Review of York Day Hospital Services Inverness. February 2010

Review of York Day Hospital Services Inverness February 2010 Lesley Yarrow AHP Consultant for Older People s Services, NHS Forth Valley lesley.yarrow@nhs.net

1 Introduction The purpose of this review was to examine the current model of practice in York Day Hospital in the light of national policy directives, guidelines and best practice. Very specifically the role of York Day Hospital in Shifting the Balance of Care (2009) and delivering an integrated co-ordinated and co-located community service, in line with Delivery Framework for Adult Rehabilitation (2007) was considered. Consideration was also given to Local Corporate objectives specific to Older Peoples Services as outlined below. All members of the MDT were present during the review, with the exception of the Day Hospital Nurse Manager and the Occupational Therapy team lead, who were unable to attend. NHS Highlands Rehabilitation Coordinator was present throughout day one of the review. Highland corporate objectives BH2 Better Health; Improve the health and wellbeing of the NHS Highland population: The health and independence of older people is maximised Better Care; Maximise the delivery of quality healthcare in the most appropriate setting: Patients experience no harm from healthcare services Better Value; All services are efficient and cost effective: Productivity increases through working smarter, not harder Changing for the Better Improvement Programme: Anticipatory Care community hospitals, discharge planning, supporting people with dementia, hospital beds) In line with Shifting the Balance of Care (2009), the elderly rehabilitation ward (2c) at Raigmore Hospital closed in December 2009, thus it is necessary to ensure day hospital and community rehabilitation services can effectively manage the elderly rehabilitation requirements resulting from that closure. The scope of the review included considering: the purpose and role of the day hospital referral pathways and criteria links with other services and agencies leadership, structure and model of delivery of the service Recommendations in light of the findings of the review will be included in the report.

2 Findings 2.1 Composition of the Multi Disciplinary Team (MDT) The team comprises of the following healthcare professionals: Physicians Consultant Geriatrician, Specialist grade Geriatrician Clinical Assistant Nursing Ward manager (Band 7) 1.0 whole time equivalent (WTE) Staff nurses (Band 5) 1.6 WTE Admin and Clerical post (Band 3) 0.54 WTE Nursing Assistants (Band 2) 2.11 WTE (including a housekeeper role) AHP Physiotherapist (Band 6) 1 WTE Physiotherapy Assistants (Band 4) 0.82 WTE Occupational Therapist( Band 6) 0.8 WTE Occupational Therapy Assistant (Band 3) 1.0 WTE Speech and Language Therapist (Band 7); 0.6 WTE covering RNI, day hospital and community Dietician (Band 6); 1.0 WTE covering RNI, day hospital and community including nursing homes With the exception of Nursing who are dedicated entirely to day hospital services, Physiotherapy, Occupational therapy, SALT and Dietetics all have a wider remit providing additional services to community based patients or other areas. There are therefore quite high demands on these staff with staff working to capacity. No Social worker is assigned to the team but referral can be made for this service as well as to Podiatry, Dentistry and Opticians. 2.2 Observation 2.2.1 Team Culture The MDT are all very professional individuals without exception. Individual teams members have genuine mutual respect for each other and relationships within the team are good as a consequence. 2.2.2 Awareness of Local and National Drivers for Change During discussion all team members identified the need for change in light of local drivers e.g. ward closure and redesign of Intermediate care teams. While the team members are aware of the national drivers

such as Shifting the Balance of Care (2009) and the Rehab Framework (2007), they are not familiar with the detail or how they might implement some of the high impact changes recommended themselves at Day Hospital. The team were unaware of corporate objectives which may impact on their services. Good relationships within the team will be a key factor in any the change process in Day hospital services. Positive attitudes to engaging in any change process are expressed by the team, albeit some staff are understandably anxious about change. This team have the ability and enthusiasm to actively engage in the process of delivering the changes required at Day Hospital. They will require some organisational support and strong leadership to deliver this. There will need to be transparency for the team if they are to take ownership of this. 2.2.3 General Observations Relationships are strong within the MDT, however some team members report that the team tend to work in professional silos and that there is a lack of understanding and clarity about roles within the team. Lack of clinical supervision for difficult/complex cases, lack of steer from management and lack of clear leadership are all sited by individuals as being problematic. The role of ward manager is clearly defined by the team as a management role No team member could identify a leader within the team, although as an external observer there are obvious leadership qualities demonstrated by some staff who have a can do attitude and who demonstrate the ability to develop services in line with evidence based practice and flexibility in their own role development. Historically the day hospital Is Consultant led and all disciplines have their own professional lead. 2.2.4 Good Practice There is good evidence of evidence based comprehensive geriatric assessment (CGA) in line with British Geriatric association guidelines. All the elements required from CGA are in place and the MDT utilise well recognised and validated tools in their assessment processes e.g. Barthel, Elderly Mobility Scale, Geriatric Depression Scale, Timed Up and Go, Waterlow and most recently the introduction of the Short Form 36 Quality of Life measure measure. There is a strong patient focus with patient centred goals driving treatment interventions. There is clearly documented evidence of this

