Appendix 4.1 MEETING: Haringey Clinical Commissioning Group Governing Body DATE: Wednesday, 30 November 2016 TITLE: Integrated Out of Hospital Update LEAD DIRECTOR/ Rachel Lissauer, Director of Commissioning MANAGER: AUTHOR: CONTACT DETAILS: SUMMARY: Marco Inzani, Head of Integrated Commissioning (Adults) Marco.inzani@haringeyccg.nhs.uk Tel: 020 3688 2780 The targets associated with urgent and emergency care include accident and emergency four hour waiting times, non-elective hospital admissions and the delayed discharges from hospital. Haringey CCG has led two programmes to make an impact on discharging patients from hospital to reduce length of stay which will impact on all the urgent and emergency care targets. These programmes are: Improving Out of Hospital services as part of the Safer Faster Better Programme which is improving urgent and emergency care at North Middlesex University Hospital. Developing a joint approach towards integration of out of hospital services with the London Borough of Haringey. This forms part of the Integrated Target Operating Model which is the process to deliver Priority 2 of the Haringey Corporate Plan 2015-18. Priority 2 is to enable all adults to live healthy, long and fulfilling lives. There have been a number of successes through the North Middlesex Safer Faster Better Out of Hospital Services Programme including: Undertaking assessments of patients long term health and social care needs once they have been discharged out of hospital which has resulted in one to three days delay being avoided for up to four or five patient per week Reducing unnecessary paperwork for continuing healthcare assessments which has streamlined the process from 15 to 10 days and reduced delays This learning will be incorporated into work with The Whittington and Barnet, Enfield and Haringey Mental Health Trust. Work initiated in Haringey will also be used to support further collaboration with Islington CCG and will be built on to help implement the North Central London STP urgent and emergency care workstream. 1
SUPPORTING PAPERS: Integrated Out of Hospital Services Update Nov 2016 RECOMMENDED ACTION: The Governing Body is asked to: NOTE progress with plans to improve the process of discharging patients from hospital to reduce length of stay as part of the Integrated Out of Hospital Programme. Objective(s) / Plans supported by this paper: Audit Trail: The majority of services within the Integrated Out of Hospital Programme are funded via the Better Care Fund which has had three internal audits and is overseen by a joint governance structure between Haringey CCG and the London Borough of Haringey. Patient & Public Involvement (PPI): Patient and public representatives were present at the Integrated Out of Hospital workshop on 3rd November 2016. This will be built on as the programme develops. Equality Analysis: This will be planned for any agreed changes. Risks: The risk log for the programme is being developed. Risks will be escalated through the governance structure that has been developed to oversee the Integrated Out of Hospital Programme. Resource Implications: The cost of services for Haringey CCG within the Integrated Out of Hospital Project is approximately 10m. Figures are approximate as some services are still being scoped. 2
INTEGRATED OUT OF HOSPITAL SERVICES UPDATE November 2016 1. INTRODUCTION Haringey CCG has been working with North Middlesex University Hospital to deliver improvements in the Accident and Emergency four-hour waiting time target trajectory. This waiting times target trajectory is supported by improving the flow of patients through the hospital and reducing the length of time they spend in a hospital bed. Haringey CCG is leading a number of workstreams that improve the process of discharging patients from hospital to reduce length of stay. A key focus of the Five Year Forward View, which has been translated into the priorities for the North Central London Sustainability and Transformation Plan (STP), is to reduce the length of time that people spend in hospital. The key rationale for this is deconditioning i.e. the longer that people remain in a hospital bed the greater their functional decline (this includes a reduction in activities of daily living, mobility, physical activities, and social activities). 10 days in hospital (acute or community) leads to the equivalent of 10 years ageing in the muscles of people over 80 (Gill et al (2004) Hospitalization, restricted activity, and the development of disability among older persons. Journal of the American Medical Association, 292(17), pp.2115-2124) Deconditioning leads to poorer outcomes for patients, high demand for beds and overall higher health and social care system costs. A recent audit across the four acute providers in North Central London (North Middlesex; Whittington; Royal Free; University College London Hospital) stated that there was a 98% bed occupancy rate and 18% of the beds were occupied by patients who were medically fit for discharge. Haringey has made a commitment to improve outcomes for patients; reduce the pressures and demand for beds; and reduce costs for the health and social care system. Haringey CCG is leading the work to improve patient discharge, through strengthening the support of out of hospital services, as a way of reducing the length of time that people stay in hospital. This work has been initiated with North Middlesex University Hospital through a programme called Safer Faster Better (described below) and North Central London STP have recognised the good progress this is making and are looking to spread the learning to other areas. This paper outlines progress on two key programmes that Haringey CCG is leading to improve patient discharge: The Out of Hospital Services Programme as part of the Safer Faster Better Programme which is the programme for improving urgent and emergency care at North Middlesex University Hospital. The Integrated Out of Hospital Programme as part of the Integrated Target Operating Model which is the process to deliver Priority 2 of the Haringey Corporate Plan 2015-18. Priority 2 is to enable all adults to live healthy, long and fulfilling lives. 3
