AYRSHIRE & ARRAN DELAYED DISCHARGE ACTION PLAN

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1 AYRSHIRE & ARRAN DELAYED DISCHARGE ACTION PLAN PARTNERS: Ayrshire & Arran NHS Board Ayrshire & Arran Acute Hospitals NHS Trust Ayrshire & Arran Primary Care Trust East Ayrshire Council North Ayrshire Council South Ayrshire Council ADDITIONAL ALLOCATION 1,544,000 TARGET REDUCTIONS FOR THE PARTNERSHIP Target extra patients to be transferred to more appropriate care 77 Target reduction in acute sector: 33 Target reduction one year and over: 6 Ayrshire & Arran s delayed discharges baseline figure based on January 2002 ISD Census: 266 4

2 AYRSHIRE & ARRAN DELAYED DISCHARGES JOINT ACTION PLAN 1. BACKGROUND The March 2002 report to the Minister for Health and Community Care detailed short and longerterm action required to tackle delayed discharges in Scotland. The group of experts agreed there were five main components to the current problem, these are: The demand and admissions to hospital for emergency care The available supply of full range of care packages to support hospital discharge The choice exercised by and available to individuals for the appropriate care home The resources available to develop appropriate care The organisation and management of care services between the NHS and Local Authorities. An additional 20m has been allocated to reduce the number of blocked beds and delayed discharges across Scotland. Ayrshire s share of the additional allocation is 1.544m against a target of 77 extra patients to be transferred to more appropriate care, including 33 from the Acute sector and 6 patients waiting one year or more. Ayrshire & Arran s baseline delayed discharge figure is 266, based on the January 2002 census figure. 2. CURRENT SITUATION 13% of NHS beds in Ayrshire are occupied by patients whose discharge is delayed, the second highest level in Scotland. Ayrshire has 10% of the national total of delayed discharges against an expected average of around 7% based on local population. The majority of delayed discharges are in continuing care beds and almost 90% of patients are over the age of 65. Three quarters of delayed discharges are patients who are either undergoing community care assessment or have been assessed but not yet placed in residential or nursing home. A much smaller number are awaiting health care assessment or health care arrangement. Of the 249 patients waiting at 15 July 2001, 65% had been waiting more than six weeks. 53% of those in the Acute Trust waiting longer than 6 weeks and 76% of those in Primary Care Trust which reflects a faster turnaround in the Acute Trust. The proportion of patients moving on within 3 months varies markedly between Local Authorities with two thirds of patients in South Ayrshire, one third in North Ayrshire and one quarter in East Ayrshire having waited less than three months. At 15 October 2001, East Ayrshire Council had twice as many delayed discharges as South Ayrshire Council with over twice as many frail elderly beds. This could indicate a relationship between bed numbers and delayed discharges The partners analysed the main reasons for the delayed discharges in Ayrshire and agreed that these were linked to the following factors: Speed of assessment Funding available for placements Availability of nursing or residential homes Patients exercising choice or with legal/financial issues Availability of alternative care and treatment to avoid patients being identified as delayed discharges. Partners agreed that priority must be given to initiatives which addressed the above issues both in the short and longer term. 3. DEVELOPMENT OF JOINT ACTION PLAN WITHIN AYRSHIRE AND ARRAN 5

3 The multi-agency Ayrshire Winter Group, which has developed an excellent track record of effective partnership working in agreeing initiatives to cope with winter pressures, was remitted the task of preparing the Joint Action Plan. The group tackled this in two stages: STAGE 1 An immediate plan for the first 25% of expenditure involving approving funding for the transfer of a number of delayed discharge patients who could be transferred to alternative accommodation without delay, focusing in particular on patients waiting more than one year. STAGE 2 A more detailed and longer term action plan for the balance of funding. 4. STAGE ONE - IMMEDIATE ACTION a) PATIENTS DELAYED MORE THAN ONE YEAR 18 Ayrshire & Arran patients were reported to be in this category. It was agreed that these patients should be targeted first and by doing so allow the movement of patients from the Acute sector to the spaces vacated. It was agreed, under phase 1, to transfer 10 patients: 2 each from Biggart, Kirklandside, Holmhead, Brooksby and Cumbrae Lodge. It was recognised that some of those patients were delayed for reasons other than availability of funding and that detailed discussions would be required to agree transfer arrangements for patients and families involved. Transfers will be on a named patient basis and expenditure monitored and reported. The remaining 8 patients were identified and further action confirmed in each case. It is expected that the Stage One Action Plan will reduce patients delayed over one year by 50% which is in excess of the target required. b) OTHER DELAYED DISCHARGES AND BLOCKED BEDS A further 14 patients, 6 from East Ayrshire Council and 4 each from South and North Ayrshire Councils were approved for immediate funding at a cost of 15,000 per patient per year. c) STAGE ONE SUMMARY Current Patients Maximum Numbers approved cost A-patients over 1 year ,000 B-other delayed discharges , ,000 Use of Stage One funding will be tracked on a named patient basis and reallocated on a replacement patient basis by the Area Winter Group in response to the latest delayed discharge information. 5. STAGE TWO DETAILED ACTION PLAN a) CONTEXT The initiatives contained in this report have been identified and supported by the 6 partners involved against the following background: The detailed advice and actions contained in the Report on Delayed Discharges in Scotland of 5 March and Scottish Executive letter of 20 March. 6

