Appendix 1: South Lanarkshire H&SCP Improvement Plan 2017/18. South Lanarkshire - Whole System Pathway Indicators identified capture key data across the whole H&SC system, primarily based around supporting people in the community as an alternative to hospital admission. The following diagram attempts to illustrate this approach, it should be noted that many of the community supports at the point of hospital discharge are supports to prevent hospital admission. Many of the community supports and actions contribute to both admissions avoidance and facilitating early discharge from acute settings. As a result many of the actions appear against different indicators. 1
1. Emergency Admissions Strategic Commissioning Intentions 2016-19 Develop models of self-care and selfmanagement Expand intermediate care to reduce reliance on hospital and residential care. Continue to build early intervention, prevention and health improvement plans. Carers support Support people to maximise their independence through the delivery of a enablement approach across all localities Develop an anticipatory care programme Utilise telehealth and telecare to enable more people to self-manage their health and wellbeing Increase the use of Anticipatory Care Plans for priority groups whilst maintaining their use in community settings. Review and enhance current Hospital at Home model linking to the locality Integrated Community Support Teams (ICSTs) Expand the role of Advanced Practice at locality levels Continue deliver of the Care at Home Medicines Management Project to include all care at home providers. Grow capacity in the Third sector t o ensure that people are supported to achieve National Outcomes. Continue development of Community Falls Pathway to continue Level 1 screening in Voluntary Sector Work with the NHS Board to agree future service direction for Out of Hours Build on current successful services by developing and commissioning flexible models of intermediate care across all partners. Utilise existing capital assets to co-locate staff within multi-disciplinary teams. Support the continued use of the Locator Tool. Create unified AHP teams by aligning acute staff with ICSTs Development of improvement objective. Emergency admissions for South Lanarkshire are above the Scottish average. Data received from ISD shows that the numbers of admissions increased over the period Nov 2014 Dec 2016. If the overall trend in emergency admission continue for South Lanarkshire then overall admissions will increase by 8% by 2020/2021. For under 65 age group there will be an decrease of approximately 1%, however for the 65+ age group the increase will be 39% and 39% for over 85 age group. With the actions outlined above it is proposed that the rate of increase is halted with a view to during 2017/18, this numbers are based on the number of admissions during 2015/16.
4,000 South Lanarkshire Emergency Admissions 3,500 3,000 2,500 2,000 1,500 1,000 Actual Projected Target 500 0
2. Unscheduled Bed Day Strategic Commissioning Intentions 2016-19 Develop models of self-care and selfmanagement Expand intermediate care to reduce reliance on hospital and residential care. Continue to build early intervention, prevention and health improvement plans. Carers support Create unified AHP teams by aligning acute staff with ICSTs to support opportunities for early discharge from acute settings Utilise existing capital assets to co-locate staff within multi-disciplinary teams linking with acute colleagues Increase the use of Anticipatory Care Plans for priority groups to reduce hospital stays. Review and enhance current Hospital at Home model linking to the locality Integrated Community Support Teams (ICSTs) Expand the role of Advanced Practice at locality levels Continue deliver of the Care at Home Medicines Management Project to include all care at home providers. Grow capacity in the Third sector to ensure community supports Explore with ISD/Others Partners/Acute Sector underlying reasons for high rate of emergency admissions Development of improvement objective. There has been decrease in the numbers of unscheduled hospital bed days over the period Nov 2014 to Dec 2016. However there may be data lag for Nov/Dec 2016 which will affect the overall numbers. One action outlined in the Health and Social Care Delivery Plan was reduce unscheduled bed days by as many as 400,000 It is proposed that the South Lanarkshire contribution to this target is a reduction of 6.5%. This is based on a reduction from 2015/16 levels.
South Lanarkshire Unscheduled Bed Days 25,000 20,000 15,000 10,000 5,000 Actual Target 0 Nov-14 Feb-15 May-15 Aug-15 Nov-15 Feb-16 May-16 Aug-16 Nov-16 Feb-17 May-17 Aug-17 Nov-17 Feb-18 May-18 Aug-18 Nov-18 Feb-19
3. Accident and Emergency Attendances Strategic Commissioning Intentions 2016-19 Develop models of self-care and selfmanagement Expand intermediate care to reduce reliance on hospital and residential care. Continue to build early intervention, prevention and health improvement plans. Carers support Increase the use of Anticipatory Care Plans for priority groups to reduce A&E attendances. Continues use of Care Managed Patients pathway Review and enhance current Hospital at Home model linking to the locality Integrated Community Support Teams (ICSTs) Expand the role of Advanced Practice at locality levels Continue deliver of the Care at Home Medicines Management Project to include all care at home providers. Grow capacity in the Third sector t o ensure that people are supported to achieve National Outcomes. Continue development of Community Falls Pathway to continue Level 1 screening in Voluntary Sector Work with the NHS Board to agree future service direction for Out of Hours Build on current successful services by developing and commissioning flexible models of intermediate care across all partners. Utilise existing capital assets to gain further benefits from co-location of multidisciplinary teams. Support the continued use of the Locator Tool. Create unified AHP teams by aligning acute staff with ICSTs Development of improvement target. If the trend in emergency department attendances over the past four years continues then overall attendances will increase by 1% by 2020/2021. However for the 65+ age group there is estimated to be a 14% increase and 32% increase for the 85+ age group. This is a more frail group of people with greater complex health and social care need, who require greater support from across all sectors to support them to remain in their own homes and reduce hospital attendances and admission. Taking into account actions outlined above and the greater proportion of frail older people it is proposed that the target for this indicator remains at current levels.
