Intensive Rehabilitation Service & Community Treatment Team

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1 Intensive Rehabilitation Service & Community Treatment Team Caroline O Donnell Integrated Care Director North East London Foundation Trust Carol White Deputy Integrated Care Director North East London Foundation Trust Alan Steward Havering Chief Operating Officer BHR Clinical Commissioning Groups

2 New community services providing care in peoples homes rather than hospital An intensive rehabilitation and crisis management pathway was created to enable patients to make a realistic choice of preferred place of care and to increase their control over the management of their treatment Clinically, there are associated risks with inpatient admissions e.g. reduced independence, increased risk of hospital acquired infections etc. which also supported the need for new community services Pathways were reviewed with commissioners and stakeholders and the new IRS and CTT services were established (November 2013) The new services were agreed to be permanently established following Governing Body decision December 2013 Both services have been continuously monitored and developed to support a flexible inpatient and community pathway that aids patients to achieve the best outcomes and receive care in the most appropriate place These services form part of the Better Care Fund programme

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4 Care closer to home: intermediate care Community Treatment Team Team of doctors, nurses, physiotherapist, social workers and others Provides short term support to people experiencing a health or social care crisis Provides care at home so people either don t need to go to hospital or return from hospital sooner 8am to 10pm 7 days a week including public holidays

5 Care closer to home: intermediate care Intensive Rehab Service A multidisciplinary team consisting of Physiotherapists, Occupational Therapists, Nurses and Rehabilitation Assistants Treatments are patient centred, goal orientated and negotiated between the team and the patient to ensure a smooth and efficient rehabilitation pathway is experienced Aims to replicate and provide an alternative to community bed rehabilitation, supporting people in their own homes Acts as an early discharge pathway option to provide intensive rehab to patients who are safe and well enough to continue to achieve their goals within their own homes IRS operates a 7 day service, 8am 8pm including public holidays Access to rehabilitation within hours where there is an intensive need

6 Havering patient impact and outcomes: CTT Community Treatment Team: Dec 2014 Community Treatment Team: Quarter /16 From November 2013 Sept ,151 Havering patients were referred to CTT This represents 58% Of referrals to CTT during that time From November 2013 July ,454 Havering patients were referred to CTT This represents 55% Of referrals to CTT during that time From April 2015 June ,617 Havering patients were referred to CTT This represents 54% Of referrals to CTT during that time Of these, from April June 2015: 93% were maintained at home without the need for an admission to hospital Less than 1 hour Average wait to access CTT 8 minutes Average referral to assessment time in hospital Of these, from April June 2015: 93% were maintained at home without the need for an admission to hospital 29 minutes Average referral to first contact time - community CTT: Proportion of patients by length of intervention 55% 1 day 13% 2 days 99% were likely to recommend CTT 9% 3 days 23% 3+ days CTT: Proportion of patients by length of intervention 72% 1 day 15% 2 days 7% 3 days 7% 3+ days 100% were likely to recommend CTT 100% felt the CTT met their expectations 100% felt involved in their care 100% felt it was easy to get care, treatment or support form the service Satisfaction figures above based on both patient and carer responses

7 Havering patient impact and outcomes: IRS Intensive Rehab Service: DEC 2014 Intensive Rehab Service: Quarter /16 From November 2013 Sept Havering patients were referred to IRS This represents 44% Of referrals to IRS during that time From November 2013 July ,171 Havering patients were referred to IRS This represents 48% Of referrals to IRS during that time From April 2015 June Havering patients were referred to IRS This represents 53% Of referrals to IRS during that time From November 2013 Sept % were maintained at home without the need for an admission to hospital From November 2013 Sept % Of patients demonstrated a positive improvement in mobility following an IRS intervention Of these, from April June 2015: 93% were maintained at home without the need for an admission to hospital from April June 2015: 96% Of patients demonstrated a positive improvement in mobility following an IRS intervention 7 days Average length of IRS intervention 15 days Average length of IRS intervention 98% were likely to recommend IRS 96% were likely to recommend IRS 100% felt the IRS met their expectations 100% felt involved in their care 100% felt it was easy to get care, treatment or support form the service Satisfaction figures above based on both patient and carer responses

8 Regular surveys are conducted to monitor the patient experience element of the services. Opposite is a selection of actual patient feedback from this process. For both CTT and IRS, patients have identified that if the services had not been there, it would have resulted in a hospital attendance and possible admission. Patient feedback CTT: Immediate treatment instead of going to hospital CTT: I had a visit within 2 ½ hours, the therapist bent over backwards to get the help I needed, I was followed up to make sure everything was ok CTT: They exceeded expectations, nothing was too much trouble If patients use the feedback opportunity to flag issues, these are fed back to the project group who work to ensure that the issues are rectified; thus patient feedback directly drives service improvement. IRS: I think it is so good how I improved quickly IRS: I lack confidence because I am 100 years old. But now I am happy to walk around my house with my new frame IRS: I don t know what I would have done without you

9 Contribution of Intermediate Care to system resilience In supporting a significant number of Havering residents to be maintained at home without the need for a hospital admission (over 11,000 Havering residents since the trial began), the services have made a substantial contribution to overall system resilience. This has been reflected in improved performance at BHRUT and the need for less community beds. In addition, the services have presented opportunities for further development including: LAS/CTT falls car: staffed by a paramedic and a CTT nurse, operating 7 days a week from 7am to 7pm. From October 2014 to March 2015 the team visited 652 patients and managed to keep 389 at home (60%) avoiding the need for an emergency ambulance, A&E attendance and admission (where that would have been appropriate). IRS/CTT in-reach: Community Treatment Team support in A&E at Queens hospital and an in-reach Intensive Rehabilitation Service to the orthopaedic and geriatric wards on both the Queens and King George hospital sites to support patients to go home sooner and reducing the number of re-admissions to hospital. The impact of this service has been to free up the equivalent (on average) of around 10 hospital beds per month and support patients to maintain their independence at home.

