Newcastle Gateshead: testing new models to improve transfers of care

For Newcastle Gateshead CCG, one of the very best things occurring as a result of being part of the NHS England New Care Models programme has been the opportunity to test and evaluate new models. This example of how local areas are working to implement overall system change forms part of our managing transfers of care resource.

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The confidence to test and be open to failing as well as succeeding comes from a now well-established clinical engagement forum. Frontline staff need support to explore and evaluate new ways of doing things and a cross-agency, multidisciplinary forum that includes statutory, independent and charitable organisations is stronger both in terms of planning and evaluation.

As a care home vanguard, the main focus for transfer of care has been in relation to transferring care home residents between care homes and hospitals and vice versa. This has included developing a robust plan to introduce a ‘transfer of care’ bag which will be launched before the end of 2017, and the introduction of a trusted assessment model for when patients are moving between hospital and residential intermediate care.

In terms of the ‘transfer of care’ bag, through clinical engagement the CCG has been absolutely clear that this is not about the introduction of a bag but is about raising the profile of older people living with frailty and very complex needs in care homes. The introduction of a’ transfer of care’ bag takes time to ensure all stakeholders hold a common vision and purpose – which are known contributors to implementing change successfully.

The approach to introducing trusted assessment included holding a workshop with key personnel to consider Care Quality Commission (CQC) guidance and the perspective of all stakeholders, paying attention to the direction set by national standards as well as to the clinical evidence base and anecdotal experience. Most importantly the local system considered the needs of care home residents and the impact of introducing trusted assessment in terms of the quality of care delivery, and their safety and experience./

Trusted assessment is expected to result in earlier discharge planning and improved patient flow. To measure these, however, partners have learned that a baseline for comparison is needed and time needs to be spent working out how best to collate this. There is also an opportunity to think about broader learning and metrics such as decision making, time frames and any links with readmission rates.

More widely than this, learning can be shared with strategists and policy writers, for example in terms of local hospital discharge policies and with BCF initiatives.

Underpinning the work is an agreed set of best practice standards relating to transfers from one care setting to another. Their aim is to ensure that timely communication (verbal and written) occurs whenever a person moves from one care setting to another.

Lesley Bainbridge Lead Nurse, Care Home Vanguard Programme
Newcastle Gateshead CCG