Workstream Highlights

In Pennine Lancashire we have a joint health and social care response that enables patients to be discharged home from hospital as soon as they are medically fit. This response has recently being reorganised and enhanced to meet the demands of the rapid discharge work needed to create capacity in our acute care settings. The aim is to assess patients in their most familiar environment and provide responsive, personalised services for functional recovery at home, the safest way to operate discharge from acute care. When home is not an option out of hospital rehabilitation or recovery beds are used to support discharge from acute care.

COVID-19 Hospital Discharge Service requirement: advice and support for Allied Health Professional’s (AHP’s)

* Full paper will be circulated with presentation slides

COVID-19 Hospital Discharge Service requirement: advice and support for Allied Health Professional’s (AHP’s)

• Principles of personalised care embedded across all the key delivery teams.• Positive risk taking within a multi-skilled environment.• Home First approach is everyone’s business.• Ensure the system has a ‘let go’ and a community pull model.• Review your delay themes and find solutions.• Trusted assessment approach, with a concept of utility so the information is proportionate to the patient’s

needs and can be further developed in the right environment.• Create safety nets.• Be solution focused and take patient led positive risks.• Ensure the operational delivery has integrated therapy staff with generic skills.• Flexible staffing – move staffing to support patients need.• One System working.• Constant monitoring of responsiveness, capacity and skill mix.• Develop a commissioning function allowing discharges to happen without delay.

Key tips for success:

Jill Foreman – Senior Clinical Professional – UHNT

Eoin Carroll – Head of Integrated Community Services – HBC

Transforming our services - Putting patients first - Valuing our people - Health and wellbeing

Covid 19An Integrated

System Approach

HOME

FIRST

Discharge to Access

Integrated Single point of Access; iSPA; 7/7, 8am-8pm

Continued Refinement of Existing Discharge Processes

Trusted Assessor

Workforce Reconfiguration

CHC

CCG

LA’s

RED; AMBER; GREEN

Nursing

IP&C

Person Centred Outcomes

Early, proactive engagement with Provider market re support & IP&C

SBARD

Integrated Community Workforce

Palliative Care

Existing Relationships Vital for Dynamic

Evolution

Fast Track

TEWV

SBARD Tool

Situ

atio

n

• I am [name, occupation, team, telephone number]

• I am referring [name]

• Working Diagnosis / Ongoing investigations?

• Confirmed COVID-19? YES / NO

o If YES, DATE CONFIRMED……………………

• Date of last known symptoms (i.e Temp >37.8˚C) ………………………….

Ba

ckg

rou

nd

• Advise of any future follow up appts/ clinics patient may need to attend in relation to this episode

• Any Safeguarding issues (Ward / NEAS)?

As

se

ssm

en

t

• From our assessment the person can…

• Any cognitive needs / DoLS in place?

• Moving & Handling – Level of Assistance / Weight bearing status / Aids or Equipment required / Falls Risk / Orthosis worn?

Name:

Address:

DOB:

CRN/ Hospital No:

NHS Number:

R

eco

mm

en

datio

n

(this

is th

e c

are

pla

n)

• What are the recommended actions or interventions?

• DNACPR forms for community discharge?

• Medication supplies arranged? (2 weeks minimum)

• Level of support required with medications

• Nursing supplies arranged? Wound / dressings / catheter care (1 week minimum)

• Where care provision is involved please include; ▪ Care provision start date ▪ Numbers of calls required daily ▪ Times at which each individual call is to be made ▪ The tasks that are required to be completed on each call ▪ Please include the overall goals to be achieved through provision of support

• Please check if any other referrals are required, specifically regarding community nursing, please state which service and ensure SPA referral sent.

D

ecis

ion

• Clinical reasoning for decision making / service identified to meet assessed needs / risks

Thank You

Questions??

Examples of positive practice with regards to care home COVID management

System-level examples (detailed case studies not available at this time)

A systems leads forum was held to understand from STPs the positive practice that has been enabled and to discuss the ongoing challenges still in place. Modelling community care demand and capacity including social care, home care and community health providers has been undertaken by all STPs, with some like SWL, SEL and NCL referencing the value of understanding the end to end model of care, and having data to inform their demand and capacity planning. STPs, like NEL have referenced a positive impact from the pandemic being how both the health and care sector have harnessed technology, including the use of NHSmail in care homes, and are eager to see how this embeds.

Management of residents safely and enabling new admissions to care homes remains a key challenge raised by local systems, though its widely recognised that the sector has done a great deal in rising to meet the challenges from this pandemic, supporting residents under difficult circumstances, with limited external support and caring for many people who have been very unwell.

Examples of positive practice with regards to care home COVID management

Regional examples:

In support of a clarification and simplification of key messages to the care home sector, London multidisciplinary colleagues have collated key elements from guides and resources for care home staff, signed off by the Regional Clinical Advisory Group chaired by the London Medical Director. The first, a single sheet ‘quick guide’, describes key points from the Suspected Coronavirus Care Pathway, including instructions and links for communication with the NHS, PHE and Primary Care. The other product is a series of resource packs to be issued fortnightly, covering key topics of relevance to care home staff and providers. The first of these resource packs includes staff wellbeing, PPE use, talking to relatives, support to specific types of resident – those with dementia, learning disabilities or at the end of their life. The second edition is currently in draft, and will include information on testing, working with primary care and supporting residents with diabetes, frailty and care after death.

London currently have 65% of care homes with NHSmail accounts, an increase of 46% since March 2020. This has been achieved through agreeing engagement plans with STP Leads, and following advice of local leads in regards to local engagement. The NHSmail team has 3 project officers who all have assigned boroughs and have worked alongside local leads, calling care home managers to complete sign up, supporting with webinars, sharing best practice and following up with ongoing support and troubleshooting. Most importantly this relationship with the care homes has continued with project officers providing care homes with ongoing tech support and advice.

