‘Navigating the System’

Finding early opportunities to access Community Services-

‘Discharge to assess’ work stream

Bie GrobetSouth Warwickshire Foundation Trust

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Warwickshire North CCG challenges

• Nuneaton and Bedworth : top 1/3 most deprived areas in England

• Warwickshire: 26/37 deprived areas are in Nuneaton and Bedworth

• Rural North Warwickshire: 18.3% >65 years old

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George Eliot Hospital

• District General Hospital

• Serves a population of 290,000

• North Warwickshire, South West Leicestershire and North Coventry

• 352 beds4

Bed based model Community Team modelNHS WarwickshireBramcote Hospital

• 41 bedded Rehabilitation Unit

• Reduced to 20 beds 2008/09

• Option appraisal for re-provision 2010

• Closure April 2011

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4 Principles to improve Care for Older People (Prof. Ian Philp):

• ‘Choose to admit’ only those frail older people who have evidence of underlying life-threatening illness or need for surgery – they should be admitted, as an emergency, to an acute bed

• Provide early access to an old age acute care specialist, ideally within the first 24 hours, to set up the right management plan

• ‘Discharge to assess’ as soon as the acute episode is complete, in order to plan post-acute care in the person’s own home

• Provide comprehensive assessment and re-ablement during post-acute care to determine and reduce long term care needs

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Simplified access

Emergency Capability

Reducing variation

• Expansion of Intermediate Care and Virtual Ward Services- Doubling capacity and workforce

• Service opening hours: 8.30 am till 12 Midnight

• Development of Community Emergency Response capability- 2 hour response

• Simplified referral criteria – ‘Discharge to Assess’

• Drive to improve confidence and understanding of Community Services by Acute and GP colleagues

• Reducing variation: 5 Daily Discharges- managing Acute and Community flow commitment

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‘Orange’ and ‘Green’ Flow:Bed days for adult emergency admissions 2008/09

Source: Dr Foster Intelligence &NHS Institute (2011)

‘5- A- Day’ Project

Community Navigators

Project Manager role across Acute and Community

• Early opportunities for 5 patients to be discharged daily

• 2 Community Nurses navigating patients to

Community Services

• Project Manager working across Acute and Community

• 2 work streams: ‘Orange flow’ short stay, ‘Green flow’ ward stays

• 677 patients supported

• Shared data collection to measure success

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• Retraining Community Hospital staff

• Change of culture and approach

• ‘Hearts and minds’ presentations

• Senior Leadership sign up and ‘Can Do’ approach

• Ward level engagement in discharge planning

• Integrated Emergency Care Board

• CCG and Board (x2) support

Change management

Improving confidence

Whole system sign up

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• Closure of Community Hospital savings - £2.07M:

• £1.03 M reinvested in Intermediate Care and Virtual Ward Services

• £400k invested in Intermediate Care beds in Nursing Home

• £1M of further savings re-invested in Acute contract

• 18 Acute beds closed

• Winter capacity only opened sporadically

Re-investment

Acute Trust savings

Bed Closure plan

Reduction in excess bed days

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Delayed Discharges

Length of Stay

Excess Bed days

• Reduction in bed days lost due to delayed discharges from 3 months to 4 weeks

• Reduction in Length of Stay by 1 day for Medicine and 0.4 day in Surgery on average

• 15% reduction in excess bed days compared to increase by 8% in similar size Hospital with similar demands in the area

Quarter 1 Quarter 2 Quarter 3 Quarter 4Emergency 09/

1010/11 11/12 09/

1010/11 11/12 09/1

010/11 11/12 09/10 10/11 11/12

ALL 6.4 5.3 5.6 5.6 5.4 4.9 5.9 6.0 5.1 5.9 5.9 5.2Medicine 8.6 7.1 7.0 7.8 7.8 6.4 8.0 8.0 6.3 8.1 8.1 6.7Surgery 6.9 6.0 6.7 6.0 5.7 5.3 6.6 7.0 6.1 5.9 6.5 5.2

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• 677 patients supported in 6 months

• 30% of patients supported by the Virtual Ward for Long Term Conditions management

• 94% of surveyed Virtual Ward patients felt they benefitted from the service

• 87% felt more confident to manage their Long Term Condition

• 68% of patients discharged from Intermediate Care without ongoing support

• 0.6% of cohort re-admitted

• 16% requiring ongoing care package from Social Care

• 85% of patients still living independently at home 91 days post Discharge (NI 125)

‘Discharge to Assess’

Re-admissions

Independence

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• ‘Right patient- Right bed’

•Estimated Discharge Date compliance from 43% to 96%

• Less inter-hospital transfers

• Ahead of Deep Cleaning Programme

• Increased Qualified Nursing levels on the wards

• 25 Discharges a week compared to 6-7 to bedded unit

Estimated Discharge Dates

Deep Cleaning

Reducing Variation

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Lessons Learnt• Project Manager role invaluable• Consistent message regarding ‘Discharge to Assess’

at all levels (standardised presentation)• Partnership Board and Emergency Care Board

scrutiny and endorsement • Evaluating outcomes across organisations regularly

and early on, managing the changes in bed use• Commissioning support regarding contracting and

performance

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• Ahead of Deep Cleaning Programme

• Increased Qualified Nursing levels on the wards

• 25 Discharges a week compared to 6-7 to bedded unitEstimated Discharge

Dates

Deep Cleaning

Reducing Variation

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56 6

76 6 6 6

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5 54

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1 12

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Reducing Variation: September 2011 versus January 2012

No of Discharges Escalation Level

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No of Discharges Escalation Level16

• Electronic Common Assessment Tool developed between Health and Social Care

• Critical success measures openly shared between organisations

• Twice weekly Tele Conference between Health and Social Care to ensure patient flow in Community

Automating Navigation

Shared data

Community Flow

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