10 A&E back end A&E front end 2014/5 CURRENT BHR system Home Enablers: Care Plans Carers Discharge from acute: TTAs // Equipment // Transport Patient aged 75+ in medical crisis initiates contact 111 Information & advice Direct referral to out of hours primary care UCC 8am midnight Requiring nonserious urgent care BHRUT focus on increasing utilisation Access Hubs Extended opening 7/7 Any age; patients with an urgent primary care need. X1 hub per borough GP OOH 6pm 8am Any age; patients with an urgent primary care need. GP Care home Scheme 9am 5pm Each care home to be aligned to a named GP Care Home Schemes Improving care home access to advice via pilot MDTs with clinical staff KEY Referral into service Discharge Home Phone contact Underutilised service Intervention at home Schemes bolstered by Interface plan S1 schemes S2 schemes Standard services Exclusions: Stroke, Surgical, CPCP WICs 8am 8pm or to 10pm 7 days Requiring non-serious immediate care. Access to some diagnostics e.g. x-ray Triage with GP support Majors Lite Requiring non emergency urgent care e.g. fractures Access to diagnostics e.g. X-ray 4hr turnaround Majors Assessment and treatment of patients who exhibit signs of being seriously ill. Advanced diagnostic testing Psychiatric Liaison 8am 9pm/7 days from Jan hr response wards GP 8am 6pm (Some extended hrs) Patients with primary care need. Any age Psychiatric Liaison 8am 9pm/7 days from Jan 15 SPA for referrals 18+ with suspected mental health, selfharm, DAA problem presenting at ED or on a ward 1hr response ED 4hr ERU/MAU 24hr response wards MAU 30 beds for patients requiring up to 48hrs assessment TRIAGE / STREAMING Decision taken to admit, onward referral or discharge following assessment/ monitoring Pharmacy 9am 6pm Some Pharmacies in BHR Patient initiated for advice/ medication CTT Acute Hub 8am 10pm 18+ non emergency with health or social care need, would otherwise be admitted Target: 33/wk Actual: 49/wk ERU 30 beds normally 12hr stay then discharge home or onward referral as required e.g. IRS. If patient requires hospital stay, transfer to: 3-4 days: Sky A, Queens 4+ days: Acute elderly ward Acute admission Discharge 999 Triage process. Advice given for nonemergencies. Medical emergencies transferred to acute by LAS Rapid Assessment and Triage FOPAL 8am 8pm 7 days 75+, Frailty Score 3, triaged through ED, with medical illness, to the medical team 2 dedicated beds Gentian ward KGH if patient requires a short (less than 4 day stay) Ambulatory Care Queens: 8am 8pm Mon-Fri 8am-4pm Sat-Sun KGH: 8am 4pm Mon-Fri Cardiac chest pain / Cellulitis / DVT / Low risk upper GI bleed / Pneumonia / Pneumothorax / Pulmonary embolism / Unilateral Pleural Effusion Access to diagnostics Rapid access to diagnostics including x- ray, bloods etc. to enable patient to be treated in the community without the need for an acute admission JAD 18+. Health & Social Care supporting complex discharges. Walk in to A&E Patient initiated or based on advice e.g. 111/GP Community Pharmacy 9am 5pm 75+ taking multiple meds. Review of medication at home with follow up. ICM/ICT 9am 5pm Mon - Fri 18+ Patients at risk of acute admission CTT/LAS Car 7am 7pm 18+ in crisis, at risk of unnecessary acute admission Capacity: 31/wk CTT Community 8am 10pm 7 days 18+ in crisis, at risk of unnecessary acute admission Target: 83/wk Actual: 145/wk Community rehab beds Patient requiring rehab to facilitate discharge home from hospital, or prevent an acute admission Discharge to assess beds IRS 8am 8pm 7 days. 18+ with rehab need - support early discharge or avoidance of acute admission. Response: 24hrs step up 48hrs step down Target: 15/wk Actual: 25/wk Developing a hospital at home service to create a virtual ward BHR CCGS_EP_Jun_2015

11 National Recognition We have received national recognition for our work to develop Intermediate Care including: - HSJ Value in Healthcare Awards Finalist, 2014 (Value and improvement in Community Health service redesign category). - Featured example of good practice in Leading Local Partnerships in the NHS Clinical Commissioners publication, October BHR were asked to lead a workshop and be part of the panel discussion for the National Rehabilitation Conference on 31 st March 2015 as an example of an area which has successfully implemented excellent practice. - National Patient Safety Congress award nomination for the CTT/LAS car for successfully supporting 80% of falls patients referred to the service at home, without the need for an acute admission. - International requests from Finnish and Dutch representatives to view our work as an example of an area which has successfully implemented excellent practice.

12 Next Steps Integration of services at the front door of Queens A&E Urgent and Emergency Care Vanguard bid

13 Questions?

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