Context

• Trusted relationships and existing shared working arrangements – eg DTOC board, JCB, Better Care Fund arrangements

• Partners have worked together for a number of years on progressing many elements of the guidance.

• There is a strong D2A model already in place.

• Place based working embedded, with an integrated OOH and acute trust in South Warwickshire

• Culture shift to deliver more care at or close to home

Hospital discharge development

• System wide support for rapid hospital discharge for patients considered medically fit

• Twice a week virtual working groups established at Place including CCGs, acute trusts, social care, out of hospital, LA commissioning

• Once a week virtual commissioners meeting, focussed on increasing system capacity

• New processes developed collaboratively

• Daily discharge tracker implemented at detailed pathway level

Hospital discharge development• Trusted assessment implemented countywide

by Discharge Teams to care homes on behalf of LA and CCG• Discharge Team vertically integrated and within OOHCC

so cross references with hospital and community settings• Discharge Team working 7 days a week• Daily teleconference between Discharge Team, CCG and

LA for all discharges• Out of Hospital single point of access (iSPA) utilised as a

central point of contact for patients post discharge• Hospital social care staff supporting pathways 1 and 2• CHC staff redeployed to support all D2A pathway 3

discharges and exits from pathway• Increased social care capacity to support discharges

Discharge process map

Discharge pathway detail

End of life discharges

Discharge tracker

Building capacity

• Releasing community staff by stepping down priority 2 patients and non essential therapy

• Staff redeployed to support hospital discharge

• Extra beds commissioned in residential and nursing homes

• Re purposing of community hospital beds

• Commissioning of extra health beds to accommodate EOL patients and P3

OoH South Place Adult Services Offer During Covid-19 Pandemic

**Red = urgent response required 1-2 hours: Green = Vulnerable patients needing monitoring and safety netting calls

Primary Care: Nursing and Residential Home offer

Weekly video virtual ward round

[PBT Nurse in attendance - virtual ward

round]

Medication review

MOPT support

RESPECT forms and ceilings of care

GP Tele/Video Consult

Direct Access Phone Line

Access into ICC

Paramedic: Holistic Assessment and

treatment within home as per agreed

clinical pathway protocol

Verification of Death – where required

ACP: Assess/Undertake intervention-

Treatment in home including IV abs and

fluids as required/Discharged

Verification of Death

*OOH COVID19 Offer

SWGP

Paramedic Visiting Service

Admission

Out of Hospital*

iSPA Admission Avoidance

*Nicol Unit/Castle brook

*CERT

ACUTE Referral

Palliative Care

*Hospice @ Home *Ellen Badger

Primary Care

SWGP

Remote Monitoring Service

[Nursing Homes not covered by

DES + Residential Homes]

LES Practice

Nursing Home Monitoring

OOH

ACP Visiting Service + Other OOH Service

Remote

Monitoring

Face to Face

Assessment & Treatment

Onward Referral &

Ongoing Management

Continued Remote Monitoring

Eg. DES/SWGP

Referred to Own GP

eg. Prescription

Challenges and actions

• Population health demand predictions –multiple and changing models

• Discharge of Covidpositive patients, particularly to care homes and back home where there is a shielded relative

• PPE - conflicting messages between LA and Health

Challenge Response

Population health demand predictions – multiple and changing models

Best guess based on national predictions and local

Discharge of Covid positive patients, particularly to care homes and back home where there is a shielded relative

Commissioning of extra capacity beds for system

PPE - conflicting messages between LA and Health

Initial hospital support to provide PPE with patient at discharge

Working with Public Health and infection control across the system to agree approach

Out of area patientsClarified referral process and contactsfor Warwickshire patients in out of area hospitals

Positive developments

• Greater collaborative working across the system

• Greater use of technology

• New ways of working –cultural changes

• Preparation for recovery – taking learning forwards

• Risk stratification for therapy services to avoid longer term decompensation.

• Models of care principles accelerated supported by technology for high risk shielded patients

Guiding Principles

• Integrated working between health and care and supporting people home first from hospital was already in place

• LCO supporting system integration• Pre-COVID, we had one of the lowest

DToC rates in GM• Home in a Day (D2A)

• Care Home Trusted Assessor

• STARS – Reablement service

• IMC

• D2A beds = care home capacity

• Patient Flow Lead to pull MOATs

• Build as much capacity as we can in the community to pull people out of hospital quickly and reduce the amount of people needing admission

COVID Discharge Pathways

Pathway 1a & 1b – Home First – Home in a Day & Reablement

Pathway 2 – IMC and Norton Grange Hotel

Pathway 3 – D2A Placement/24Hr Care

We removed the quick light touch hospital assessment, withdrew

adult social care staff from the IDT’s into a locality hub and

implemented;

Daily review of all the NNTR HMR patients across all NES hospitals

with a pull into appropriate pathway

Learning from Experience

• Working flexibly between system partners supported by a system wide SMT approach

• Voluntary sector engagement supporting delivery of place based social care

• Developing a virtual hospital/virtual beds approach has fast tracked our envisaged urgent & primary care model

• Care homes as part of a system need more support

• Doing what is right for the locality

• Lower but safe threshold for discharge

• Opportunity to review ways of working

• Build services that are proactive and not just a solution that responds to failure demand

ANY QUESTIONS

THANK YOU

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https://future.nhs.uk/system/home

If you have any evidence of good practice examples, please email them to

the Better Care Support inbox

England.Bettercaresupport@nhs.net