9,500 9,000 8,500 8,000 7,500 7,000 6,500 6,000 5,500 5,000 Nov-14 Jan-15 Mar-15 May-15 Jul-15 Sep-15 Nov-15 Jan-16 Mar-16 May-16 Jul-16 Sep-16 South Lanarkshire A&E Attendances Nov-16 Jan-17 Mar-17 May-17 Jul-17 Sep-17 Nov-17 Jan-18 Mar-18 May-18 Jul-18 Sep-18 Nov-18 Jan-19 Mar-19 Actual Projected
4. Delayed Discharge Bed Days Strategic Commissioning Intentions 2016-19 Expand intermediate care to reduce reliance Deliver care at home services to existing levels on hospital and residential care. Invest in the care at home market to achieve zero delays in non-complex home care delays of 3 days and over Models of self-care and self-management Build on current successful services by developing and commissioning flexible models of intermediate care across all partners Seven day services Facilitate earlier discharge by developing AHP rehabilitation /reablement series in the community Review and enhance current Hospital at Home model linking to the locality Integrated Community Support Teams (ICSTs) Expand the role of Advanced Practice at locality levels Grow capacity in the Third sector to ensure community supports Agree future direction of Out of Hours services Re-designation of local authority care home beds from respite/long term care beds to intermediate care beds Changes to the management of AWI patients in the context of a wider remodelling of care Increase capacity from external home care providers Provision of intermediate care. Subsequent and further actions will include: Review effectiveness of Discharge HUB Explore discharge to assess models Development of improvement targets. Data supplied to South Lanarkshire includes bed days prior to July 2015, this data cannot be used for the purposes of forecasting as changes were made to internal data management prior to this date. There has been an overall reduction in delays from July 2015 November 2016 with a downward trend, however it must be acknowledged that data for forecasting purposes. It is proposed that improvement targets are based on zero Homecare delays under 3 days 2017/18 with further reduction realised 2017 /18 as intermediate care is developed further. In addition to bed days South Lanarkshire aims to continue to perform within the top quartile for Scotland for patients discharged within 72 hours of Clinical Readiness Date.
South Lanarkshire Delayed Discharge Bed Days 5,000 4,500 4,000 3,500 3,000 2,500 2,000 1,500 Actual Improvement Target 1,000 500 0 Jul-15 Sep-15 Nov-15 Jan-16 Mar-16 May-16 Jul-16 Sep-16 Nov-16 Jan-17 Mar-17 May-17 Jul-17 Sep-17 Nov-17 Jan-18 Mar-18 May-18 Jul-18 Sep-18 Nov-18 Jan-19 Mar-19
5. End of Life Care Strategic Commissioning Intentions 2016-19 Expand intermediate care to reduce reliance Further development and use of Anticipatory Care Plans to support people to die in on hospital and residential care. their place of choice. Support for people whose wish is to die at home. Carers support Fully develop and roll-out of an outcomes support planning approach that delivers personalised services to support carers in their caring role Seven day services Utilise Telehealth and telecare to support people to remain at home Review and enhance current Hospital at Home model linking to ICST Community Capacity Building Expand the role of Advanced Practice at locality levels Build on current successful services by developing and commissioning flexible models of intermediate care Working with VASLan we will support the continued development of the Locator Tool and community and Third Sector capacity building Development of improvement targets. Percentage of people who spend their last 6 months in a community setting has steadily increased over the previous three years. With a shift of resources from acute to community it is expected that the numbers of people who spend the last six months in the community will increase. Initially the Partnership aims to achieve the average of the Discovery peer group. South Lanarkshire Percentage of last six months of life by setting 2013/14 2014/15 2015/16 2016/17 2017/18 2017/19 Community 84.3% 84.7% 85.6% 86.10% 86.60% 87.0% Large Hospital 14.0% 14.1% 13.2% 12.7% 12.2% 11.70%
6. Balance of Care (Community vs. Institution) Early Intervention, prevention and health Improvement Carers support Models of self care and self-management Seven day services Expand intermediate care to reduce reliance on hospital and residential care. Development of improvement targets. Strategic Commissioning Intentions 2016-19 Support people to maximise their independence through the delivery of a enablement approach across all localities Develop an anticipatory care programme Utilise telehealth and telecare to enable more people to self-manage their health and wellbeing Increase the use of Anticipatory Care Plans for priority groups whilst maintaining their use in community settings. Review and enhance current Hospital at Home model linking to the locality Integrated Community Support Teams (ICSTs) Expand the role of Advanced Practice at locality levels Continue deliver of the Care at Home Medicines Management Project to include all care at home providers. Deliver respite to existing levels in supporting carers in their caring role Grow capacity in the Third sector t o ensure that people are supported to achieve National Outcomes. Continue development of Community Falls Pathway to continue Level 1 screening in Voluntary Sector Work with the NHS Board to agree future service direction for Out of Hours Build on current successful services by developing and commissioning flexible models of intermediate care across all partners. Utilise existing capital assets to co-locate staff within multi-disciplinary teams. Support the continued use of the Locator Tool. Create unified AHP teams by aligning acute staff with ICSTs Fully develop and roll out an outcomes support planning approach that delivers personalised services to support carers in their caring role The percentage of people over 75 who are living in their own homes independently has increased during 2015/16 and South Lanarkshire compares at the average level when measuring against the Discovery peer group. Given the increase in the 75+ age group it is suggested that the 2015/16 percentage remains the target through to 2018/19.
South Lanarkshire Balance of Care 2013/2014 2014/2015 2015/2016 2016/2017 2017/2018 2018/2019 Home (Unsupported) 81.1% 81.9% 82.0% 82.0% 82.0% 82.0% Home (Supported) 9.6% 9.0% 9.0% 9.0% 9.0% 9.0%