Page 1 Delayed Transfer of Care Adult and Community Services Overview Committee 9 Date of Meeting 20 January 2016 Officer Director for Adult & Community Services Subject of Report Delayed Transfers of Care Executive Summary Delayed transfers of care are reported on a monthly basis with a league table of local authorities performance produced. Currently Dorset County Council is in the bottom quartile of the league table with delays above the targets set and an increasing number of days delayed. The County Council has produced an Improvement Plan for delayed transfer of care performance which looks at whole system improvements across all services where delays can occur. The County Council is also being supported through the investment of 350,000 funding to deliver some schemes throughout the winter period which will help to avoid admissions as well as support timely and safe discharges. Impact Assessment: Equalities Impact Assessment: An Equality Impact Assessment Screening Tool has been completed for the new service and identified an EqIA is not required.
Page 2 Delayed Transfer of Care Budget: Better Care Funds of 350,000 have been identified to fund the schemes to support the whole system during the winter period. Risk Assessment: Having considered the risks associated with this decision using the County Council s approved risk management methodology, the level of risk has been identified as: Current Risk: MEDIUM Residual Risk: MEDIUM Other Implications: There are inherent changes required in the culture and delivery of services for both the County Council s staff and staff across the whole system to better deliver more responsive, innovative and flexible support that focuses upon avoiding admission where possible and supporting timely and safe discharges. Recommendation The Committee is asked to: (i) Support the use of the Better Care Funding to fund the schemes to strengthen services over the winter period and improve Dorset s delayed transfer of care performance (ii) To note and comment on the Dorset s current delayed transfer of care position and the proposed Improvement Plan. Reason for Recommendation To help deliver the County Council s priority on health and wellbeing for the people of Dorset. Appendices Appendix 1 Dorset County Council Delayed Transfer of Care Improvement Plan Background Papers Officer Contact Care Act Guidance, Annex G Monthly Delayed Transfer of Care Situation Reports, Definitions and Guidance Name: Ruth Davis, Hospital Service Development Manager Tel: 07776 423963 Email: ruth.davis@dorsetcc.gov.uk
Page 3 Delayed Transfer of Care 1 Background 1.1 Information about delayed transfer of care is collected for acute and non-acute patients, including mental health and community patients on the monthly Delayed Transfers Situation Report (SitRep) return. The focus on the return is to identify patients who are in the wrong care setting for their current level of need and it includes patients waiting for external transfer in all NHS settings, irrespective of who is responsible for the delay. 1.2 A SitRep delayed transfer of care from acute or non-acute (including community and mental health) care occurs when a patient is ready to depart from such care and is still occupying a bed. A patient is ready to transfer when: a) A clinical decision has been made that the patient is ready for transfer AND b) A multi-disciplinary team decision has been made that the patient is ready for transfer AND c) The patient is safe to discharge/transfer. 1.3 The Care Act brought in some changes which include that every day of the week counts, including weekends and Bank Holidays, previously delays were only counted during the working week. These changes are in line with the move towards seven day services. For social care delays, reimbursement is no longer mandatory and it is up to the discretion of the local system whether they want to charge or instead use the resources in a different way to support effective discharge. 1.4 From April 2004 there has been a requirement to return the monthly SitRep report, this identifies all delays in transferring patients from acute and non-acute settings across three broad categories: a) reasons related to social care; b) reasons related to health care (non-acute); c) reasons related to delays in both health and social care. 1.5 When delays are reported they are categorised, each category has a clear definition that ensures that delays are counted consistently across the country. 1.6 All health and social care delays are required to be reported on a monthly basis, it is common for this to be increased to weekly from October through to April, and sometimes daily. There is a requirement that the return is validated, agreed and signed by the trust and social care. This should be at Executive Director-level in the acute trust and the Director of Adult Social Care-level in the local authority. Delegation is acceptable as long as there is a process for escalation if there are any disputes. 1.7 From the monthly SitRep there are two specific performance reports, these are known as ASCOF 2C Part 1 and ASCOF 2C Part 2. ASCOF 2C Part 1 is a report on the number of delays at midnight of the last Thursday of the month. ASCOF 2C Part 2 is the number of delays at midnight of the last Thursday of the month that are attributable to social services.