within the patient notes which are accessible to all team members. This patient centred approach is also demonstrated by the team in the case conference, where goal setting and goal attainment drive the discussions and discharge planning. There is a very dynamic falls prevention/management programme. There is clear evidence of flexible working by Physiotherapy (PT) staff, Speech and Language Therapy (SALT) and dietetic staff who work across boundaries into the community. The PT and SALT also have OP outpatient lists at end of the day when patients have left day hospital. This demonstrates flexibility and a responsive service which strives to meet individual patient needs. A one stop Parkinson s clinic with full MDT assessment takes place monthly, with a Parkinson s Disease Specialist Nurse in attendance. Again this model reflects good practice. 2.2.5 Current Service Model The model of service delivery is a very traditional model which staff, themselves report has not changed in many years: Patients attend for 8 weeks for a full day and are fully assessed by the MDT over the first 2 weeks of attendance. Patients who require investigation such as x-ray, ultrasound or CT scan have these investigations at Raigmore. Access to these investigations is relatively prompt and can be arranged within the first week of attendance. There are 20 places available for patients. Most patients are brought to the day hospital by Scottish Ambulance Service, (SAS) which can offer around 12 patients transport. The remainder are brought by taxi or own transport. Transport was reported as being problematic, due to a 10 mile radius from day hospital being designated as the uplift area and the transport of wheelchair dependant patients limiting the number of patients who can be brought to day hospital. Generally the MDT case conference takes place at 2 weeks and 7 weeks of the patient s attendance. Initial outcomes of assessments are discussed at week 2 with patient goals and plans for treatment interventions being the focus of discussion. The MDT are, however very patient focussed and will discuss patients treatment plans, progress and review goals when it is timely to do so. This can be at any point in the episode of care and is not restricted to weeks 2 or 7.. Patient progress in terms of goal achievement, outcomes and planned discharge are discussed at week 7. A Parkinson s clinic takes place monthly and there are regular carers days. Falls assessment is integral to everyday working at day hospital, therefore is a daily occurrence.

Patients arrive between 9.30-10.30 am and are taken home between 3.00-4.30pm. This can vary considerably, with some patients arriving much later and leaving early, reducing contact time at the day hospital. Staff comment that more activity could take place in the afternoons if patient transport was improved. 2.2.6 Referral Pathway All referrals are directed through the department of Medicine for the Elderly and are screened by the ward manager. A recent audit of 50 patient notes undertaken by medical staff in January 2010 reported on the following: Referral source: GP s- 26% Acute wards and MOPD Raigmore- 36% Community teams 28% PD service 10% 54% of patients were female with an average age of 80 years and patients were cognitively intact.. 48% of patients were fallers. Activity On a typical 4 week month 400 place days are available to patients based on 20 places daily On average, in 2009, 74% of attendance was achieved. The average number of new patients monthly in 2009 was 27 which is a little more than 1 new patient daily 2.2.7 Referral Criteria Patients requiring specialist assessment and intervention by the MDT can be referred to Day Hospital. Patients referred are aged 65 years or over, though some younger patients with complex problems can be referred. Patients must live within a 10 mile radius of the day hospital for transport.

