Staff
Roadshows
April/ May 2017
Doncaster Intermediate Care
A range of integrated services to promote faster recovery from illness, prevent unnecessary acute
hospital admission and premature admission to long-term residential care, support timely
discharge from hospital and maximise independent living.
Plain English approved definition.
National audit of Intermediate Care 2015. NHS Benchmarking
Two commissioners (NHS DCCG and DMBC).
Provided by four organisations (DBTHT, RDaSH, DMBC, FCMS)
Spend
£17,590,623
Workforce
Approximately 400 people work in intermediate care services
Access
Six access routes
Assessment
teams
2 hospital based assessment teams
Bed-based
Services
Home-based
Services
IDT
RAPT
Four bed based units (approx 100 Intermediate care beds)
Hazel and Hawthorn
Fred & Ann Green Rehab
Positive Steps
2 Community teams have a combined case-load of over 200.
CICT
STEPs
ECPs element of the ECP service
commissioned as part of urgent care
Vision for intermediate care in Doncaster
We want to move away from the current configuration of;
•
•
•
•
•
•
two community teams
four bed based services (100 plus beds)
two hospital based assessment teams
with six access routes
delivered by four providers
providing more step down than step up support…
…to a more streamlined, integrated health and social care service,
providing a more even balance of step up and step down support.
Offering;
• a single point of access and assessment.
• rapid response and short term interventions,
• medium term rehabilitation and re-ablement in the community
• and a smaller integrated health & social care bed based service.
Four key aims…
1.
2.
Simplify services and reduce
duplication.
Offer more step up support to help
prevent admissions.
3.
Develop an integrated physical,
mental health and social care offer.
4.
Provide more home based
interventions.
A reminder of why this is important…
https://www.youtube.com/watch?v=HynytVepxZc
#endPJparalysis
Update on progress…
• We are currently testing some of the proposed
changes and refining the future model to prepare for
full transition.
• Between now and June 2017 we hope to have
agreed a joint health and social care model for
commissioning and providing intermediate care and
will start full implementation later in the year.
• We have started by asking providers to work
together to develop a rapid response…
Rapid Response
Rapid response pathway opened to Yorkshire
Ambulance Service for people who had fallen
on the 23 January 2017
•
•
•
•
•
•
•
•
•
Operating 8am – 8pm – 7 days per week.
Speedy access to a multi agency assessment (Therapy, Nursing, ECPs, STEPs Case
Managers, Geriatrician and soon to be AGE UK and MH Liaison)
Single point of coordination and care planning.
Support for up to 72hrs.
Access to equipment, and technologies such as telecare to support people to remain at
home safely after a fall.
Referrals onto other community services where needed.
Brings together existing responses.
Focus on a single referrer initially to test and build confidence.
Opened up to GPs from beginning of March and wider range of conditions now being
seen.
Partnership response
Overview of activity up to 17th April 2017…
Types of care and
support provided
First responder
•
56 referrals
Service(s) deployed
for first response
Therapy
•
•
•
STEPS
•
•
Nurse
ECP
Joint
0
20
40
6 people transported to A&E
Service or MAU
following discussion with rapid
response triage practitioner.
•
•
•
•
•
•
Provision/ adjusting of
equipment.
Falls assessment.
Therapy
assessment/advice.
Dressing/ monitoring of
wounds.
BP monitoring.
Medication review
arranged.
Key safe info.
Telecare.
Temporary increase in care
package
Advice on arranging respite
Reablement support.
Referral/ signposting.
Sample
Outcome of referrals
accepted.
43 (86%) supported
at home
1 person taken to
A&E for an x-ray
6 people admitted
to hospital.
Case Study
Joan is an 87 year old who lives alone. Fell and her neighbour called 999.
Ambulance attended and she had no major injury but there were some
concerns about her managing safely at home. This was her second fall in a
few days, the last one had resulted in an admission to hospital where she
was found to have a urine infection.
Previously
The ambulance service would have had to
phone three different numbers to arrange
for this type of follow up at home and
none of the services would have been able
to respond immediately.
1.
2.
3.
RDaSH SPA for a therapy assessment
– would have been within 24- 48 hrs.
Adult Contact Team for social care
and STEPs would usually book an
assessment visit within a few days.
GP follow up- She would have only
required routine GP assessment as no
urgent clinical need.
It would have been safer and easier to
transport Joan to A&E to get a rapid
assessment in hospital.
What happened instead?
ONE number. YAS called while with Joan and spoke
to a triage practitioner.
Agreed that a response was needed and agreed to send
a therapist and social care worker out within 2 hours.
Co ordinated multi agency, rapid response provided
instead of transporting to hospital, including;
•
•
•
•
•
Full assessment by therapist, provision of equipment immediately
and arranged for a pendant alarm to be provided.
Falls prevention advice to Joan and her family.
‘Get up and Go’ leaflet provided and exercise programme to
improve strength and balance given by therapist.
Arranged for short term social care reablement at home (one call a
day) for few days as she was struggling with personal care.
Medication review with GP arranged and community nursing to
follow up to review blood pressure and monitor bloods.
Medium Term
Scoping the development of an integrated model of
health and social care community based
rehabilitation and reablement by bringing together
• the current health reablement service (CICT)
• and social care reablement team (STEPS)
The new model will complement the locality based
neighbourhood teams and community led support.
Workshop on 3rd May 2017 to launch the work.
Bed Base Response
•
Series of work shops for staff from across all the bed bases to come together and look at how
they can work more closely to improve the experience of people leaving hospital and reduce
delays.
•
First time many of the staff had visited some of the other bed bases so it was also an
opportunity to have a look around and meet people from different services.
•
A number of case studies were reviewed to start to identify what the teams have in common
and potential opportunities to work together.
•
Since the workshops an action plan has been developed and a monthly bed base meeting has
commenced. Some of the outcomes so far include;
–
–
–
a daily telephone call involving all four bed bases and IDT has been established to help with understanding pressures
in different units and opportunities to work together to facilitate discharge from the acute hospital.
Identification of shared training opportunities.
Working together to review access to social care assessment from intermediate care bed based services
•
This group will be starting to develop the detail around what a future bed base should look
like and are planning to include a regular case study slot in future meetings.
•
Changes to the bed base are not anticipated until later this year/ early next year.
Integrated IT solutions
• A recurring theme in the review was the challenge of sharing information
between teams with so many separate record keeping systems across
intermediate care.
• The need for an integrated digital care record which provides a single view
of information from all health and social care providers was also identified
in Doncaster’s Local Digital roadmap (LDR) and the new rapid response
pathway has provided further evidence of how important this is.
• Consequently the rapid response pathway will be used to develop a proof
of concept for an IDCR for Doncaster and we are currently completing a
procurement process for a supplier to work with us on this.
• We look forward to announcing the outcome of this very soon!
• e-assessment form.
Integrated workforce
• Joint health and social care workforce review
• Self assessment tool – 73% response rate!!
• Working through the results now to develop a
workforce development strategy.
• Areas for development indicated so far;
– Continence
– Advanced practice skills across organsiations.
– Falls
– Making better use of staff who have training but
currently not able to utilise skills.
Any questions?