Tackling delayed transfers of care in Ipswich and East Suffolk

Overview of progress

Ipswich and East Suffolk covers around 500 square miles and has a population of around 367,000. It is a coastal area with the large town of Ipswich in the south, and several medium sized towns and market towns. The population of older people is higher than the England average.

The main partners tackling delayed discharges in Ipswich and East Suffolk (IES) are Ipswich Hospital NHS Trust, Suffolk County Council, Suffolk Community Healthcare and Ipswich and East Suffolk CCG.

In the last year, there has been a major transformation in how partners in IES work together to tackle delayed transfers of care (DTOCs). For example, on 1 February 2018, 10 DTOCs were reported; in the same period in 2017 it was 49.

IES aims on a weekly basis to meet its national target of 3.5 per cent, which works out at 20 DTOCs on a bed base of around 560. The local system is seeking to improve performance further with a stretch target of 18.

Achieving this change has involved:

• system-wide transformation
• a shift in organisation cultures
• ongoing operational oversight to identify opportunities for change.

System-wide transformation

The discharge system is being redesigned through a discharge to assess (D2A) model which involves augmenting capacity for assessment and re-enablement. A wide range of other high impact change developments are also underway. The Better Care Fund (BCF) and Improved Better Care Fund (iBCF) have been used to fund many of these changes, based on a requirement for robust business planning. Major developments are described below, with more detail in the strategies listed at the end of the case study. Change is overseen by the monthly Integrated Care Network Board which involves GPs, clinicians, chief officers, directors of the partner organisations and voluntary and community sector (VCS) representatives.

Shift in culture

IES partners indicate that they are developing ‘mature relationships’ in which people from different organisations trust each other, work together to find joint solutions and are able to have difficult conversations. People involved in tackling DTOCs describe how they see the ‘bigger picture’ and are committed to improving the whole system, not just the elements for which they are responsible.

Operational oversight

Weekly oversight of DTOCs by senior operational leads in the ‘Deep Dive’ meeting brings a focus on achieving the best outcomes for individual patients as well as opportunities for system-wide improvements.

Many of these developments have only been fully implemented in recent months, and partners are clear that there is much more to do to embed the new systems and develop a common culture based on promoting maximum independence. However, even at this early stage there have been major improvements in DTOCs, and a good start has been made in developing an ethos of continuous improvement across the system.

Key messages

• Outcomes for individuals, rather than numbers, must be at the heart of discharge planning.
• Successful change involves each partner ‘putting their house in order’ as well as working together to improve the system.
• Giving operational staff the autonomy to identify and implement solutions is an effective way of improving systems.
• Concentrated effort can result in some quick wins, but changing cultures and embedding new working practices is not easy or quick. Providing additional capacity in terms of project leads is important for this, as is identifying champions in operational and clinical staff. National and local leaders need to be realistic about how long it takes to bring about sustainable change.
• To maintain momentum, it is important to keep the profile of DTOCs high and celebrate success.

Key factors that make a difference

A wide combination of factors has led to DTOC improvements in IES. The following are the main factors that have been identified by partners as having the greatest impact on system change.

Kick starting reform

In Autumn 2016, key individuals came together over two days for an in-depth examination of system-wide DTOC causes and solutions. It was agreed that individual organisations would improve how they operated and that together they would implement system-wide change. To support the process, external expertise was provided by NHS Improvement which provided input on elements of system re-design including D2A and the red to green (R2G) approach.

Full details about system-wide change are reflected in a series of strategic plans, listed at the end of the case study.

Reforming the discharge process

The IES discharge process is being redesigned into a D2A model with the aims of ensuring safe, effective discharge to the most independent living arrangements that are possible, and avoiding hospital admission. The model has four pathways:

• Pathway 0 (zero): the individual is ready to return to their usual place of residence with their usual support – informal support or a reinstated care package.
• Pathway 1: the individual’s needs can be met safely at home with further reablement to regain independence.
• Pathway 2: the individual is not safe to return home and further reablement in a bed-based community service is needed before they return to their usual place of residence.
• Pathway 3: the individual is not safe to return home and there are doubts about their ability to regain independence and return to their original place of residence.

Each patient’s pathway is identified at the earliest stage by multi-agency hospital board rounds, or within the A&E department if the individual is not admitted. The programme has a lead post to oversee the four pathway workstreams, each of which has a dedicated project team of resources to support its work – for example the Pathway 0 reablement project team consists of therapy, nursing and voluntary sector staff within the hospital.

One of the aims of the programme is that a greater proportion of people can be discharged on Pathway 0, leading to better individual outcomes and financial savings for all partners. An evolving programme of communication and training is taking place so that pathways are embedded operationally. For example, a discharge event in December 2017 focused on making ward staff more aware of reablement and the importance of deconditioning. Also, pathway therapy leads now attend hospital board rounds to reinforce the message, ‘why not home, why not today?’

