Delayed Transfers of Care (DTOC) PDF 374 KB - Gloucestershire ...

Report for Health, Community and Care Overview and Scrutiny Committee on
Reducing Delayed Transfers of Care – June 2012
Introduction:
This report provides an overview of activity and progress in relation to reducing delays in
transfers of care between sectors in the Gloucestershire health community for the year 2011/12.
It sets out some baseline data, then explains how managers in the health and social care
community have worked with practitioners and clinicians to improve performance,
demonstrating outcomes of the changes we have made.
Baseline Position:
1200
Gloucestershire Hospitals NHSFT
Weekly Emergency Admissions for NHSG responsible population
1000
Number of Admissions
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2009/10 2010/11 2011/12
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Notes:-
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Control limits are 3σ from mean
No. Admissions Mean Lower Control Limit Upper Control Limit
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The first graph plots the number of emergency admissions per week to the acute hospitals from
the beginning of April 2009 until March 2012. The second graph shows emergency admissions
to the community hospitals during the same period of time which were reduced by -2.5%.
Overall, emergency admissions to both acute and community hospitals have been reducing, as
people are better cared for in their own homes and clinical pathways have been redesigned.
However we would prefer to see more people admitted directly to community hospitals.
The chart below shows the volume of transfers into community hospitals from acute hospitals.
The total volume of transfers has reduced by 5% (-162) in the period 2010/11 compared to
2011/12.
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Gloucestershire Care Services
Weekly transfers for NHSG responsible population
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Number of Admissions
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Notes:-
Week 1 starts on April 1st
Control limits are 3σ from mean
2009/10 2010/11 2011/12
Year and Week No.
No. Transfers Mean Lower Control Limit Upper Control Limit
This may reflect both the reduced number of admissions and the fact that more people are
going straight home, rather than transferring to another hospital facility. The general picture is
of relatively flat figures, however there was an improved position in relation to the Christmas
period in 2011/12.
The graph below shows the average length of stay for people in our acute hospitals, between
April 2009 and March 2012. Since April 2011, the average length of stay is 5.6 days compared
to an average of 5.3 days in the previous year (April 2010 – March 2011).
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8.0
Gloucestershire Hospitals NHSFT
Weekly Emergency Average LoS for NHSG responsible population
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6.0
Number of Admissions
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08/09 09/10 10/11 11/12
Year and Week No.
Notes:-
Week 1 starts on April 1st
Control limits are 3σ from mean
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Av LoS Mean Lower Control Limit Upper Control Limit
Within community hospitals, a similar trend is evident. The average length of stay between April
and March this year is 18.4 days against a target of 14 days. The average last year was 19.6
days.
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Gloucestershire Care Services
Weekly Transfers Average LOS for NHSG responsible population
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Length of stay
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2009/10 2010/11 2011/12
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Notes:-
Week 1 starts on April 1st
Control limits are 3σ from mean
los Mean Lower Control Limit Upper Control Limit
These rises may have been a result of rising delays in transfer of care. Senior managers in the
health and social care community have been reviewing and revising processes to improve
performance, but to do so, we had to get a better understanding of the total picture.
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Delayed Transfers of Care:
When we reviewed the delayed transfer of care information, we concluded that there were
significant data quality issues in quarter one of 2011/12. These have now been resolved,
although they remain reported. If we disregard the first quarter, the levels of delayed transfers
are in line with the targets within expected norms. Practically all of the delays were because the
patient was either awaiting their choice of further NHS care (75%) or preferred residential or
nursing placement (14%).
Data Source: Weekly DTOC figures
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The volume of delayed transfers of care within community hospitals is also in line with expected
norms. The major causes for the delays are awaiting domiciliary package (31%), awaiting a
residential or nursing placement (29%) and patient/family choice (22%).
‘No delays’ Project:
Over the summer of 2011, in response to the information about how long people stay in
hospital, and what services they were waiting for, we instigated a project with the ambitious title
of ‘no delays’. This set out to capture detailed information about the reasons for delays in
discharge, both prior to the patient being medically fit for discharge, and once medically fit for
discharge.
