Developing the AHP Neuro Navigator in NWL – Lessons from Barnet Nadia Jeffries: Neuro-rehabilitation pathway co-ordinator for Barnet and Enfield and Jess Henderson ICHP 6 July 2015

Example : trauma pathway diagram BSRM produced Specialist Rehabilitation in the Trauma Pathway Core Standards Jan 2013. This describes the rehabilitation pathways that patients may go through depending on their rehab complexity and reflects the NHS England service specification for specialist rehabilitation for patients with highly complex needs that defines 3 levels of service (1-3) with 4 levels of need (A-D). Neuro –navigator pathway we are looking acute to level 1 or 2 and into community : level NW work with IHCP covers whole pathway Figure 1: For the majority of patients (category C or D needs) rehabilitation is provided and commissioned through the local general (Level 3) rehabilitation services along the RR&R pathway (i.e. the green). Recovery, Rehabilitation and Reablement Patients with more complex rehabilitation needs (category B) will require specialist rehabilitation(yellow pathway) from their local Level 2 services, which are further divided into Level 2a (supra-district) and 2b (local) specialist services A small number with very complex (category A) needs will require rehabilitation in a tertiary (Level 1) service - or in a level 2a service with enhanced capacity to support patients with highly complex needs However delayed transfer to rehab remains a significant problem for the MTC and generally so I would now like to consider some of the current challenges along the specialist rehab pathway.

The QIPP Challenge: There are 197 Level 1/2a Specialist Neurorehab beds across London. There is a mismatch between demand and capacity for Level 1/2a. There is a shortage of Level 2 beds (77 across NWL, NCL and SWL) Long acute waits (median* 52 days from referral to admission) with an average 95 number of patients waiting at any time. 2014/15: at any one time 13 patients recorded as Delayed Transfer of Care to leave Level 1 units (NHSE 2015) 2014/15 approx. 5,400 bed days were lost in Level 1/2a units due to Delayed Transfer of Care equivalent to £1.6 million cost to London CCGs (NHSE 2015). * Median wait based on NCL data (Barnet , Enfield, Haringey and Camden for 14/15 from UKROC) but likely to be similar across other sectors

INNOVATION: Here is what the patients of North West London told us We don’t think we get access to all the services available to us, because teams don’t know what is available in the system We waited a long time to get access to specialist neuro-rehabilitation We felt discharge planning was not fully considered We think community and voluntary services are available but we struggle to access them Each injury is different, we need tailored support packages to help us recover We need to get life back on track, this means help with getting into work and access to benefits As patients and families, we don’t feel we are kept up to date on what is happening with our care This event has impacted our families and changed their lives, they need help too We don’t think information is exchanged across the system about our care and needs

QUALITY: We see the neuro-navigators as key roles for alleviating some of the issues in the system Advocate for patients and families and act as a ‘communication beacon’ between them and clinical teams Understands the system complexities and how to leverage the services available locally They will be a critical role within the MDT, proactively advising on how best the system can accommodate the patient needs promptly Manages transitions between acute, specialist rehab and community discharge and accessing appropriate support services Minimises delays and optimises rehabilitation outcomes by navigating the most appropriate individual patient pathway

The Barnet Experience: Innovation through the Development of a District Level service Person Centred Community Neurological Conditions Management Team (including Vocational Rehabilitation) Information Resource Single point of access Case Management In-patient condition management In-patient rehabilitation The Barnet Neuro-navigator was developed in 2011 within the CNCMT (2010) with whole system innovation since 2008 The NRC district service is led by an AHP Clinical Lead Rehabilitation and provides inpatient, outpatient and community services to support patients with all neurological conditions. This includes a vocational rehabilitation service . This range and co-location of services enables bespoke patient pathways including step down from Level 1, day attendance and graded discharge planning. A consultant neurologist is part of the IP and CNCMT. Neuro navigator works across all ensuring that where appropriate local services are utilised Having a whole service through which patients can move is felt to be essential for value of NN post Life long access

Productivity: Discharge from acute ward Economic impact analysis is challenging due to multi-factorial influences on patient pathway. 2013/14 Barnet Neuro-navigator supported 29 patients. 19 patients were transferred to Level 1 units (median waiting time 63 days (Min 6 to Max 117 days) and 8 patients re-directed to Level 2 unit (Median waiting time 14 days). This equated to an average saving of 49 acute bed days per patient and a total of 392 acute bed days equivalent to £81,312. Identifying the productivity and efficiency contributions can be challenging to attribute to Neuronavigator due to complex factors impacting on patient pathway. Different pathway options including from acute to specialist nursing home Discharge from acute ward : 2013/14 30% of patients identified as requiring Level 1 (NHSE funded) rehabilitation were appropriately re-directed by the Neuro-navigator to local specialist Level 2 unit. Patient on average waited 49 days less in acute care to access rehabilitation with associated cost saving of 392 days and cost savings of £81.312 Advice and consultation to acute teams facilitate direct discharge home from acute care with community team input. 2013/14 data used to illustrate this as more measurement taken in this period 2014/15 : pathways more established , with gains sustained, understanding of local pathways direct referral to level 2 and CHC from acute

Productivity: Discharge from Level 1 to Community DTOCs from Level 1 units associated with £1.6 million cost across London CCGs (NHSE, 2015 ) * Possible correlation with support from Neuro- navigators -complex analysis. Cost of 8a Neuro- navigator: £60,500* 5370 bed days due to DTOC x £260 OBD (low complexity tariff) but can be higher Actual cost to CCGS per day Day cost can be higher Possible correlations in that fewer DTOCs in NCL where there are 3 people in post working with CCG’s and in SE 1 London and SW London 1 but not straight forward as other factors impact on reason for delay NW london : good level 2 cover and Rehab consultant outreach may explain good outcomes with DTOC;s 2 legal cases Post pays for itself * Ref : NHS Purchased Healthcare, 2015 Specialist centre delayed discharge improvement project output

Prevention and Sustainability Prevention of rehabilitation and health related secondary complications associated with extended acute stays (often in non specialist environments). New NN posts in NW London , Enfield CCG, Ealing CCG and SE London supported by NHSE funding. 2015/16 : collaborative approach to data collection to improve economic evaluation and document cost savings across NCL and NWL. Future developments: Joint review of patients within the community supported by CHC has potential to prevent secondary complications and achieve further cost savings. The post in Barnet has been commissioning by CCG : with demonstrable costs savings by prevention of DTOCs in 2013/14/15 Replicated in Enfield CCG and new posts across London using NHSE funding 2015/16 : need to improve data collection with improved economic evaluation to demonstrate cost savings across NCL and we have plans not collect more data to demonstrated outcomes 2015 : New NN posts in NW London , Enfield CCG, Ealing CCG and SE London

Some ways we hope to measure success Contribution towards NWL target of reduction of Delayed Transfer of Care by 85% Patient satisfaction Clinician satisfaction Contribution to reduction in Average Length of Stay in Neuro-Rehab services Influence on level of neuro-rehabilitation required Suggestion for service improvement/ development Reduction in referral time to assessment (target 7 days) – level 2/3 Reduction in referral time to admission (target 14 days)-level 2/3