2. SAFER FASTER BETTER: OUT OF HOSPITAL SERVICES The North Middlesex University Hospital (which will be abbreviated to North Middlesex) developed The Safer Faster Better programme to improve patient flow and in particular accident and emergency performance and hospital discharges. The programme is focused on making improvements in four key parts of the hospital system: Emergency Department Assessments Wards Out of Hospital The Out of Hospital Group takes a system-wide approach to enable prompt hospital discharge. The group is chaired by Haringey CCG and has membership from Enfield and Haringey CCGs, Enfield and Haringey Adults Social Care, North Middlesex, Whittington Health and Barnet Enfield and Haringey Mental Health Trust. The group has focused on the Eight High Impact Interventions (High Impact Change Model Managing Transfers of Care, Local Government Association/NHS England), and has prioritised a number of projects that it takes through a Plan Do Study Act (PDSA) cycle to implement and test improvements. The current projects are: Agreed actions to reduce DTOC/ MO numbers Improving emergency department in-reach by community health and social care services Expansion of the rapid response service to deliver in-reach to the emergency department and support to care homes Discharge to assess being implemented across three hospital wards (explored in more detail below) Localising of nationally agreed Choice Policy so that patients and carers are supported with earlier and realistic decision making regarding the transfer of care once acute care is no longer required. Simplifying the Continuing Health Care process (explored in more detail below) Coding of Medically Optimised/Delayed Transfers of Care list which are codes that relate to stages of delay caused by either the hospital, community health services or social care Recruitment of an Integrated Discharge Team (IDT) project manager to develop improved discharge pathways Developing options for double handed care where patients need two carers at a time, a few times a day. This can be more challenging to procure due to needing to meet the complex care needs of these patients Improving discharges to care homes Undertaking an audit of Rehab, Recovery and Reablement (RRR) Review of inpatient stay that exceeds six days Two of the main interventions that that have been progressed through the Out of Hospital Group and have demonstrated a positive impact are: Discharge to Assess When a patient is medically optimised this is the point at which care and assessment can safely be continued in a non-acute setting. Medically optimised patients do not require a hospital bed but may still require care services in the short term in order to return to their own home or another community setting. Assessments for longer-term care and support 4
needs are then undertaken in the most appropriate setting and at the right time for the person. This is known as discharge to assess (Quick Guide: Discharge to Assess (2016) NHS England). The benefits of implementing a discharge to assess process are that it reduces length of stay in hospital and therefore improves outcomes and reduces the pressures on hospital beds. Haringey has implemented discharge to assess at North Middlesex. The project started in September 2016 with the reablement service (which provides physiotherapy and occupational therapy) identifying a few patients in hospital that would be suitable for a safe discharge home with the right level of support and testing the process. These initial tests were positive and led to the expansion of the project to encompass all simple discharges i.e. all patients that could be supported home with minimal home care interventions. This simple discharge to assess pathway is now resulting in one to three days delay being avoided for up to four or five patients per week. It has eliminated the use of the previous social care notification process for these patients which, again, has streamlined service delivery for both North Middlesex and Haringey Social Care. The project has gone from a test phase to now becoming business as usual and the learning is being used to implement the process in Enfield. The next stage for the project will be to expand the process to cover more complex discharges where more substantial home care interventions will be needed. Continuing Health Care Process NHS continuing healthcare is the name given to a package of care that is arranged and funded solely by the NHS for individuals who are not in hospital and have been assessed as having a care need that relates primarily to their health e.g. care needs due to mobility, cognition or skin care (wounds and ulcers). The assessments for continuing healthcare are lengthy, involving an initial screening with a checklist, a full multidisciplinary assessment with a Decision Support Tool and an additional London Health Needs Assessment Tool. Haringey has implemented a project to move to a single assessment form to reduce unnecessary paperwork whilst being mindful to ensure all critical information is included. The intention was for a more efficient process to reduce the time taken for the continuing healthcare assessment and identify patient s needs earlier. Haringey has now implemented the continuing healthcare post discharge single assessment process, where only the continuing healthcare checklist and decision support tool is completed. This has helped streamline continuing healthcare assessments from 15 to 10 days and reduced delays. Enfield is using the learning from this process to implement the same changes. The next stage for this project is to increase the volumes of simplified assessments and to sustain the changes. In addition the project will link to the discharge to assess project so that more of the assessments can be conducted in people s homes with the right support and packages of care. Next Stage North Middlesex and partners are starting to adopt a home first attitude so that patients who are medically fit are discharged home with the right support so that they can be assessed and continue their recovery out of hospital. There are still a number of issues 5