4 The detailed evaluation of the 2000/01 Winter Initiatives supported by the Area Winter Group and early evaluation of the 2001/02 Winter Initiatives. The recommendations contained in the Delayed Discharges Learning Network document. A detailed analysis of recent ISD patients ready for discharge census data for Ayrshire & Arran, to identify the key reasons for delayed discharges locally. The strategic review of older people s services in Ayrshire and Arran Partnership for Older People chaired by NHS Ayrshire which includes, in addition to Local Authority and health partners, additional statutory, voluntary and lay representatives. The implementation of Joint Futures which is being led by the Ayrshire Joint Development and Resource Group and by a number of sub -groups. The local partnership agreements for Older People s Services within South Ayrshire, North Ayrshire and East Ayrshire involving Local partners in taking forward joint futures implementation. The wider strategic legislative framework within the field of health and social care and in particular the Community Care and Health (Scotland) Act (b) PARTNERSHIP S PRIORITIES FOR ACTION The partners considered a range of initiatives and prioritised these against the analysis of the key issues and problems faced by the partnership in managing problems arising from delayed discharges and the targets set out in the Delayed Discharges report. The overriding priority was that the package of initiatives required to deliver real reductions in the number of people waiting to be discharged from hospital. It was agreed that: A further 225,000 should be allocated, on a one year non-recurring basis in the first instance, to transfer at least 15 additional patients direct from NHS to nursing or residential care; the balance of funding should be aimed at initiatives to reduce assessment delays, enhance existing services and develop alternative models of care which would maximise independence and, in the longer term, reduce the number of patients being classed as delayed discharges. The initiatives outlined below were prioritised against the headings contained in the Delayed Discharges Report as follows: Help develop more community care services and support. Employ a community support co-ordinator for Biggart, Ayr & East Ayrshire Hospitals Utilise extra care home places where appropriate. Transfer an additional 15 patients currently in NHS beds to alternative nursing or residential accommodation. Combined with the transfers in Stage 1 of the Action Plan, this will result in a reduction in delayed discharge of at least 40 patients. Bring into use extra NHS continuing care beds where the capacity of the care home market is limited 7

5 Make better use of existing continuing care beds by supporting the extension of the pilot Intermediate Care Project at Kirklandside Hospital until March The pilot will be independently evaluated during October to December 2002 and a decision taken on whether to fund the initiative on a recurring basis. Provision has been made in the Delayed Discharge Action Plan for the resource transfer associated with the closure of 12 continuing care beds to the three Local Authorities from April 2003, although some of this funding may be reinvested in the Kirklandside project. Increase the rate of assessments by social work staff Employ additional hospital based social workers in North, East and South Ayrshire Councils to work within multi-disciplinary teams to reduce assessment delays. Provide more support at the pre-admission and admission stages Further develop the highly successful Rapid Response Service within Ayrshire and ensure that the service is effectively linked to other community based initiatives. Support the extension of successful pilot arrangements within the acute hospitals to plan discharge effectively from date of admission and minimise risk of blocking beds in Ayr and Crosshouse. Develop stronger liaison between social work and NHS emergency services for older people to head off avoidable hospital admissions Allocate funding to partners currently involved in providing out of hours care to develop a more co-ordinated, integrated approach to out of hours services and to agree further initiatives which will be fully piloted and evaluated prior to recurring funding being allocated. Begin rehabilitation earlier Employ an additional Consultant Geriatrician based at Crosshouse Hospital and additional therapy staff in Acute and GP units throughout Ayrshire in order to maximise the opportunity of patients returning to independence within their own homes. Support the innovative development of a Consultant Gerontology Nurse to work across older people s services. (c) STAGE TWO SUMMARY Further non-recurring allocation to transfer patients to nursing/residential care 225,000 Other initiatives - 959,000 TOTAL 1,184,000 8