Pathway 0

A ticket home initiative has been introduced so that individuals and their families think about discharge from the start of admission. The ticket includes prompts about what to organise when they go home, such as food and heating, as well as a list of community support services. Some older people who are ready to return to an independent life experience lack of confidence following a hospital stay, so a pilot programme has been commissioned with the Red Cross in which support workers on wards will help people work through practical ways of managing at home. The hospital has also implemented the ‘Get up and Go’ campaign to increase the number of people able to return home without the need for support in the community. The percentage of people being discharged without the need for reablement or longer-term support in the community has already improved.

Pathway 1

People who need reablement support in their homes are supported over a period of up to six weeks by the NHS and council teams that provide reablement in the community –  NHS Crisis Action Team (CAT+) and Home First. These teams are increasingly working more closely together to provide home-based intermediate care over a period of up to six weeks, and there are plans to fully integrate the two services over the next year.

Pathway 2

A community hospital has been designated a Short-Term Assessment Reablement and Rehabilitation service (STARR), providing two-weeks intensive rehabilitation and reablement under the direction of a consultant geriatrician and a multi-disciplinary team of nurses, therapists, healthcare assistants and social workers. Pathway 2 has achieved significant improvements, with patient flow increasing from averaging 30 a month in October 2017 to 55 in February 2018. Patients at STARR have also experienced a reduction in length of stay from averaging 28 days to 12.

Pathway 3

Analysis of patient need resulted in six CCG commissioned beds for patients with delirium in a nursing home, with GP support. Up to six beds have also been made available in a community hospital for non-weight bearing patients. Consideration is now being given to support for other groups with specialist rehabilitation needs, such as neuro-rehabilitation.

Oversight and escalation

IES have developed a multi-agency approach providing tight oversight of potential DTOCS, combined with identifying effective solutions – both for individual patients and to address systemic barriers.

A local RAG (red, amber, green) listing is applied to each patient, dependent on whether or not their discharge is on track or at risk. These are laid over national OPEL (Operating Pressures Escalation Levels) for a combined assessment of DTOC levels. Escalation is triggered at amber level – between 18-23 imminent DTOCs.

A weekly DTOC Deep Dive meeting takes place, increasing to twice-weekly in an escalation period. The Deep Dive involves key operational and strategic staff from all partners with a role in assessment, reablement and post-discharge support across all D2A pathways.

The Deep Dive group considers the reasons why individuals are facing delayed discharge and collectively identify solutions that will maximise the best outcomes for each person in returning to the most independent life. A lead is identified for each patient to focus on action for swift discharge.

The Deep Dive group also considers the ‘bigger picture’ and identifies solutions to systemic barriers. For instance, it found that the need for assessment by both hospital OT and Home First teams pre-discharge was causing delays, so a trusted assessor approach will be piloted. (This will feed into wider trusted assessor work being undertaken with the integrated neighbourhood teams.) It was also found that discharges could be increased if care homes could undertake assessments and admissions at the weekend. This will be taken forward for further discussion with the care home sector.

The Deep Dive is described as taking a different approach to previous discharge planning forums. It operates with a collaborative culture in which patients are at the centre of planning, and in which a wide range of partners share ownership of the full health and care system. It is also transparent, with action points circulated to all those involved.

Restructuring

Suffolk Council has restructured its Adult and Community Services Directorate into localities, one of which covers IES. The locality has a senior team bringing together leads for operations and partnerships, service development, and contracting, which means that these functions can be joined-up and focused on the community’s health and care needs. This has brought greater autonomy to respond to local situations, and a better understanding of the social care market and how it can contribute to integrated health and care. Work also takes place on a county-wide basis where this is beneficial – for example, strategic planning and taking advantage of economies of scale.

In October 2017, Ipswich Hospital Foundation Trust took on responsibility for three community hospitals and community teams. This means that acute and community services are starting to work as a single team with links between community nurses and wards. In the longer-term, there will be seamless working, with the same standards and processes, such as a single patient record.

Ipswich and East Suffolk CCG has continued to invest in its commissioning and transformation team to support the development and delivery of strategic change and integration. In the next stage, transformation teams in the CCG and Hospital will be formally integrated to continue to drive system-wide change.

‘Connect’ is a Suffolk-wide integrated care model in which professionals, including doctors, district nurses, adult community services, police, councillors, the voluntary and community sectors and many others, work with communities in integrated neighbourhood teams. This is an asset-based approach which aims to help people link with a wide range of local support, not just health and care but services such as housing, and benefits advice. Integrated neighbourhood teams will mobilise community assets to tackle problems like loneliness, with the aim of encouraging independence and self-care and reducing demand on health and care services. Following two pilots, the plan is to roll-out integrated teams by April 2019.

Finance and contracts

Since 2016/17 the CCG has moved from a contractual relationship with the hospital based on payment by results to a guaranteed income contract.  This has given both partners more financial confidence about how much the hospital will be paid, and has supported the agreement of a transformation plan, shifting from a traditional commissioner/provider relationship to one based on achieving shared outcomes.