3 High Impact Changes The Day Hospital was reviewed using the 8 High Impact Changes as criteria. The 6 dimensions of care were considered within each high impact area. Safe Effective Patient Centred Timely Efficient Equitable Shifting the Balance of Care 8 High Impact Changes 1.Maximise flexible and responsive care at home with support for carers Response times for day hospital appointments are 3-4 weeks, though it is reported that if an urgent request is made then patients can be seen earlier. Carers support is provided in the form of a monthly carers group, where carers attend to see the facilities, meet staff and discus the services available. SALT operate a flexible response for Stroke patients who are discharged from the Stroke unit. The Stroke unit contact the SALT in anticipation of the patients discharge. If there is a wait for first appointment then the SALT arranges a home visit. SALT will continue to see the patient on discharge if there is an identified need. This demonstrates good practice and in line with the Rehab framework this reduces patient transitions between services Dietetics offer a very similar responsive service with a combined community day hospital role. Recommendations: An important role of day hospital is in supporting discharge and avoiding hospital admission (British Geriatric Society Guidelines). Consideration needs to be given to drive down response times to first appointment, if acute / sub-acute patients are the target group (Timely). There are a number of approaches that could be considered; changing the 8 week attendance to a more patient centred service where patients attend only for the time required to undergo investigation as well as intervention. In many cases this would be less than 8 weeks, though for a few it may be longer. This would open up additional spaces for new patients to attend. There should be daily allocations for rapid access for new patients to improve response times. It should be an achievable target to book 2 new patients daily. Part- day attendance for some patients could be considered. Alternatively, given that the average percentage of attendance is 82% it could be assumed that there are always patients who are unable to attend. By overbooking return patients daily

by 2 patients this could drive down the response time and waiting list. Carers forum is an ideal opportunity to gain views of carers on what their needs are in terms of support. There are some very good alternative ways of gathering this information from carers, rather than formal questionnaires. Consideration to a World Café format, where carers would be invited to put comments on specific themes on napkins or paper table cloths. Comments are anonymous and there is generally 100% participation. Comments are collated and any actions required are driven by this. For example: The most important benefit I get from my partner attending day hospital is? 2 things I would like to see happening at day hospital are 2. Integrate health and social care support for people in need and at risk There is little evidence of integration of social services in this team, Referrals to social care colleagues can be made if required but Social Workers were not integral to the team. Currently the integrated care team (ICT) are co-located in the building with social work colleagues. It is my understanding that with redesign of the ICT this integration will be lost. Staff at day hospital report that social care provision in the Highland area is a particular problem, and that patients with identified social care needs are not having these needs met due to lack of resources in social care. It is my view that closer working relationships with social services may improve efficiency by avoiding duplication of effort. Recommendation: Every effort is made to retain and to strengthen strong links with social services and engage social work colleagues in joint working to develop an enabling culture. Enabling patients to function more independently will free up resources for those more in need. A joint approach from health (day hospital and ICT) and social care is required to develop this approach. Rehabilitation at home requires a whole system approach with all parties having a clear understanding of the goals. Undoubtedly education and training would be required to ensure patient safety. This could be provided by Day hospital/ict teams. There may also opportunities with redesign for the ICT and day hospital team to forge stronger links.

3. Reduce avoidable unscheduled attendances and admissions to hospital It is particularly difficult to estimate the impact of the current day hospital service in the avoidance of unscheduled attendances and admission to hospital. Anecdotally staff do feel some patients are maintained at home who would otherwise have been admitted to hospital had they not attended day hospital, however no formal means of measuring this or audit had been undertaken. Over the past 4 months Medical staff from YDH have been liaising with the A&E department at Raigmore, highlighting the service available at YDH. Recommendation; There is considerable scope to influence unscheduled attendances and admissions to hospital utilising day hospital services (HEAT Target T12). It may be possible to identify patients from the SECHP, who fit Day hospital criteria, who have attended A&E and have then been discharged over the previous 24 hours who would benefit from CGA by the MDT at day hospital. The development of a rapid response pathway for fallers to day hospital should be considered and developed. Pathway example: A daily patient list would be pulled from EDIS (A&E management system) and suitable patients requiring assessment/ intervention would be contacted to determine if the patient requires input and if day hospital is the appropriate service to meet their needs. This would be done by Senior clinical staff. This would be particularly useful for targeting Elderly fallers who are either uninjured or with minor injuries. There is a skilled workforce in York Day Hospital particularly for elderly fallers who have the skills to provide this specialist assessment and intervention. Day hospital also has an important function in Long term condition management through partnership working with GP s and Community teams. By proactively identifying and regularly reviewing frail elderly patients at risk, hospital admission may be reduced in this patient group. National tools (SPARRA) or local tools (Nairn algorithm) may be utilised for this. Alternatively GP practices could be asked to provide Day Hospital with a regular update of those elderly patients on their list who are being actively case managed in an effort to avoid admission. Close relationships with the community based ICT should be developed further, with the ICT being encouraged to use the CGA model provided by Day Hospital when appropriate.