Page 4 Delayed Transfer of Care 2 Dorset Performance 2.1 The September outturn for ASCOF 2C Part 1 is 19.35 per 100,000 population compared to 19.00 for August and 21.31 for 2014-15, and against a target of 9.70. ASCOF 2C Part 2 is 8.11 per 100,000 population compared to 7.74 for August and 7.98 for 2014-15, and against a target of 3.10. 2.2 The monthly reporting also produces a 'league table' of all 151 local authorities according to the delayed transfer of care performance. The September outturn showed that Dorset is in the bottom quartile for both indicators (141st of 151 authorities for ASCOF 2C Part 1 and 132nd for ASCOF 2C Part 2). A majority of the south west authorities and a majority of the Dorset comparator group authorities are also in the bottom two quartiles. 2.3 Delays are categorised by which provider is responsible for discharging the individual, so either health, social care of both. Where the delay is attributable to health the most likely reason is that the person is being assessed for continuing health care or is eligible for continuing health care funding and is awaiting a package of care or a placement. 2.4 The Provider Summary part of the monthly SitRep shows 58% of Dorset s delays are attributable to the NHS. In non-acute beds in community hospitals, over half of all delays (55.4%) are attributable to Adult Social Care in Dorset. 2.5 The monthly SitRep also reports on the number of days people have been delayed. In September there had been 1064 days delayed in acute hospitals and 896 days delayed in non-acute hospitals. 2.6 Recent performance figures have not significantly changed this summary. 3 Improving Performance 3.1 Dorset County Council has developed a performance Improvement Plan (Appendix 1) for delayed transfers of care which is regularly monitored by the Director. This Improvement Plan is supported by the allocation of 350,000 of funding allocated from the Better Care Fund. This funding is being allocated to support hospital discharges and admission avoidance over the winter period. 3.2 The funding will support the following schemes; a) Rapid Response Service A domiciliary care service that can provide a urgent response to support admission avoidance and discharges. This service will cover the whole of Dorset and will be operational until after the Easter weekend in March. b) Roaming Night Service A domiciliary care service that operates over night to support urgent night care needs for people in their own home, supports discharges from Accident and Emergency departments and supports the Out of Hours GP Service. c) Transfer of Care Officer A 1 year fixed term post to support the Hospital Service Development Officer in implementing the Improvement Plan and improving Dorset s Delayed Transfer of Care performance.
Page 5 Delayed Transfer of Care 3.3 The Rapid Response Service has been piloted in the East of the County and was very successful in supporting the whole system. During a 16 week pilot it supported discharges from 44 acute beds, helped avoid 38 admissions into a hospital, avoided 320 days delayed in a hospital bed and helped release 97 hours of reablement service. 3.4 The Roaming Night Service has successfully supported Dorset residents for the past two winters by responding to calls to Careline, supporting people to return home after visiting Accident and Emergency departments, supporting the GP out of hours service by assessing people and providing information to the on call GP and supporting the ambulance service by supporting people who they have visited but don t need to be taken to hospital. The South West Ambulance Service state that this service it crucial to supporting them to provide suitable services during the winter period. 3.5 The Transfer of Care Officer will support the Hospital Service Development Officer to deliver the Improvement Plan and improve Dorset s delayed transfer of care service. The Officer will support the delivery of a robust validation process so we can ensure we are clear on the reason for the delays so that we can target certain areas through improved processes or a different commissioning approach. 3.6 The Improvement Plan is focused on the whole system and supports the various areas where delays can occur and supports the identified eight high impact changes that can support local health and care system reduce delays. 3.7 Areas of work within the Improvement Plan will include looking at health having direct access to certain services so that patient flow can take place over seven days. This will include bringing in a framework for trusted assessments to take place both within the hospitals and localities. 3.8 The plan will also focus on the development of a Discharge to Assess approach to discharges from hospitals. The move to this model will mean that we are no longer assessing a person s long term care needs in a hospital setting but in their own home or in a suitable bed-based service. The model will also support our duties around providing information and advice and early intervention and prevention. 3.9 The County Council will be receiving the support of the Local Government Association to deliver the Improvement Plan. 3.10 During the forthcoming winter period the above services will be supported with other incentives and ways of working. The council will be expecting providers to supply details of their capacity on a daily basis, this will allow early planning for discharges and bring more efficiencies into the brokerage system. As well as this, internally, discharges and delays will be actively monitored on a daily basis and solutions sought where discharges are problematic. 3.11 The County Council will also be working alongside Dorset Fire and Rescue to utilise the 100 volunteers they have across the county to support people to return home after a stay in hospital. The council will also be linking with other voluntary services and good neighbour schemes to ensure a local and coordinated approach which will allow the person to be supported by their community.
