1. Reflecting on the presentations: Share experiences from your own Health Board area / locality / site in relation to the part of the patients’ flow discussed: What works well in your area / locality / site? What and who have been the drivers for this? What could work better? Who needs to be engaged? Where local practice could be improved, consider how to utilise the evidence / learning from the workshop to influence change.

2. Arranging Effective Discharge Karen Anderson Diane McCulloch

3. Content Dundee Position Challenges Facing the System and Partnership Improvement Steps Future Challenges

4. Dundee Demographics Increasing number of very old people Decreasing population Area of high deprivation Hospital Model - Pre 2009/2010 Ninewells Hospital serves the acute requirements of the population of Dundee City and Angus 5 MfE Assessment and Rehabilitation wards in Royal Victoria Hospital No Community Hospital Model Social Care/Social Work Model – Pre 2009/2010 Establish Early Supported Discharge but targeted at specific wards Social Work Teams chasing services for discharge Separate Adult Services/Older People hospital Teams – different referral /assessment procedures High number of people admitted directly to care home from hospital Reactive Responses Focussing on patients delayed longest in system Problem solving at point of trigger (ie pre census date) Culture of Acceptance of Delays Families and staff ‘expected’ to be delayed for up to 6 months in hospital Use of ‘CHOICE’ as last option, seen as punitive not supportive

5. Challenges High number of delayed discharges Number of Unallocated Social Work Assessments Long waiting list for placement No step down facility Resources limited

6. At Risk Support Virtual Ward - multi agency team approach. Care Management Case Management Care Homes Hospital Care Universal Services Health Leisure & Communities Housing Voluntary Sector Private Sector Mainstream Extra Support Social Work Services Community Rehabilitation Enablement Independent Living & Equipment Centre Sheltered Housing Targeted Extra Support Comprehensive Geriatric Assessment Day Services Day Hospital Intermediate Care Intensive Home Care Very Sheltered Housing Pipeline Approach The main statutory agencies will assess every older person at key milestones with the aim of enabling the person to regain/retain as independent a lifestyle as possible. Service providers will then have a clear outcome to achieve. Integrated Assessment Framework Single Shared Assessment Integrated Care Record End of Life Pathway Self Determined Physical & Mental Health Decline Life Crisis Significant Illness Palliative Care “AS IS” Self Care/Self Management Direct Access Anticipatory Care Healthy Communities Mainstream Extra Support Enablement Approach for All Rehabilitation at Home Tele-health Tele-care Targeted Extra Support Intermediate Care - step-up Day Hospital Community Geriatric Care At Risk Support Virtual Ward approach across city. Assessment in Appropriate Setting “TO BE” Complex Needs Targeted Multi-agency Care Mainstream Additional Support Universal Services and Self-Care Dundee Integrated Care Model for Older People Living Independently User & Satisfaction Faster Access Support for Carers Quality of Assessment & Care Planning Identifying Those at Risk Moving Services Closer to Users/Patient

7. Improvement Step – Use of Edison Tayside was one of the original pilots for EDISON, well supported by IT (Joe Donnelly) Developed a Weekly Update Spreadsheet Originally only used by ESDS and Care Management Team Leaders Expanded to include SCNs, HoPCN (Heads of patient Care and Nursing) Twice Weekly Email Distribution System Updated by Ward and Care Management Staff on Weekly Basis Used by HoPCNs for Tracking Flow in Wards Used by Partnership to Track and Manage Patients’ Pathway Triggers for ‘CHOICE’ – Collaborative Approach All Delayed Patients are Actively Monitored and Managed Clinical and Care Management Staff are Responsible for Action Planning Improved Communication BUT still a Challenge

8. Improvement Step – Review of Hospital Social Work Model Model Analysed referral, allocation and assessment processes. Amalgamated OP care Management Teams and Hospital intake Team into one service with single line manager. Redesigned referral process with new documentation and reintroduced telephone referrals. Introduced single process across all hospital sites. Outcome Simpler referral processes. Quicker assessments resulting in quicker discharges. Reduction in duplication of assessment. Equal service across all hospital sites. Improved communication between hospital and social work staff. Challenges Size of teams – very large for single manager Skill mix in teams to be reviewed. Impact of other changes impacting on the end point of assessment.

