Capacity Manager. Seamless Pathways of Care Test duration Mar 2013 Mar 2015 Author/Lead. Paula Tate Contact details

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1 Capacity Manager Workstream Seamless Pathways of Care Test duration Mar 2013 Mar 2015 Author/Lead Paula Tate Contact details Contents tick Comments 1 Test of Change Proposal 2 PMP 3 Final Report 4 Appendix Test Description Testing the creation of a post to improve capacity within acute services for specialist care. The post will be tasked with improving patient flow through the hospital and improve bed management within hospitals across the region. Improved communication between clinical staff within acute service should also lead to an improved patient experience. Evaluation to Date Report states:- Consistent approach to bed management Improved communication Pro-active planning and engagement Senior Charge Nurse time released Improved patient flow 1

2 Title of proposal CHANGE AND INNOVATION FUND PROPOSAL Developing specialist Care of the Elderly clinical leadership within communities in Dumfries and Galloway Organisation NHS Dumfries and Galloway Responsible Lead Mr John Knox Dr Ian Hay Brief description - Outline of purpose, nature of service, delivery model, links to strategic priorities (maximum 250 words) It is proposed to develop and test an integrated model 1 of Care of the Elderly provision where a senior member of the Care of the Elderly Medical Team is responsible for patients within a defined geographical region. The clinician will work very closely within the cottage hospitals and with the community teams in their catchment area to support the older person s re-enablement and return to the community. They will also offer (using the geographical model) early engagement and specialist advice to support excellent care for the older person within the acute wards in DGRI 23 in general and one clinician will be identified with a specific focus upon developing support to the orthopaedic ward 4 for older patients experiencing trauma or undergoing surgery. This model would support the Reshaping Care for Older People Pathways in particular Effective Care at Times of Transition (re-enablement / rehabilitation and specialist clinical advice for community teams) and Hospital and Institutional Care (Urgent triage to identify frail older people; Early assessment and rehab in the appropriate specialist unit; Prevention and treatment of delirium; Effective and timely discharge home / transfer to intermediate care). 1 National Service Framework for Older People D.O.H 2 Acute medical care. The right person, in the right setting- first time. Oct 07, Royal College of Physicians. 3 Older People in Acute Care a national Overview Feb 2004 NHS QIS 4 Maintaining good health for older people with dementia who experience fractured neck of femur. Report for phase 2 Henderson, Malley and Knapp 2007

3 Key Features: Those aspects that are considered to be particularly significant in the context of Putting You First Putting you first objectives Shifting the balance of care A recent review of research evidence by the King s Fund 5 around avoiding emergency admissions suggests that integrating primary and secondary care is effective in reducing admissions and that structured discharge planning is effective in reducing future readmissions. Deliver more benefits including better outcomes Curry and Ham s 6 review of integrated care highlights the need to integrate care at the individual patient level. The proposed model affords the opportunity to : - Provide in-reach support to wards within DGRI which ensures that the older person with complex needs admitted to hospital has early involvement from the Care of the Elderly team, - Integrate condition specific specialist care with Care of the Elderly care ensuring that appropriate treatment and management decisions are made 7, thus supporting the rehabilitation and re-enablement of the older person whilst they remain within the acute sector. - Provide continuation of involvement from the Care of the Elderly team across acute and community which supports safe, person centred and structured discharge planning. - Develop good links with the community, afforded by geographical linkage and developing relationships with the local NHS and social care providers which means that appropriate arrangements have been made to ensure that support is in place prior to discharge home or transfer to community resources. - Provide ongoing involvement from the Care of the Elderly team in complex cases thus supporting the continuation of rehabilitation, re-enablement and anticipatory care planning. - Provide proactive support and input from a care of the elderly specialist into the early hip fracture sufferer which has been proven to reduce the incidence of delirium by 33% 8. Reablement A recent review 9 of the evidence base around best practice care for older people who sustain a hip fracture recommends the proposed for orthopaedic in-reach model so that involvement of the care of the elderly team begins in the orthopaedic unit, early after 5 Avoiding hospital admissions. What does the research evidence say? Purdy S, The King s Fund Dec Integrated Care. What is it? Does it work/ What does it mean for the NHS? Curry and Ham The King s Fund National service framework for older people; DOH 8 Reducing delirium after hip fracture: a randomised trial. Marcantonio, Flacker, Wright & Resnick (2001) Journal of the American Geriatrics Society, 49 9 Maintaining good health for older people with dementia who experience fractured neck of femur. Report for phase 2 Henderson, Malley and Knapp 2007

4 admission. Evidence suggests that adoption of this approach leads to a reduction in overall length of stay, a reduction in admissions to care homes and a corresponding increase in the likelihood that the older person will return home. This improvement in outcome was seen in people with and without dementia alike. Develop and innovate partnership approaches Curry and Ham 10 in their recent review of Clinical and Service Integration concluded that improved outcomes for older people can be achieved via many models of integration. However the best outcomes for older people are seen to occur where multiple models of integration are combined. In the pictorial below, taken from the same document, the approach proposed by this model demonstrates elements of service, and clinical integration. Curry and Ham go on to promote the development of integrated clinical approaches between primary and secondary care such as proposed by this model where consultant physicians and primary care clinicians collaborate across professional, organisational and geographical boundaries to ensure best outcomes for the patient. 10 Clinical and Service Integration. The route to improved outcomes. Curry and Ham 2010; Kings Fund

