Doncaster Intermediate Care A range of integrated services to promote faster recovery from illness prevent unnecessary acute hospital admission and premature admission to longterm residential care support timely discharge from hospital and ID: 634906
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Slide1
Staff
Roadshows
April/ May 2017 Slide2
Doncaster Intermediate Care
A range of integrated services to promote faster recovery from illness, prevent unnecessary acute hospital admission and premature admission to long-term residential care, support timely discharge from hospital and
maximise
independent living.
Plain English approved
definition.
National
audit of Intermediate Care 2015. NHS BenchmarkingTwo commissioners (NHS DCCG and DMBC). Provided by four organisations (DBTHT, RDaSH, DMBC, FCMS)
Spend£17,590,623WorkforceApproximately 400 people work in intermediate care servicesAccessSix access routesAssessment teams 2 hospital based assessment teams IDT RAPTBed-based ServicesFour bed based units (approx 100 Intermediate care beds)Hazel and HawthornFred & Ann Green RehabPositive StepsHome-based Services2 Community teams have a combined case-load of over 200. CICT STEPsECPs element of the ECP service commissioned as part of urgent careSlide3
We want to move away from the
current configuration
of;two community teams
four
bed based
services (100 plus beds)
two
hospital based assessment teamswith six access routesdelivered by four providers providing more step down than step up support…
…to a more streamlined, integrated health and social care service, providing a more even balance of step up and step down support. Offering; a single point of access and assessment.rapid response and short term interventions, medium term rehabilitation and re-ablement in the community and a smaller integrated health & social care bed based service. Vision for intermediate care in DoncasterSlide4
Four key aims…
Simplify
services and reduce duplication.
Offer more step up support to help prevent admissions.
Develop an integrated physical, mental health and social care offer.
Provide more home based interventions.Slide5
A reminder of why this is important…
https
://
www.youtube.com/watch?v=HynytVepxZcSlide6
#
endPJparalysisSlide7
Update on progress…
We are currently testing some of the proposed changes and refining the future model to prepare for full transition.
Between now and June 2017 we hope to have agreed a joint health and social care model for commissioning and providing intermediate care and will start full implementation later in the year.
We have started by asking providers to work together to develop a
rapid response
…Slide8
Rapid response pathway opened to Yorkshire
Ambulance Service for people who had fallen on the 23 January 2017
Operating 8am – 8pm – 7 days per week.Speedy access to a multi agency assessment (Therapy, Nursing, ECPs, STEPs Case Managers, Geriatrician and soon to be AGE UK and MH Liaison) Single point of
coordination
and
care planning.
Support
for up to 72hrs. Access to equipment, and technologies such as telecare to support people to remain at home safely after a fall.Referrals onto other community services where needed. Brings together existing responses. Focus on a single referrer initially to test and build confidence.Opened up to GPs from beginning of March and wider range of conditions now being seen.
Rapid ResponseSlide9
Partnership responseSlide10
Overview of activity up to 17
th April 2017…
43 (86%) supported
a
t home
1
person taken to
A&E for an x-ray
6 people admitted to hospital.Outcome of referrals accepted.Provision/ adjusting of equipment.Falls assessment.Therapy assessment/advice.Dressing/ monitoring of wounds.BP monitoring.Medication review arranged.Key safe info.Telecare.Temporary increase in care packageAdvice on arranging respiteReablement support.Referral/ signposting.Sample Types of care and support provided 56 referrals First responder6 people transported to A&EService or MAU following discussion with rapid response triage practitioner. Slide11
Previously
What happened instead?
The ambulance service would have had to phone
three
different numbers to arrange for this type of follow up at home and none of the services would have been able to respond immediately.
RDaSH
SPA for a therapy assessment – would have been within 24- 48 hrs.
Adult Contact Team for social care and STEPs would usually book an assessment visit within a few days.
GP follow up- She would have only required routine GP assessment as no urgent clinical need. It would have been safer and easier to transport Joan to A&E to get a rapid assessment in hospital. ONE number. YAS called while with Joan and spoke to a triage practitioner.Agreed that a response was needed and agreed to send a therapist and social care worker out within 2 hours.Co ordinated multi agency, rapid response provided instead of transporting to hospital, including;Full assessment by therapist, provision of equipment immediately and arranged for a pendant alarm to be provided.Falls prevention advice to Joan and her family.‘Get up and Go’ leaflet provided and exercise programme to improve strength and balance given by therapist.Arranged for short term social care reablement at home (one call a day) for few days as she was struggling with personal care. Medication review with GP arranged and community nursing to follow up to review blood pressure and monitor bloods. Case StudyJoan is an 87 year old who lives alone. Fell and her neighbour called 999. Ambulance attended and she had no major injury but there were some concerns about her managing safely at home. This was her second fall in a few days, the last one had resulted in an admission to hospital where she was found to have a urine infection. Slide12
Scoping the
development of an integrated model of health and social care community based rehabilitation and reablement by bringing together
the current health reablement service (CICT) and social care reablement team (STEPS)
The
new model will complement the locality based neighbourhood teams and community led
support.
Workshop on 3
rd May 2017 to launch the work. Medium Term Slide13
Bed Base Response
Series of work shops for
staff from across all the bed bases to come together and look at how they can work more closely to improve the experience of people leaving hospital and reduce delays.
F
irst
time many of the staff had visited some of the other bed bases so it was also an opportunity to have a look around and meet people from different services.
A number of case studies were reviewed to start to identify what the teams have in common and potential opportunities to work together
.Since the workshops an action plan has been developed and a monthly bed base meeting has commenced. Some of the outcomes so far include; a daily telephone call involving all four bed bases and IDT has been established to help with understanding pressures in different units and opportunities to work together to facilitate discharge from the acute hospital. Identification of shared training opportunities.Working together to review access to social care assessment from intermediate care bed based servicesThis group will be starting to develop the detail around what a future bed base should look like and are planning to include a regular case study slot in future meetings.
Changes to the bed base are not anticipated until later this year/ early next year. Slide14
Integrated IT solutions
A recurring theme in the review was the challenge of sharing information between
teams with so
many separate record keeping systems across intermediate care.
The
need for an integrated digital care record which provides a single view of information from all health and social care providers was also identified in
Doncaster’s Local Digital roadmap (LDR)
and the new rapid response pathway has provided further evidence of how important this is. Consequently the rapid response pathway will be used to develop a proof of concept for an IDCR for Doncaster and we are currently completing a procurement process for a supplier to work with us on this. We look forward to announcing the outcome of this very soon!e-assessment form.Slide15
Integrated workforce
Joint health and social care workforce review
Self assessment tool – 73% response rate!!Working through the results now to develop a workforce development strategy. Areas for development indicated so far;
Continence
Advanced practice skills across
organsiations
.
Falls Making better use of staff who have training but currently not able to utilise skills. Slide16
Any questions?