North Yorkshire: trusted assessment - integrated discharge pathway

‘Transforming our Communities’ was a consultation undertaken by Hambleton, Richmondshire and Whitby, and helped to provide a mandate for the local system to develop new models of care closer to home. This example of a local initiative forms part of our managing transfers of care resource.


There had been a period of poor performance in relation to decisions on continuing healthcare being undertaken in the acute trust. NHS England’s target was for no more than 15 per cent of decisions to be made in an acute setting, however in August 2017 performance was at 48 per cent.

The plan

When an individual no longer has care needs that can be met in an acute setting, there are three pathways.

  • Pathway 1: Home/Home with support
    Patient needs can be safely met at home.
  • Pathway 2: Community based beds
    Unable to return home and requires further rehabilitation/reablement.
  • Pathway 3: D2A / nursing home bed
    Unable to return home and has very complex care needs and may need continuing care.

The plan for each of these pathways was to discharge to assess (D2A) everyone and use trusted assessment to facilitate this through one referral process, one form, one assessment.

Implementation

Implementation of this model happened in stages. To start, in 2016 the focus was on Pathway 2 where trusted assessment referral processes were trialed for Step Up Step down Beds. Under this pathway, a person is discharged to a community bed or temporary residential care via trusted assessment for up to six weeks. During these six weeks the Integrated Locality Team manage the discharge home.

In 2017, for Pathway 3 an objective was set to not complete any decisions on continuing healthcare in an acute setting. They used dedicated D2A beds in community settings, as well as spot purchase arrangements to facilitate this.

Finally, in 2018 accredited trusted assessors were used in relation to Pathway 1 to complete referrals to social care in order to transfer the person home prior to assessment with third sector support. Under this pathway, people are discharged through the Age UK ‘Home from Hospital’ service, and if they required additional support at home they would stay on the pathway and support would be provided for up to six weeks. The ward multidisciplinary team completes a single trusted assessment for ongoing care needs in the person’s home, and this is then shared between social care and community health teams.

Outcomes

Since the introduction of D2A (mid-August 2017) the average number of referrals for decisions on continuing healthcare have reduced by 30 per cent. The outcomes of decisions on continuing healthcare  assessments has also changed:

  • 14 per cent reduction in fully funded patients
  • 37 per cent reduction in patients awarded Full Nursing Care
  • 100 per cent reduction in patients fast tracked following assessment
  • 38 per cent reduction in patients identified as not eligible for funding once assessed.

An end of year review of Pathway 3 revealed a number of positive outcomes, including:

a reduced level of need for long-term funding

  • fewer patients going through CHC assessment process
  • 85 per cent of people transferred to a Spot Purchase bed qualified for funding
  • packages were brokered through North Yorkshire County Council on behalf of health
  • savings to the whole system
  • reduced delayed transfers of care
  • 0 per cent decisions on continuing healthcare in acute settings.

The learning the local system identified from this process to improve decisions on continuing healthcare was that it required good working relationships; a pragmatic approach; clear clinical leadership; and wide ranging and ongoing engagement as a system.

Contact

Gemma Umpleby, Senior Commissioning Manager
Community and Integration
gemma.umpleby@nhs.net

This case study is an example of the High Impact Change Model (Change 6): Trusted Assessment.