rachana vyas-presentation-(urgent-care)-final
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LLR Urgent & Emergency Care Improvement Plan
Rachna Vyas, Cluster Unscheduled Care Lead
29th September 2011
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Governance
LLR Emergency Care Network (ECN) set up Jan 2011
Senior Executive membership, both managerial & clinical with
clear links to each Clinical Commissioning Group
Multi-agency plan with timescales & leads
Weekly performance dashboard Other stakeholders bought in as
required
Local Authorities
LPT
GEH EMAS
UHL
Clinical Comm.Groups
PCT
ECN
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Key multi-agency challenges tackled through the ECN
1. Management of attendance levels to ED/Bed Bureau 2. Management of Mental Health Patients in ED3. EMAS Patient Transport Service; Service delivery &
cancellations4. Tackling delayed discharges 5. Robust winter planning6. Systems design7. Delivering reablement services8. Pathways for Frail Older People9. Improving Discharge processes10. UHL internal processes & workforce development11. Creating a LLR Single Point of Access
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Challenge 1: Rising demand on acute services affects service delivery in the ED
Actions:1. Cluster-led streaming project initiated in June 2010 to reduce the number of patients
treated in the ED by up to 10% (at additional cost). 2. Every GP practice across LLR monitored weekly against an agreed target to reduce
usage of acute care, inc. both ED attendances and admissions. 3. Targeted communications/social marketing work launched in certain areas of Leicester
City showing highest inappropriate use of ED.
Progress: LLR current position is -1.4% against planned activity
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Challenge 2: The response to ED by the Crisis Response Team causes delays in the patient journey
Actions:1. LPT undergoing a full review of the acute adult mental health pathway2. Enhancing the Adult Liaison Psychiatry Service to:
– Increase out of hours liaison psychiatry presence within ED in UHL between 5pm – 12pm seven days a week
– Provide dedicated Mental Health expertise at point of admission– Reduce waiting times– Provide improved care pathway for the acute medical units (15 & 16) and short stay units
(33)– Divert patients from ED to the Urgent Care Centre where they can be assessed in a more
appropriate environment – Improve the transfer of patients requiring crisis intervention or admission to LPT– Support the redesign of Acute Mental Health Care Pathway
Progress:The enhanced service is due to go live in Oct 2011
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Challenge 3a: The ‘re-bedding’ of patients causes unnecessary delays in the patient journey
Actions:1. Re-specify Patient Transport Service contract to provide a fit-for-purpose service within the
current financial envelope2. Increase communication channels between UHL-EMAS3. PTS crews will be made available earlier to transport those patients who are made ready before
midday4. Earlier escalation to UHL to ensure that mitigating actions can be enabled if delays arise5. Re-issue PTS Eligibility criteria to city and county General Practices, as well as all UHL wards.
Progress:
Average number of rebeds per week for 11/12 has been 9.
10/11 Q3/4 average was 12 per week.
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Challenge 3b: Late cancellations of PTS services reduces availability of crews and interrupts service delivery
Actions:1. Root cause analysis of
cancellations by reason 2. Targeted multi agency teams
tackling specific issues
Progress:The number of ambulance
cancellations has dropped across all categories, taking the total number of cancellations to over half of that in Jan 2011
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Challenge 4: Multi factorial delays in discharging medically fit patients block beds – reportable & non reportable delays
Actions & progress:In talks with community equipment provider to
reduce waits for community equipment to less than 24hrs where possible, esp. in periods of surge
Discharge planning principles discussed earlier are also being applied to community provision to ensure patient flow is not disturbed due to delayed/late discharges
Work continues with nursing and residential homes to improve quality of care at points of admission and to ensure timely discharge
LPT undergoing an acute pathway review, with a view to ensuring that delayed discharges due to access to beds are minimal for patients transferring to LPT inpatient beds
Review of bed capacity agreed across LLR. Toby Sanders is the SRO
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Challenge 5: Winter planning needs to be both innovative and meticulous to ensure a robust urgent care system through winter 11/12
Actions:• Specific holiday period service availability planner prepared across primary care,
secondary care & social care• Agreed escalation & de-escalation process agreed across all LLR agencies• Joint multi-agency public signposting & communication• Weekly communications from Sept 1st to the Health Protection Agency re Flu • Director to Director contact for any closure/stop• Multi agency ‘Plan B’ being drafted – what do we need to do over and above what
we have already prepared?
Progress: • LLR Escalation plan re-engineered with full stakeholder support following
comments from IMAS and learning from winter 10/11• ‘Plan B’ options being modelled ready for winter 11/12
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Challenge 6 – Application of ‘Systems thinking’ to ensure that we work across agencies to deliver an innovative and tailored system of care for LLR
STREAMING
999Walk In
URGENT CARE SERVICE
SERIOUS ILLNESS &
INJURY
Integrated Governance & Training
Shared Diagnostics / Staff
Shared Social Care
Psychiatric Care
AMBULATORY EMERGENCY PATHWAYS
Clinical Decisions Unit –Paediatrics/Geriatrics &
Ambulatory Emergency Pathways
Assessment Wards & RehabINTEGRATED DISCHARGE
Minor Illness
Minor Injuries
DISCHARGE +/- FOLLOW UP
Ambulance
Out of Hours Face to Face
EMERGENCY DEPARTMENT (A&E)
Actions & progress:
1. The Urgent care pathway across LLR is currently being modelled in conjunction with the CCG’s & UHL, but will be geared towards multi agency partnership working to deliver an integrated, safe and consistent service.