6 6. MONITORING AND REVIEW Ayrshire s Joint Action Plan will be monitored and reviewed by the Area Winter Group which meets throughout the year. This will allow delayed discharge initiatives to be co-ordinated with winter planning initiatives and will provide a forum for partners to meet regularly to discuss progress with individual initiatives and to monitor their overall effect on number of delayed discharges. The Area Winter Group will reserve the right to amend to Joint Action Plan if required in order to ensure maximum impact on delayed discharges and to respond to changing balance of demands as initiatives are implemented. 7. CONCLUSION AND RECOMMENDATION The Ayrshire & Arran Partnership welcomes the opportunity provided by the additional funding to implement initiatives to reduce delayed discharges in the area. It believes that it has identified innovative and effective proposals which will deliver the target reduction of 77 additional patients being transferred to more appropriate care and will achieve a sustained reduction in delayed discharges. 9

7 INITIATIVE Additional Social Worker and part-time Home Care Supervisor at Ayrshire Central. Additional Social Workers and support and Biggart and Ayr hospitals LEAD AGENCY/AGENCIES COST TIMESCALE IMPACT ON DELAYED DISCHARGES North Ayrshire Council 65,000 Within 6 months Reduced assessment delays; More input to multidisciplinary rehab South Ayrshire Council 65,000 Within 6 months Reduced assessment delays; more input to multidisciplinary rehab Community support coordinator and Social Worker for Biggart, Ayr and East Ayrshire Hospitals Support worker for Crosshouse and the Intermediate care facility at Kirklandside Continuation of intermediate care pilot project at Kirklandside Hospital to provide 8 place facility until March 2003 potential permanent facility thereafter Older Peoples Nurse Consultant Increase Occupational Therapy and Physiotherapy input at the Davidson Cottage Hospital Support for effective discharge arrangements and initiatives to minimise inpatient delays Ayr and Crosshouse Hospitals Additional Consultant Geriatrician, Crosshouse East Ayrshire Council 60,000 Immediate for care support; Within 6 months for Social worker 10 Reduced assessment delays; more input to multidisciplinary rehab East Ayrshire Council 27,000 Within 3 months Promote links with community services; facilitate discharge Primary Care Trust 70,000 on non-recurring basis until 31/3/03; After April 2003, (subject to agreed continuation) 70,000 recurring plus potential resource transfer of 220,000 (see note 1) Primary Care and Acute Trusts Immediate for funding existing pilot; within 6 months for extended service Alternative model of care to maximise independence of patients; reduced delayed discharges 50,000 One year to realise benefits Alternative model of care to maximise independence of patients; reduced assessment delays and delayed discharges Primary Care Trust 56,000 3 months More input to multidisciplinary rehab to maximise independence of patients and reduce delayed discharges Acute Trust 120,000 Immediate (extension of existing pilot arrangements) Reduce risk of patients experiencing delayed discharge from acute care; more support at admission and discharge Acute Trust 105,000 6 months one year Reduce assessment/ rehab delays; maximise

8 Hospital Improve therapy support to existing assessment and rehabilitation wards at Crosshouse, Ayr, Biggart and Ayrshire Central Hospital Local leadership and support to Rapid Response Service Transfer 10 patients waiting more than one year to nursing/residential care; further 14 patients transferred Further 15 placements in nursing/community care Increase out of hours provision across spectrum of care. Initiatives will be piloted in the first instance and funded recurringly subject to satisfactory impact on delayed discharges Training in single shared assessment Total proposed investment: independence of patients Acute Trust 100,000 3 months More input to multidisciplinary assessment to maximise independence of patients North, South, East Ayrshire Councils, Primary Care and Acute Trusts North, South and east Ayrshire Councils North, South and East Ayrshire Councils 30,000 3 months More support at preadmission and admission; avoid admission and early discharge to maximise independence 360,000 Immediate (short term action plan) 225,000 on a non-recurring basis in the first instance (see note 1) Over next 12 months At least 24 patients transferred from NHS to alternative care with a possible 7 further transfers At least a further 15 patients transferred from NHS to nursing/residential care All agencies 211,000 Over next 12 months Avoid hospital admission and support people in their own home All agencies 1,544,000 recurring 50k non-recurring (see note 2) Over next 12 months Support joint futures agenda; reduce assessment delays and promote effective discharge Note 1 Note 2 After year 1, 225,000 allocated non-recurringly for transfers to nursing and residential homes will be available, if required, for resource transfer associated with Kirklandside Project and closure of long stay beds. In year 1, first priority for use of slippage will be to carry out training in single shared assessment. 11

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