Working in partnership with Senior medical colleagues, and specialist Nurses may help maintain a patient at home who would otherwise be admitted. This does require timely and rapid access to Day hospital. 4. Improve capacity and flow management for scheduled care An audit of 50 sets of patient notes was conducted previously in January 2010. If an additional question is asked of this audit; has patient been discharged from an acute hospital in the past 6 weeks, this may give an indication of the impact the Day hospital currently has in providing support on discharge. Maintaining patient flow in areas where scheduled activity takes place can be very challenging. Elderly care physicians currently have input to Ortho geriatric patients in the acute unit at Raigmore and are therefore well positioned to influence patient flow from this clinical area. Twice weekly Consultant ward rounds take place at Raigmore with daily Clinical assistant rounds also being conducted. This proactive approach generates active referrals to the Day Hospital. Recommendation; Develop these links and good practice with Ortho-Geriatrics further and influence patient flow by identifying patients who are for discharge in a planned way (planned date of discharge (PDD) and directing them to Day Hospital for follow up. Arrangements for this would be contained within the patients discharge information and GP discharge letter. An example of appropriate patients would be, fracture neck of femur patients who have other co-morbid conditions and are likely to require MDT intervention on discharge, either at day hospital or home. Pre-arranged day hospital attendance planned prior to discharge may facilitate early safe discharge. Pulling patients through to day hospital by in reaching to Acute in this way may well influence Planned date of discharge if there is a confidence in planned follow up for frail elderly patients. There is also potential to evaluate and report on the impact of this approach through clinical audit. 5.Extend scope of services provided by non medical practitioners outside the acute hospital There was some evidence of extended scope activity at day hospital by non-medical staff. All disciplines were undertaking some health education roles in a small way. In doing so they were supporting other staff from smaller professions such as Dietetics. The health education role of staff involved in delivery of Falls prevention was clearly a priority and well delivered. The OT assistant also delivered exercise programmes, a role traditionally provided by Physiotherapy.

Recommendations; Patients do not mind who delivers their care, so long as the person is skilled and that the care is delivered well and at the right time. This view is supported by the Rehab Framework There is potential to extend the scope of some of the team further to enable a more efficient use of services. Prescribing by non-medical practitioners is an obvious area for Nursing and possibly physiotherapy staff in the team. Patients with COPD, Diabetes, PD and pain may benefit from this. The Generic role of assistant staff should be developed. This ensures a more flexible workforce who can deliver treatment interventions planned by a range of professional staff (physiotherapist, occupational therapist, speech and language therapist, dietician). At times of scarce staff resources during annual leave or sick leave, the team are in a better position to continue with planned interventions. 6. Improve access to care for remote and rural populations There are considerable challenges for the SECHP in providing both efficient and equitable services for some of the rural community. Transport is very problematic. For those patients in some areas such as Aviemore and Kingussie, this means they are unable to benefit from the specialist assessment of the MDT at day hospital. While some success is using alternative means of transport such as Taxi services for very locally based patients has been achieved, some innovative thinking is required to address the inequity for those patients further a field who have no means of personal transport. Recommendations; Alternative transport utilising volunteer drivers (RSVP service) may be a possibility. Day hospital already runs a monthly PD clinic, a fortnightly or monthly clinic for rural patients to have full assessment could be considered (hub and spoke model). With day hospital being the Hub for initial assessment and spoke services being delivered closer to home in other health/ social care facilities or in the home by the ICT. It may also be possible to consider other models of transport, such as joining up with other organisations utilising social care transport, sharing journeys with hospice and utilising community transport. There are successful examples of this approach to problem solving transport issues in rural areas on the Joint Improvement Team website. These should be

7. Improve palliative and end of life care 8. Improve joint use of resources investigated e.g. Blairgowrie model End of life care is not delivered at the day hospital. The location of a highly respected hospice next door with its dedicated MDT also providing day hospital services ensures this care is available to the local population. There are however patients attending day hospital who have palliative needs and support in managing long term conditions: PD, MS; COPD, Heart Failure. Joint equipment stores are in place but access to equipment and training for teams to allow access to the full range of equipment is required. Large equipment and housing alterations are an exception, with these being assessed and provided by social services. The initial assessment for equipment is carried out by an OT. The OT then undertakes a home visit to ensure the equipment is safe for use in the patients home. Where supportive tasks are undertaken OT assistants generally undertake these tasks. Recommendation: Currently the use of a clinical member of staff (OT assistant) to fit equipment is not an efficient use of clinical staff time. Where possible the fitting of equipment should be the remit of equipment store staff, releasing OT assistant for clinical duties.. 4 General Recommendations 4.1 Organisational Development The Day hospital team understand the need to change in light of both National and local drivers. They are a very professional team who have the capacity and capability to make any necessary changes. I believe with the right leadership and support that they will embrace and deliver the changes required. Organisational development work would be helpful, in the form of a workshop, where some of the detail of Shifting the Balance of Care, The Rehab Framework and the corporate objectives are set out to begin with. I would also recommend that the PDSA method of planning change is introduced to the staff at this and that they are encouraged to come up with ideas and action points themselves. There is more likelihood of success with this approach. Staff will need to be empowered to make these changes. Some staff did point out that the team did not feel empowered to make decisions, this could be addressed during development days.