This work led to a streamlining of processes and a strengthening of the multi-disciplinary
approach to discharge planning, and accounts for the reduced LoS in Community Hospitals at
that time.
As part of the ongoing development of integrated services in the county, the Living Well model
of assessment and support has been adopted, which places a focus on supporting a person
focussed approach, with timely and proportionate responses across the whole care system. The
model promotes independence and the importance of planning well, this will further contribute to
a reduction in inappropriate admissions.
Joint Agency Discharge Process:
Whilst the ‘no delays’ project had a positive impact on the people in community hospitals, we
also wanted to ensure that patients who require support with being discharged home from acute
hospital care are supported effectively.
When someone is identified as no longer needing acute medical care, they are denoted as
‘medically fit’ and placed on a list to signal action is required to identify an alternative care
setting or focus on supporting discharge.
A range of options is then available:
• Any vulnerable older patient with low level care and/or enablement needs can be referred
to the Hospital to Home Scheme commissioned from Age UK. The discharge coordinators
based in CHT and GHT are currently dealing with 100 patients per month with
capacity to increase this figure and promote the service to a greater proportion of
patients.
• Any patient requiring a significant amount of discharge planning who also has further
rehabilitation potential is transferred to a community hospital or interim placement.
• Any patient who would benefit from bed based intermediate care is referred on.
• Where it is possible for a patient to go home, the relevant support is offered and if this is
not immediately available an alternative is offered, such as an interim residential
placement may be appropriate until specialist domiciliary care is available.
• When there are safeguarding or mental capacity concerns, patients may be denoted on
the medically fit list as “medically fit” but it is usually preferable for them to remain in
hospital until appropriate safeguarding or best interest arrangements are made.
Close inter – agency working takes place to support the movement of patients through the acute
hospital system. This includes a joint escalation process, daily conference calls, weekly
discharge planning and meetings and an agreed reimbursable delay sign off process. Earlier
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and more timely referrals are now being made, and GCC has increased Social Work capacity
which is aligned to the hospital teams to support this.
Reimbursable delays are those attributable to social care and they attract a daily fine, paid by
the council to the NHS, of £100 per day, per patient. There have been no reimbursable bed
days in Gloucestershire since August 2010. However the reports sent to the Department of
Health and circulated locally indicate a small number of acute delays attributable to ASC.
These are an anomaly of the reporting system, referred to earlier in this report as a data quality
issue, and it is expected that the current sign off process will prevent this from occurring
prospectively.
The reimbursable delay process does not apply to people being discharged from community
hospital beds. However, all community hospitals use the same system of denoting patients as
‘medically fit’ and report delays in the same way to NHS Gloucestershire. Gloucestershire Care
Services have consistently met their target and are currently performing better than target. A
robust internal sign off process takes place to ensure correct reporting of any delays.
The following graph shows how Gloucestershire performs compared to other councils in
delayed transfers of care.
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NI 131 (May 2011 - April 2012) Rolling Year -
Gloucestershire nearest neighbour comparator group
30
25
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Essex
Leicestershire
Hampshire
Kent
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North Yorkshire
Somerset
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Cumbria
Cambridgeshire
West Sussex
Devon
Warwickshire
Oxfordshire
The following graph shows how GNHFT performs compared to other acute hospital trusts in the
South West.
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Changes were made during in October 2011 to improve these processes within acute care
settings. Discharges home or to community hospitals continue. Any patients who potentially
needs longer term support prior to returning home and who would not benefit from inpatient
rehabilitation has been offered an interim placement in a care home setting for their ongoing
assessments and reablement to take place. 100 interim care beds have been used for this
purpose during 2011-12. Activity and outcomes relating to this change are now being evaluated.
The needs of people with dementia who may also have other co-morbidities has been
highlighted, with work identified to increase the availability of a responsive ‘wrap around’
domiciliary care provision that can be flexible to an individuals needs in order to ensure as many
people as possible have the opportunity to return to their own home as quickly as possible
rather than being transferred to another less appropriate care environment. This requires a well
trained workforce and 60% of accredited domiciliary care agencies now have Dementia Link
Workers (DLW). Each community hospital now has at least one DLW, and the acute hospitals
are undergoing a comprehensive training programme to ensure the needs of people with
dementia are recognised, and services and environments adjusted appropriately wherever
possible.