and barriers to patient flow and discharge but the programme gives a forum for these issues to be aired and escalated to try to reach resolution. The success of the programme has been recognised across North Central London and is being used to start to shape a programme within other acute trusts. In Haringey the learning is also being brought into the Integrated Out of Hospital Project. 3. INTEGRATED TARGET OPERATING MODEL: INTEGRATED OUT OF HOSPITAL PROGRAMME Building on the work outlined above, and with a recognition of our inter-dependency, we are now taking a joint approach across the council and the CCG towards planning our out of hospital services. The London Borough of Haringey has initiated a process to develop an Integrated Target Operating Model (ITOM) to deliver on its commitment to enable all adults to live healthy, long and fulfilling lives (Priority 2 of the Haringey Corporate Plan 2015-18). Six projects have been identified and prioritised within the Integrated Target Operating Model. One of these projects is the Integrated Out of Hospital Programme. We are bringing together all new and existing out of hospital services to improve their coordination, capacity and quality with a particular focus on frail and pre-frail adults and older people. We are viewing our services within three categories: Primary Care (Before Hospital) Services that are primarily linked to/based in GP practices including: Locality Teams; Mental Health Hubs; Primary Care Hubs; Dementia Navigators Hospital Services (In Hospital) Services that are primarily linked to/based in hospitals including: Home from hospital; North Middlesex at Home; Discharge to Assess; Integrated Discharge Teams; Mental Health Discharge Co-ordinators; Seven Day Working Intermediate Care Services (After Hospital) Services that are primarily linked to community/home based services including: Bed Based Intermediate Care; Reablement; Cavell/Bridges Ward; Rapid Response Over the last two years Haringey has reviewed national evidence and best practice to determine the gaps in out of hospital services to reduce unplanned hospital admissions and improve hospital discharges. A number of services have been implemented to fill these gaps and are being monitored to determine their impact. A workshop was held on 3 rd November 2016 and undertook a stock take of current Out of Hospital services; determined barriers and issues to delivering the benefits and outcomes expected; and developed the guiding principles for a model that will improve the coordination and efficiency of the system. There were 44 attendees from across the range of health and social care organisations, including voluntary/community sector and public/patient representatives. Representatives also attended from neighbouring boroughs Enfield and Islington. Eight guiding principles for the Integrated out of Hospital Model were debated and ways they could be strengthened were identified. Twenty three key themes were also identified to improve the coordination, capacity and quality of out of hospital services. Highlights include: 6
Simplify the integrated out of hospital pathway with fewer initiatives Develop trusted assessors (people from one organisation who can undertake a health and social care assessment that is accepted by people from other organisations) across all health and social care organisations Develop a discharge to assess model in the mental health trust The Haringey and Islington Wellbeing Partnership has agreed that it will collaborate on developing its intermediate care services. The Integrated Out of Hospital work programme will be shared with Islington and the opportunities for collaboration will be identified. Initial thoughts include the potential to develop options for integrated intermediate care services (e.g. reablement and rapid response) that will be delivered across Haringey and Islington from April 2018. The North Central London STP has recently developed an urgent and emergency care workstream delivery plan 2017-21. This is intended to have an impact on accident and emergency attendances, non-elective hospital admissions and the length of stay in hospital resulting in financial savings for each CCG. A number of initiatives being proposed across North Central London will build on the services discussed as part of the Integrated Out of Hospital Project. The North Central London STP is currently developing the financial and activity impacts for the proposed initiatives with each CCG for the final submission of a risk assessed operating plan by the 31 st January 2017. 4. CONCLUSION The targets associated with urgent and emergency care include accident and emergency four hour waiting times, non-elective hospital admissions and the delayed discharges from hospital. Each of these targets continue to be incredibly challenging to achieve in Haringey. Haringey CCG has led two programmes to make an impact on discharging patients from hospital to reduce length of stay which will impact on all the urgent and emergency care targets. There have been a number of successes through the North Middlesex Out of Hospital Services Programme which will be brought into a Haringey wide Integrated Out of Hospital Programme so that the learning can be shared across the whole health and social care system. It is hoped that good practice at North Middlesex will be incorporated into work with The Whittington and Barnet, Enfield and Haringey Mental Health Trust. Work initiated in Haringey will also be used to support further collaboration with Islington CCG and will be built on to help implement the North Central London STP urgent and emergency care workstream. 5. RECOMMENDATIONS The Governing Body is asked to note progress with plans to improve the process of discharging patients from hospital to reduce length of stay as part of the Integrated Out of Hospital Programme. 7