2. Key deliverables across the pathway: Integration of Urgent Care Centre and
ED “front door” Redesign of Loughborough walk in
centre, with more medical cover made available
Review of the Minor Injury provision across Leicestershire County
Increased capacity in the Emergency Department
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Challenge 7: Promoting independence and reducing demand through reablement
Action:
Collaborative proposals drawn up and currently going through governance processes
Summary of proposals for each area below:
Leicester City
1. Coordinated Community Reablement/RIT teams
2. Additional 10 Intermediate Care Beds in 11/12
3. Help at Home, Handy Person and Assistive Technology Service
4. Development of City Single Point of Access
5. Enhanced Hospital Team 6. Community
Coordinators/Demand Managers 12/13
Leicestershire County
1. Resourcing of IC teams
2. Resourcing of social care reablement teams
3. Development of Single Point of Access
4. Hospital at home scheme
Rutland County
1. On-going development of an integrated reablement & intermediate care service
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Challenge 8: Implementing pathways for Frail Older People to deliver a coordinated and high quality service
Progress:
Emergency Frailty UnitMay-Jul 2010 vs. May-Jul 2011
Number aged 85+ attending ED has increased by 10% (relative increase)
Overall discharge rate from ED for people aged 85+ has increased by 20% (relative increase)
90 day readmission rates have halved from 26% to 14%
Action:
Frail Older People service implemented with the aim achieving a 20% reduction in admissions to base wards for those patients referred to the service.
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Challenge 9: Improving UHL Discharge processes to facilitate patient flow through the system
Action:
‘Estimated Date of Discharge’ set and adhered to
‘To Take Out’ medicine & pharmacy mobilised
Coordination with EMAS Patient Transport Service
Earlier discharge from LPT community beds
Targets & Progress:
• Discharges by 1pm – Q1 targets achieved at both UHL and community sites
• Plans for continual improvement in place to ensure targets are met for the year.
DISCHARGES BEFORE 1PM - BASELINE Q1 11/12
24.1%
29.1%
19.6%
0%
5%
10%
15%
20%
25%
30%
35%
Medicine Respiratory Cardiac & Renal
DISCHARGES BEFORE 1PM - FUTURE PLANS
30%
35%40%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Q2 11/12 Q3 11/12 Q4 11/12
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Challenge 10a: Improving ED Processes to offer a streamlined and efficient pathway through the Emergency Department
Actions & Progress: – Transfer of Neurology services from Leicester General to Leicester
Royal site
– Closure of Emergency Medical Unit on LGH site
– Emergency Frailty Unit (EFU) established
– Introduction of Bed Bureau Triage in both Medicine & Surgery (33% admission avoidance)
– Ambulatory Pathways being implemented
– ‘See, Treat And Triage’ team introduced - senior decision maker supported by qualified nurse and Health Care Assistant. In place from 10.00am to 12 midnight daily - commenced in June 2011
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Challenge 10b: Development & mobilisation of a UHL workforce development strategy
Action:
Development of a workforce development plan in conjunction with the East Midlands Deanery & external guidance
Progress:
Appointments made to date: Substantive Consultants x 2 Locum Consultant posts x 2 Enhanced consultant cover 20.00hrs to 01.00hrs Advanced Practitioners (AP) 5/6 Physicians Assistants (PA) 3/5 Health Care Assistants 2 x 18 – accelerated training to band 3 in 6/12 GP recruitment x 5 (flexible with Urgent Care Centre) Speciality Doctor x 1 Geriatrician/Physician support to the Emergency Department in place Designated consultant of the week to cover Emergency Decisions Unit established
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Challenge 11: Integrate the current 11 ‘single points of access’ across health and social care to enable 1 single point of access across LLR
Actions & progress:
• Multi agency plans are being drawn up to agree a single overarching plan, detailing a phased approach to integration of the various projects across LLR, including those in the reablement proposals.
• NHS 111 pilots are currently running across Nottingham City and Lincolnshire, with plans for the rest of the region to pilot the service in April 2012.
• Discussions are underway across agencies to provide to a safe and effective pilot for the LLR region with each CCG.
Health SPA
Regional piloting of the NHS 111 project
Leics County LA
SPA
Leics City LA
SPA
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Critical issues to address in the next few months:
1. Designing a robust ED-UCC interface and ensuring that other urgent care provision across LLR is aligned to form an integrated service
2. Efficient patient flows out of ED into rest of hospital
3. Out of hours service delivery across providers to reduce inappropriate admissions
4. Single point for admissions into UHL5. Single Point of Access/111/bed bureau delivery
model
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Thank you for your time.
Please feel free to ask any questions.