Reablement services:
Key to the support for effective and timely discharge is access to reablement services. GCS
has, during 20011-12 been reshaping locality teams to provided an integrated reablement
service.
The number of new service users accessing reablement was planned to rise from the current
performance of around 200 to over 300 a month by the end of 2011/12. We projected a March
new service user figure of 310 but only achieved 228. The restructuring of GCS has had an
impact on staff recruitment and capacity. There is an improvement plan in place to increase
capacity within the teams and train staff to support an enabling time limited approach. Adjusted
targets are being set for 2012-13 which take into account the timescales now in place within
GCS for the full roll out of the locality teams.
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400
Reablement Services - Services Started during the Period with projections for new service user starts from
January 2012 to March 2012
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2010 2011 2012
New Service User Projections All Service Starts New Service Users
Reablement services are designed to be short term interventions that provide intensive and
appropriate input to assist an individual in regaining confidence and maintaining or maximising
their independence. It is important that the service is responsive and dynamic. Currently 30% of
those people who accessed reablement services did not finish their service within a 6 week
period – this is against a projected outturn of 20%.
Encouragingly the percentage of people going into ongoing services with no reablement in each
month has steadily fallen from over 67% at the start of January 2011 to 61% in March 2012.
The number of people starting ongoing services each month was projected to decrease to less
than 200 by the end of 2011/12, whilst the percentage of these who do not receive reablement
services first is planned to fall to 55% a month. Arrangements for monthly monitoring are in
place, which will enable all teams to review their progress and performance against these
targets.
Whilst the number of people ending reablement services each month has varied considerably,
the percentage of people who went on to receive adult care services immediately after
reablement had been increasing slowly, averaging 51% in 2010. Encouragingly, in 2011/12 the
average for the year has fallen to 47%.
Assistive Technology:
A key part of the reshaping of support is the increased use and application of assistive
technology (telecare and telehealth). There is a programme in place to increase usage of both
technologies. There was a waiting list for telecare assessments in GCC in 2010 and this has
been cleared during 2011-12 with input from GCS. Further work is also required to mainstream
telecare installations into the community teams in all except complex cases, there is
improvement in place to support this.
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T e l e c a r e : N e w S e r v i c e U s e r S t a r t s
w i t h p r o j e c t i o n s t o M a r c h 2 0 1 2
9 0
8 0
7 0
6 0
5 0
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3 0
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1 0
0
A p ril M a y J u n e J u ly A u g u s t S e p t e m b e r O c t o b e r N o v e m b e r D e c e m b e r J a n u a ry F e b ru a ry M a rc h
N e w s e rv ic e u s e r s t a rt s - e x c lu d in g w a it in g li s t c le a ra n c e e x e rc is e P ro je c t io n N e w s t a rt s in c lu d in g w a it in g lis t c le a ra n c e e x e rc is e N e w S e rv i c e U s e r
Future Plans
Our shared aspiration is to continue developing practice, processes and systems which result in
people getting the right service, in the right place, at the right time. The Living Well model of
care is being adopted across all partners, supporting a person focussed approach with timely
and proportionate responses across the whole care system. We have demonstrated a strong
partnership approach in developing the strategic thinking required, as well as recognising the
interdependencies that support such changes, with further development of outcome monitoring
and evaluation arrangements for all agencies.
Conclusions
This report demonstrates the considerable whole systems work that has been undertaken to
reduce delayed transfers of care. Acute admissions to hospital are down, but not as much as
we would like and DToC have been maintained at a low level, however reductions in Length of
Stay has not improved as much as we had hoped. Discharge processes are more robust,
focussed and managed as a whole system, however investment in capacity within reablement
services has taken longer than anticipated to come on stream, which has in turn impacted on
the LoS for some people, although outcomes for individuals in receipt of reablement services
has been positive.
Linda Prosser, NHS Gloucestershire
Maggie Arnold, Gloucestershire Hospitals NHS Foundation Trust
Gill Vickers, Gloucestershire Care Services
Margaret Willcox, Gloucestershire County Council
June 2012.
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