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

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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 Page 4
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 Page 5
Page 1 and 2: Report for Health, Community and Ca
Page 3: 8.0 Gloucestershire Hospitals NHSFT
Page 7 and 8: Changes were made during in October
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Delayed Transfers of Care (DTOC) PDF 374 KB - Gloucestershire ...

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