5 Consultation: Please indicate individuals, groups or professional bodies involved with or consulted on the development of this proposal Care of the elderly team Chief Operating Officer MDT was convened in 2008 to consider models for Care of the Elderly this represents their preferred option. Team included representation from commissioning, GP sub, AHPs, Social Services, Community Hospital Nursing. Community Work stream ( ) Model of in-reach into orthopaedics was recommended in 2008 by a MDT team convened to consider models of care for dementia in acute services. Team included representation from Carers, Users and Carers and Alzheimer s Scotland and was supported by a consultation visit to the Dementia Centre at Stirling University. Benefits: please list including - benefits for service users - Improved access to specialist advice for older people admitted to DGRI with complex disease presentation/ multiple medical problems. - Continuity of specialist advice if older person transferred to community. - Earlier assessment of older person s functional capacity and scope for rehabilitation. - Improved management of the older person s overall condition leading to a reduction in risk of post-operative complications and improved outcomes Improved planning with the older person and their family for their eventual discharge - Person will be discharged to home or to a facility near home as early as possible within their admission - Improved co-ordination of care between acute and community services - Improved experience of care overall. - realisation of efficiencies - Reduction in Length of Stay DGRI for patients - Reduction in Length of Stay Cottage Hospital - Reduction in readmissions. Has service redesign been considered as a possible alternative means of achieving the same benefits? If so please explain why this has been rejected. The model being proposed represents in itself a service redesign focussed upon the needs of the individual and resulting in the Care of the Elderly team increasing the scope of their current service. In order to test the methodology there is however need to provide backfill to their Associate Specialists to maintain safe service on the wards in DGRI. 11 Extremes of Age: The 1999 Report of the National Confidential Enquiry into Perioperative Deaths NCEPOD accessed from 5 th Oct 2011

6 Costs: Please indicate - the minimum required to deliver useful change and improved outcomes - the optimum to maximise the pace and delivered benefits of the proposal - whether costs are recurring or non-recurring Minimum Amount 52,000 per annum Optimum Amount 80,000 per annum Recurring/Non-recurring 2 year funding is requested. How will any funding be used? Identify what the money would be spent on, including any related capacity building Funding would be used to recruit a staff grade clinician to provide backfill for the Associate Specialists in order to maintain safe service on the wards in DGRI whilst the methodology is tested. Risk: please outline any actual or potential identified risks Risk Mitigated by Responsibility Lack of clarity around roles and responsibilities leads to poor service user experience and delays in service delivery. Investment in time at the outset developing and agreeing objectives with the team members. project team community work-stream Service demand exceeds service resources (including staff time) Poor communication of service model and contact routes etc leads to delays in patient care/ poor patient experience Proposal is predicated upon the flexible use of existing resources, however where there is need to enhance current capacity to test the model and keep existing services running additional funding has been requested from Change Fund to provide additional. Clear and involving communication strategy will be developed to ensure good communication with all stakeholders and teams project team community work-stream project team community work-stream

7 Difficulty in recruitment delays model being initiated Due to recent difficulties in recruitment of Care of the Elderly Consultant the team were mindful of potential difficulties. The model using existing staff wherever possible maximises on resources currently available and the request for backfill at staff grade reflects the belief that recruitment will be more successful at this level. project team community work-stream Project Timescales: On the basis of work to date or knowledge of relevant local systems, indicate when it is envisaged that the proposal will Commence: Dec 2011/ Jan 2012 Delay required to ensure recruitment Be Evaluated: June 2013 End: Dec 2013/ Jan 2014 Anticipated Outcomes including how these will be measured Anticipated outcomes include the following; - Reduction in Length of Stay DGRI for patients aged and 75+ years. - Reduction in Length of Stay in DGRI for specific patient groups e.g. Orthopaedics. - Reduction in Length of Stay Cottage Hospital. - Reduction in readmissions. - Reduction in the rate of occupied bed days by age groups and 75+ years. These can be drawn from existing data sets. - Improved experience of care : measured as follows: o Patient experience: The Consultation and Relational Empathy (CARE) Measure. o Carer experience: Satisfaction with Care Questionnaire. Reporting: Please indicate Frequency of reporting - monthly reports How: Update paper To whom: project team, Care of the Elderly Specialist Team meetings, community work stream

8 By Whom/Where Joan Pollard/ Ian Hay Exit Strategy: Please provide details of what is intended at the end of the agreed period of funding This proposal adopts a test of change methodology and aims to prove or disprove the methodology. Staff will be employed on a fixed term contract to enable the model to be tested and efficiencies to be created and identified. Should insufficient efficiencies be identified the service will revert to the current model. Any other points about the proposal? Once completed, this form should be returned to: Judith Proctor NHS Director of Planning & Head of SPC&P Lochar South, Crichton Hall Tele: / judith.proctor@nhs.net

9 Reshaping Care Pathway Preventative and Anticipatory Care Proactive Care and Support at Home Effective Care at Times of Transition Hospital and Institutional Care Build social networks and opportunities for participation Early diagnosis of dementia Prevention of Falls Information & support for Self Management Prediction of risk of recurrent admissions Anticipatory Care Planning Responsive and flexible home care Integrated Case / Care Carer support and respite Rapid access to equipment Range of Housing options and timely adaptations Telehealthcare Reablement / rehabilitation Specialist clinical advice NHS 24, SAS and Out of Hours access ACPs Range of Intermediate Care alternatives to emergency Responsive and flexible palliative care Medicines Management Urgent triage to identify frail older people Early assessment and rehab in the appropriate specialist unit Prevention and treatment Effective and timely discharge home / transfer Medicine reconciliation Specialist clinical support for care homes Enablers Technology / Ehealth / Data Sharing Workforce Development / Skill Mix / Integrated working OD and Improvement Support