In addition, the approach to BCF and iBCF changed over the last year, with the council and CCG agreeing to hold back a significant proportion of new funding for innovation – including many of the initiatives set out in this case study.

Increasing capacity in adult social care assessment and provision

Capacity for social care assessment in the hospital has increased, with the implementation of an extended working week. A team of three assessors, supported by a duty manger off-site, are based there on Saturdays so that discharge assessment does not stall at the weekend. This is one element of more ambitious plans to develop seven-day working. Where even greater capacity is needed, staff are flexed from the integrated neighbourhood teams and Home First to speed discharge.

With a general lack of domiciliary care in IES, the council’s locality managers have been working with providers to increase supply, particularly in more remote areas which have the least provision. Where a wait for a home care package is contributing to a DTOC, the Home First team will act as a temporary provider until the package can be arranged. In order to maintain good flow from hospital or reablement beds, at times of pressure, home care agency staff are also commissioned to provide further capacity, funded through the iBCF.

Overall, IES has a good provision of residential and nursing home beds, and has undertaken research to understand geographic demand and patient need over the winter period. Six winter pressure beds have been commissioned by the council at competitive rates to provide short term step-up, step-down support, working with integrated neighbourhood teams.

Avoiding admission

IES is also undertaking a range of measures to reduce hospital admissions, including for those with higher levels of need who may be at risk of frequent admission and potentially delayed transfer.  For example, in January 2018, Ipswich Hospital Trust and partners brought together existing approaches to admission avoidance into the Reactive Emergency Assessment Community Team (REACT). The multi-agency service includes nurses, therapists, generic reablement workers, social services staff, Suffolk Family Carers and the British Red Cross. The service will be available 24/7, 365 days a year, and aims to provide a two-hour response time from referral to initial contact followed by triage to establish the need for face to face response. As well as operating within the hospital (front door services), REACT will accept referrals from GPs and others in community settings when individuals are at risk of needing hospital, and this can be avoided.  In contrast with national and regional trends, emergency admissions at the hospital reduced by 2.7 per cent from April to December 2017 compared to the same period for the previous year.

A system-wide ‘high user group’ has been investigating the flow of people frequently admitted. This information is being fed into emerging work strands, including the care home programme, which will support care homes to manage complex care needs and avoid crisis interventions.

Results so far

An important aim for D2A is that more patients go through Pathway 0 and less through the other pathways pathways so that, as well as reducing DTOCs, there is less need for long term care packages. A review of the financial and operational impact of D2A is currently being undertaken. Interim results for December 2017, reflecting six months of operating D2A pathways, show an encouraging shift of patient flows.

As the approach fully beds in, there is an expectation that these results will be solidified and improved upon, with significant financial savings across the system in the longer term – despite the background of increasing demand and continuing financial pressures on all partners. Work to identify the impact on patient and staff experience of D2A pathways is also starting, with surveys being designed for pathways 1 and 2 in partnership with the Hospital User Group.

Next steps

All partners are clear that considerable work will be needed over the next two years. Many developments are new, and need time to bed in and become fully operationalised. Some major developments are starting, or about to start, such as a new pilot to integrate and co-ordinate end of life care services to support more patients to be cared for in their own homes and places of residence, and a system-wide approach to falls prevention, response and management.

Several reviews are planned to identify the impact of changes on other parts of the system; this includes a review of community beds and establishing how this resource is developed in the future to support discharge to assess. As well as implementing major developments, partners have many practical ideas about how they could continue to refine ways of working together, such as tightening up support on the day of discharge and making organisational hand-overs more seamless.

Contacts

Richard Watson, Chief Transformation Officer, NHS Ipswich and East Suffolk and West Suffolk CCGs

[email protected]

Rachel Bottomley, Acting Associate Director of Transformation, NHS Ipswich and East Suffolk CCG

rachel.bottomley@ipswichandeastsuffolkccg.nhs.uk

Sarah Nasmyth-Miller, Head of Operations and Partnerships, Adult Community Services, Ipswich and East Suffolk

[email protected]

Sarah Seeley, Transformation Nurse Lead, Ipswich Hospital

[email protected]

iBCF funding areas: 2017-19

Activity

• Weekend working trial hospital based social work and discharge activity
• Accelerating Integrated Neighbourhood Teams and Connect
• Support for D2A business plan
• D2A pathway 2 – STARR centre
• Care home programme
• Falls
• Tackling blackspots in care provision
• End of life
• Continuing healthcare
• Pump prime REACT
• Care purchasing and demand; inflationary increase to support care market
• Workforce development
• Learning disability pressures pro-rata county wide

Further reading

Documents without links are available from the contacts above.

• Connect Suffolk
• Discharge to assess: working together in Ipswich and East Suffolk
• Ipswich and East Suffolk optimising system flow action plan (High Impact Changes) 2017-18
• DTOC Action plan for Ipswich Hospital Trust
• Ipswich Hospital Trust System DTOC escalation process
• Suffolk Winter Plan
• Q3 iBCF scheme review
• GP Practice Briefing: REACT team