9. Improvement Step – Priority Allocation Meeting Model - Moved from a Fortnightly Schedule to Weekly (mid week) Led by OP Service manager, group includes all team leaders across city and admin for updating IT systems Health Colleagues included in group membership (DD lead, POA, ESDS) Allocation process considered on level of need (urgency), breach status and availability of placement choice EDISON spreadsheet updated and individual cases discussed CHOICE process agreed Outcomes – Improved communication between health and Social work Action plan implemented for individual cases Placements for Community and Hospital patients agreed on priority – fair system Improved placement activity and rate Challenges – Availability of suitable placements Managing perceived bias towards hospital breach patients Balancing competing needs with resource availability

10. Improvement Steps – Enablement Model - In 2009 Moved from a Mixed Model of Teams to a Single Enablement Model Step 1 - All Patients Discharged from a Hospital Setting Accessed the Enablement Team in First Instance SCO Staff Development Supported by Health and Social Work OT and Health PT Staff Single System Approach to Documentation People Requiring Long term Packages – Cases are Submitted to Weekly Resource Allocation Meeting, led by OP Service Manager Outcomes – No Delays Incurred for Patients being Discharged with a Home Care Package Within 6 Months of Commencement 703 people have been discharged through the Enablement teams Challenges – Ensuring and Sustaining that Staff are in Receipt of the Right Training and Support Access to Community Based Rehabilitation Staff Breaking Down Traditional Barriers Public Expectation

11. Old modelCurrent model Patient referred to SWD Patient assessed 0 days 10 days Care manager arranges package 10 days Patient discharged From hospital 20 days total Patient continues on Long term package No time limit Patient referred to SWD Patient assessment reduced to identify core needs Care manager Contacts enablement Patient discharged From hospital Patient progresses Through enablement programme 0 days 5 days 2 days 7 days total 42 days max 49 days Patient allocated long term package Patient discharged on no services

12. Improvement Steps – Intermediate Care Model - Introduced in 2008 providing a step down facility for older people in Dundee – 2 Year Project 23 Bedded Unit Within a Private Care Home MfE Consultant Led, Screening for Admission by ESDS team NHS Staffing – Nurse Team Leader, Pharmacy, OT, PT and N&D Dedicated Input of Care Manager from Hospital Team Ethos of Slow Stream Rehabilitation and Enablement with Aim of Discharging Patients Back to Home Setting Outcomes - Average LOS 22 days Progressed to Include Step-Up from Community Approval to Continue with Bed Based Model April 2011 for Further 2 Years, Moving to GP LES and AHP/Nurse Led Model Challenges - Provision for people with dementia Earlier Identification of Patients in their Journey Working with an External Provider Culture and Expectations of Local Population and Staff

13. Improvement Step – Moving Assessment Model Assessment started by social work staff on site in hospital. Assessment continued through discharge route – Enablement, PICU prior to final outcomes determined. Targeted community resources for people who will potentially require residential care. Planned increased service provision – tele-care, overnight care, social care and respite. Outcome Better outcomes for people. Better and more accurate assessments. Older people are not waiting in hospital for care with all the associated risks of lengthy stays. Initial patients identified as requiring residential care have returned home safely and no longer deemed as requiring residential care. Challenges Very early stages. Public expectations. Changing the culture within hospital – no early decision making! Political buy in for the policy change. Will not work if we cannot improve carer supports.

14. Future Challenges Widening the culture change in Health and Social Care Utilising technology creatively Rethinking services to meet the needs of people who have dementia. Under 65 provision Public expectations Freeing up resources for future change Engendering a Person Focussed Approach to discharge and independence

15. Reflecting on the presentations: Share experiences from your own Health Board area / locality / site in relation to the part of the patients’ flow discussed: What works well in your area / locality / site? What and who have been the drivers for this? What could work better? Who needs to be engaged? Where local practice could be improved, consider how to utilise the evidence / learning from the workshop to influence change.