmark local commissioned provision and conduct an analysis of service development need The following references have been used in informing the preparation of this strategy : - Discharge to Assess Quick Guide - Five Year forward view - NHS England Transforming Urgent & Emergency Care - Mid and South Essex STP - NICE guidance Intermediate care 18

19 Annex 1 Integrated Discharge Team Immediate actions Spring/Summer 18/19 Medium term actions Summer / Autumn 18/19 Long term actions 19/20 Responsibilities of strategic partners Proactive complex discharge planning from point of admission based on risk assessment TTAs prepared 24hours in advance Home First principles fully implemented System One in place to support all transfers between home and hospital health services Health & Social care staff resources realigned to support Home First for all complex care hospital discharge patients SUHFT Hospital Staff training in risk assessment and D2A discharge process Ward round to compile TTA Single Integrated Discharge Team referral form for complex discharge referrals that identifies which D2A pathway Redefined roles of discharge staff and development of future Integrated discharge team structure Recommissioned transport to support Home before lunch Rehab commences on ward with OT assistants All complex discharges arrive home before lunch Integrated Discharge Team under single management structure Increasing discharge capacity to manage patient flow Updated discharge policy and patient leaflet to reflect D2A Access to system one patient records for all IDT and ward staff LA / CCG Investment in realigned staffing resources to support safe discharge EPUT Integrated Discharge Team manages safe transfer to community MDT 19

20 Annex 2 Proposed Delivery Plan Pathway 1 Immediate actions Spring/Summer 18/19 Medium term actions Summer / Autumn 18/19 Long term actions 19/20 Responsibilities of strategic partners Single point of access for referrals for D2A Review of inpatient and community therapy team to support D2A Pathway 1 Engagement with Third sector and Faith communities to develop and consolidate their role as part of a D2A approach Locality/Neighbourhood MDTs based around GP populations to support assessment process Implementation of the redesign of rehab therapy services to reflect a D2A approach Pilot of Voluntary sector support for early supported discharge and monitoring social isolation and health deterioration Full mapping of voluntary sector offer in each locality for social prescribing Implementation of Digital technology to support self-management of health conditions at home Fully integrated locality based intermediate care teams managing assessment and delivery of services to support transfer home and admissions avoidance Third sector organisations as equal partners in D2A implementation Access to telehealth self-monitoring options for all people with long-term health conditions SUHFT Accuracy of discharge information and medication Referrals for equipment action taken in advance LA/CCG Commissioning and monitoring service delivery against outcomes. EPUT Co-ordinating the therapy based health response at a locality level LA/CCG Implementation of digital enhancements to support self-management of long term conditions Recognition of third sector as equal partners in hospital discharge process 20

21 Annex 3 Proposed Delivery Plan Pathway 2 Immediate actions Spring/Summer 18/19 Establish shared governance arrangements across health and social care to scrutinise and drive D2A developments Single procurement and brokerage route for all community beds via a single point of access Joint approach to market management and development of provision that encourages partnership working in D2A approach Designated social workers to manage flow from interim bed-based services Medium term actions Summer / Autumn 18/19 A single service specification for community rehabilitation beds and home based services in terms of shared rehab outcomes and standards Fully Integrated commissioning arrangements for intermediate care across health and social care Shared performance management of community based D2A services Engagement at STP level for collaborative specialist discharge commissioning plans in relation to neuro-rehab and bariatric patients Long term actions 19/20 Decommissioning plan (subject to intermediate care bed review) for bedded services in each area resulting in increased home-based support services in pathway 1 Responsibilities of strategic partners LA/CCG Establishment of SEE Transformation Partnership Board Development of pooled budget arrangement to support integrated commissioning of all aspects of intermediate care Establishment of joint brokerage function to manage bed allocation Establishment of shared contract performance review function, to inform future investment in community services Social worker management of patient flow from bedded units 21