Page 6 Delayed Transfer of Care 3.12 The Social Care Teams based in the hospitals will be implementing part of the Discharge to Assess model by retaining people who go home from hospital with a reablement service and assessing them in their own home in a timely and proportionate manner. This brings in more efficiencies to the reablement service and will take some pressure away from the locality teams so that they can focus on community work and admission avoidance. 3.13 Domiciliary Care provision will be kept open in the event that an individual is admitted to hospital for a short time so that they can return promptly home with the same provider and carers therefore providing them with continuity and confidence to return home and ensure that we can rapidly discharge people when they are medically fit. This will also provide further efficiencies within the brokerage system. Catherine Driscoll Director for Adult and Community Services January 2016
Page 7 Delayed Transfer of Care Appendix 1 Delayed transfers of Care Improvement/recovery plan September 2015 draft v3 Purpose: South West region and national data sets, published June 2015, identify Dorset as currently being 131st in the country for DToC performance; Dorset s performance being lower than neighbouring Local Authorities. The plan below sets out areas of work and actions planned or being undertaken to improve the delayed transfer of care performance in Dorset. Area of work identified Acute Hospital Delays Improvement actions Actions to date/required Timescale to undertake Monitoring of improvement Update 18/12/15 1. Develop joint systems for 1. a) Work with business 1. a) March 2016 To be included as a PAN management and prioritisation of intelligence to trial at DCH and Dorset discussion at the response to Care Act notifications roll out to acute sites if next TOC Meeting in (previously s2/5) successful meeting w/c January 2015 to get a 21/9/15 PAN Dorset approach. 1. b) Work with acute providers to ensure notifications are Care Act compliant, timely, accurate and appropriate 1. b) Sep-March 2016 To be included as a PAN Dorset discussion at the next TOC Meeting in January 2015 to get a PAN Dorset approach. Acute Hospital Delays 2. Identify and address internal processes/blockages that unnecessarily prolong length of stay and contribute to delay in patient pathway, whether that be a formal or informal delay. (e.g. Referral mechanisms, MDT assessment processes, Implementation of choice policy) 2.Hospital locality area manager/ruth Davis to arrange sessions with hospital discharge teams at each acute site to create joint action plan 2. March 2016 2. Production and agreement of joint plan Meeting with DCH held and improvements made with CHC processes. DCC team to discuss expectations around Choice Policy Completed at DCH and better links formed. Each hospital team have highlighted issues and
Page 8 Delayed Transfer of Care joint meetings with the hospitals will be arranged in the new year to discuss how to simplify and join process Acute Hospital Delays 3. Reduction in LOS and delays due to housing related issues 3. Ruth Davis making connections between District housing teams, acute hospital and LA hospital locality team to identify actions required at early stage in admission to address housing issues 3. February 2016 3. Production and agreement of joint plan Meetings to be arranged for Jan/Feb 2016 for Housing to attend and give an overview of duties and discuss how we can improve partnership working. DCC and Hospital staff will be invited to these meetings. Acute Hospital Delays 4.Implementation of discharge to assess pathway with acute providers 4. a) Sue Evans/Ruth Davis and area managers to continue to work with transfer of care group, hubs and acute providers in developing implementation of discharge to assess pathways. 4. a) January - July 2016 4. a) Models in place within each acute 4. a) Meetings with Poole hospital and RBH Sep 15. RBH funding agreed for 2x SW to support. Further meeting to progress model arranged. Poole trialling with trauma commencing 5/10/15 4 weeks. RD liaising with reablement re resource to support. Discharge to Assess across Dorset to be evaluated in the new year.
Page 9 Delayed Transfer of Care 4. b) Sue Evans/Ruth Davis/Commissioning to continue to seek the commissioning of rapid response elements to all relevant services to support discharge to assess model of care 4. b) January - July 2016 4. b) Joint development of rapid response elements to all community based services. 4. b) Meetings are taking place to improve the interface between Reablement and health community services. Reablement specification being revised to include a rapid response element. 4. c) Sue Evans/Ruth Davis to work with locality teams and Dorset Healthcare to redefine interface and transition between hospital/locality and improving admission avoidance work 4d) Area managers/area practice managers to work with teams in supporting move to MDT outreach approach required in implementing discharge to assess model 4. c) March 2016 4. c) Discharge to assess model incorporates transition back to locality teams. 4. d) March 2016 4. d) Team development plans being implemented Meetings in place in January to carry out an audit of criteria of Community Services to identify gaps or duplication Event being held in January 2016 to develop team plans 4e) development of joint social care/therapy assessments 4.e) March 2016 4e) joint assessment visible on s/u files 4. e) Trusted Assessment framework being developed which will allow health colleagues to assess
Page 10 Delayed Transfer of Care individuals and directly accesses some services. Outlying Acute Hospital Delays 1. Develop efficient ways of working that are responsive to out of county acute provider and reduce delayed transfers of care for Dorset residents 1a) RD meeting with discharge leads to review current response from DCC in out of county acute settings and where key improvements could alter response and outcomes 1. a) January 2016 1. Regular reporting is now in place and issues being identified in delays are informing commissioning needs for these areas. Outlying Acute Hospital Delays 2. Review internal processes/blockages that unnecessarily prolong length of stay and contribute to delay in patient pathway, whether that be a formal or informal delay. (e.g. Referral mechanisms, MDT assessment processes, 1. b) SE/RD to explore options for different models of working and providing a SW service to out of county hospital providers. 2. RD/area managers to arrange to meet locally and to put in place action plan to address issues identified 1. b) Referral/workload data to be obtained and consideration given to other options for provision of a SW service (e.g. DCC hospital locality manage acute provider discharges rather than locality currently) January 2016 Consideration will take place regarding the resource for discharges at these hospitals being based within the current hospital teams once further information about the number of referrals is known. 2. January 2016 2. With referral data, to consider workflow and work to be undertaken with AM s to look at potential models of delivery. RD has met with Yeovil and Salisbury Hospitals.