4.2 Stakeholders Involvement It is also important to engage with all Stakeholders in the service; service users, GP s, Acute Care Physicians, Carers, SAS, Help the Aged etc. This will assure that services are developed to meet their needs and that what works well already is retained. A Stakeholders event should be considered. This should be done after any organisational development work with the team. 4.3 Information Technology IT support in the change process is crucial, shared systems which allow timely and safe communication to take place between partner agencies is essential. IT systems which would allow electronic booking of patient appointments by GP s, would accelerate response times to first appointment and would assist staff in diary management. This would improve efficiency for the smaller professions (SALT) who sometimes struggle with scheduling patient appointments and who report that they often do not get to see patients for some weeks after first appointment.. Introduction of an electronic system may go some way to implementing HEAT target E7 (increasing the % of electronic GP referrals to Consultant led services in secondary care). In addition to this there is scope for the development of Clinical IT systems for Professional and Patient use, which again is of particular importance in some interventions for SALT and OT. IT colleagues should be involved in the Stakeholder events. 4.4 Falls Management Programmes Falls services within the Day hospital are of a very high standard and form a large part of the activity in the day hospital. A population approach (Shifting the Balance of Care, 2007) to Falls services should be explored. Frail elderly patients who have undertaken the fall prevention programme can then continue to maintain their level of function in a community based programme. To be successful these programmes continue to require health support when delivered in places such as day care or community halls. The OTAGO programme is an evidence based programme which is ideally suited to this approach. OTAGO training should be supported by the SECHP and rolled out to other facilities. This would have the added advantage of more locally delivered, evidence based services to some rural communities and would reduce the current 12 week programme down to 6 or 8 weeks, freeing up Day hospital places.

The staff delivering the current programme have already been exploring the possibilities of the OTAGO approach and therefore should be supported and encouraged to take this piece of work forward. 4.5 Managed Clinical Network Any change in delivery of day hospitals services will impact on other areas and services. Day hospital should not be considered in isolation. A Managed Clinical Network for Older Peoples Services may help facilitate change across boundaries and help in the understanding of roles. 4.6 Clinical Audit There are some good examples of Audit activity in the department which demonstrate good practice in terms of patient safety such as cleanliness and hand hygiene. Department activity has also been audited well. The audit activity has tended to be uni -disciplinary which is a missed opportunity for the team to work together. The only example of Clinical audit was the outcome audit for the falls management programme. This was a simple, effective audit looking at changes in reported risk factors for falls on completion of the programme. The audit concluded that 25 of 36 patients included in the audit reduced risk factors for falls on completion of the programme. A follow up audit is planned for 2011. Small focussed clinical audits would offer the MDT opportunity to work together as a team and would also impact on safe and effective practice in relation to Older Peoples Services. Education sessions specific to Older peoples services could be presented by team members themselves using best practice statements or up to date clinical guidelines could be used and day hospital activity could be audited in line with these. AHP team members specifically are asking for opportunities of team working, this would be a productive and structured way of doing this. In addition Personal development of individual team members would benefit. 5 Conclusion This review was instructed to assist the York Day Hospital team to identify ways of working which would assist them in meeting the changing demands on their service in light of national and local corporate strategy. It was intended to identify current good practice in Elderly Care services at day hospital and to consider ways of implementing Shifting the Balance of Care (2007) and the Rehab Framework (2007), as well meeting corporate objectives.

Patient safety and evidence based practice by a very capable MDT were demonstrated during the review process. During the review team members were positive about the need to examine the role and contribution the Day hospital can make in achieving some of these objectives. The recommendations made are based on my observations of the team and examination of data gathered by the team, as well as through individual discussion. The recommendations provide some examples of how some changes may be made which may help the day hospital implement these changes successfully and how the team themselves can take ownership of this.