Page 11 Delayed Transfer of Care Community Hospital Delays Implementation of choice policy) 1. Identify reasons for delays behind figures 1. RD/KMCK to continue ongoing work to break down length, reason of delay and patient pathway leading to a delay to understand key issues to address. 1. January 2016 1. RD/KMK pulling together sheet of information which AM can use to be clear about position of delays in area and start to address Community Hospital Delays OP Mental Health Delays 2. Develop action plans with each CH provider for methods of improving delayed transfer of care appointments at Locality level 1. Increase understanding of nature of delays and processes that may contribute to increased LOS or delay. 2. SE/Area Manager in locality has visits set up during Oct 15 - to work jointly to identify priorities. 1. a) Kerry McKenzie to gather data alongside Dorset healthcare regarding delays and audit cases to fully understand where delays occur. 2. March 2016 2. Meetings held throughout October 2015. Action plans now being developed 1. a) January 2016 Working alongside DHUFT to improve discharge processes has seen an improvement in the delayed figures. However there is still a lack of provision for really complex cases. Commissioning will be reviewing bed based mental health provision. Continuing Health Care 1. Improved CHC processes within hospital settings 1. Area managers/ CHC lead/sue Evans working with acute providers, CCG to identify and reduce inbuilt delays in the CHC process/system March 2016 DCH improved processes. SB to meet at Poole/DCC and RBH/DCC to improve process and review progress at DCH
Page 12 Delayed Transfer of Care Continuing Health Care 2. Development of joint commissioning 2. CHC implementation group workstreams/better Together progressing May 2016 Ongoing through CHC Improvement Group Continuing Health Care 3. Development of joint funding arrangements for those people who are not eligible for CHC but may still have needs which are beyond the powers of an LA to meet. 3. CHC implementation group workstream. Sue Evans working with CCG and commissioning on some test cases and in developing joint funding framework May 2016 Ongoing through the CHC Improvement Group Continuing Health Care 4. Development of alternatives to existing funding out of hospital arrangements 4. CHC implementation group workstream. Sue Evans working with CCG and other LA s - PID being submitted to CHC steering group March 2016 Ongoing through the CHC Improvement Group Reablement 1. Improve access, efficiency and response time of Tricuro reablement service to support hospital discharge 1. a) Sue Evans/Ruth Davis working with Tricuro on immediate reductions in delays due to reablement capacity including shorter holding periods, referral and provision between Fri-Mon. Reablement 1. b) Commissioning work with Tricuro to develop efficiency and free up capacity January 2016 Current review of the service specification to achieve a proactive joint approach to supporting early supported discharges. Setting clearer prioritisations for hospital discharges with a 4 hour response time to referrals. January 2016
Page 13 Delayed Transfer of Care Early Help 1. Development of early help options to support with low level need and in the provision of information and advice to support self managed discharges 1. Ruth Davis undertaking work with Early help and acute providers to design and develop hub s in acute hospitals (i.e. information centres with MLMC, resource hubs demonstration of telecare and equipment) January - March 2016 Specification being written to compliment the reviewed Popp specification and the introduction of Care Navigators. Early Help 2. Development of low level service to support discharge. (e.g. Home from hospital) 2. Ruth Davis undertaking work with Early help to look at options for low level short term support on discharge (follow up phone calls, information and advice, settling in period at home - home from hospital) January - March 2016 Event to be arranged to pull together locality volunteer groups and wider Dorset volunteers such as Dorset Fire and Rescue to provide local based support for people returning home after a period in hospital.