1. Discharge To Assess Aintree University Hospital 10 th September 2015 Angela McAvoy: Therapies CBM Rebecca Mitchell: Senior Physiotherapist Claire Denton: Liverpool Senior Social Worker

2. Biography Angela McAvoy Picture to go here Therapies Clinical Business Manager for Aintree University Hospital Occupational Therapist

3. Biography Rebecca Mitchell BSc Hons Physiotherapy Manchester Metropolitan University 2009 Physiotherapist for Aintree University Hospital since 2013 Senior Physiotherapist within Aintree@Home team at Aintree University Hospital Specialist interest in falls prevention, frailty and discharge to assess Qualified acupuncturist and pilates teacher

4. Biography Claire Denton Employed by Liverpool City Council in the role of Social Work Team Leader for Aintree University Hospital. Qualified as a Social Worker in 1999, working in an integrated Older People’s team and GP surgery. Following this was seconded to a PCT to support with the implementation of the Older People’s National Service Framework. Claire then joined an integrated disability team as senior practitioner, supporting service users with a learning disability, ASD and those with an acquired brain injury. Claire is also a qualified Social Work practice educator.

5. Discharge to Assess model Aintree’s Trust Vision “To provide world class services for all our patients” Aintree at Home encapsulates the “Discharge to Assess” model and facilitates early and safe discharge through the functional and social care assessment in the service user’s home. By identifying and providing the appropriate social care, in partnership with social care providers, Aintree at Home reduces length of stay, maximises independence and helps prevent unnecessary readmission. “The objective of discharge is not simply to get the person out of hospital, but also to provide seamless support, to ensure a return to their home or care home in the best possible physical, mental and emotional state.” Commission on Dignity in Care for Older People, June 2012.

6. Overview of the service Aintree at home began as a pilot in December 2012 adopting a discharge to assess approach for therapy. Since its success we began running the discharge to assess for social work assessments at home since April 2014. A service that adopts a strong multi-disciplinary approach of Occupational Therapists, Physiotherapists, Nurses and Generic therapy assistants. Close working relationships with hospital based social workers and community therapy and social care services, GP’s and district nurses. Seven days per week 8am-6pm, working with community outreach teams to support bedtime care calls. Outreach model with a strong ethos of “getting it right for every patient every time”

7. Drivers for Discharge to assess Improving Patient Care- The population is ageing and our older patients often have several complex illnesses, so creating tailored care for each individual is key to our ethos of getting it right for every patient, every time. Therapy and social work assessments in the patient’s own home allows them to be more patient centred, solving problems head on, setting up more accurate care packages and preventing hospital readmissions. Improving patient flow- Timely discharge of patients and financial challenges is one of the biggest problems facing NHS hospitals. Aintree at Home following the discharge to assess process are able to bridge gaps until community care agencies can start saving hospital bed days.

8. Potential for D2A highlighted by ward therapist. D2A co-ordinator screens patient. Outcome discussed with allocated social worker. Co-ordinator contacts referrer and confirms plan/information details. Paper work completed and section two completed to social worker. Information given to patient re: D2A process. Treatment plan agreed with patient. Communication with the ward and patients family as required. Process for selecting inpatients

9. Discharge process for D2A patients TTO’s collected. Escorted discharge home with therapist and social worker. Joint assessment completed at home. Therapy complete full assessment and provide any equipment required. Social worker assesses care needs and arranges POC through care agency. A@H bridge POC until care agency care start, independently or in collaboration with other agency. Evaluation form completed and statistics gathered.

10. Capacity Vs Demand- statistics kept and evaluated monthly for length of stay, prevention of re-admissions, changes in care packages, number of patients accepted, number of patients deferred and the reasons for this. Patient satisfaction forms- completed for each patient and evaluated on a quarterly basis by the clinical audit department. Blaylock assessments- standardised assessment. Referrals generated post discharge/ sign posting -recorded to examine if there has been an increase in the need for community organisations. Discharge problems identified/ resolved e.g. medication, equipment. Outcome measures

11. Discharge To Assess challenges Delay in TTO’s and difficulties with medication- employed nurses to resolve issues, developed a medication policy for and established good links with pharmacy and community GP’s. Delay in transport- applied for funding for additional vehicles to escort patients home in, currently have one available work car and two vans to deliver essential equipment. Initial lack of understanding of the discharge to assess process- established working policies and ++ promotion to members of the MDT. Lack of communication from the ward re: discharge- kept record of difficulties, provided regular feedback and training. Lack of initial crisis support in community- lack of step up beds/ capacity of emergency teams to support bed calls, D2A only available to one of our three CCG’s.

12. Results Wait till the end of Aug/ Beginning of sept to see if these improve? Summary: Our analysis clearly demonstrates that valuable bed days could be saved if patients were being assessed for packages of care earlier and in their own home. Previously, we developed a package of care based on assessments which took place in the hospital, only to find the reality in the patient’s home required different or additional elements, which would further delay the patient’s discharge. It reduces patient dependence on long term POC by incorporating a re-enabIement approach.

13. Case study one 58 year old female. PMH: COPD, depression. SH: lived alone in house Joint SW/ PT Ax at home- on arrival home house had been burgled Completed Ax and equipment to facilitate stay at daughters property Gave information and support Patient and daughter happy with support, no POC needs identified. “ You were excellent, 10 out of 10. Thank you so much for all your help ”

14. Case study two 91 year old female. PMH: Registered blind, OA. SH: lived alone, no family support. Joint SW/ OT ax at home Previous POC- patient identified as having increased needs as an inpatient (4calls) Equipment provided to increase safety A@Home provided POC 2 calls/day 7 visits completed, 7 bed days saved LT POC- 2calls/day

15. Patient feedback Are there any comments on areas we could improve? “None, It was very good care” “I was treated well…… with respect and staff were very attentive” “Excellent, 10 out of 10. Thank you so much for all your help”

16. Plan for future Increased D2A patients per week- continue to grow as the pilot expands. Better access to step up beds. Continue to improve networking with community teams/ collaborative working. Increased awareness of D2A throughout trust. Increased family/ patient education at front door/ ward re: assessment at home- some reluctant for discharge from hospital. Increased SW support from our other three CCG’s.

17. Service Evaluation Since the service was piloted in December 2012 there has been continuous evaluation to ensure we learn through good and bad experiences. We have shared our learning through training and awareness sessions, formal presentations, articles in trade publications and visits to other hospitals to share our model. Aintree at Home has also been presented to undergraduates at the University of Liverpool and at national conferences. Aintree has demonstrated with the growth of the Aintree at Home service that more patients can be supported home from the acute setting sooner with an early supported discharge approach. The model could be easily replicated within other Trusts, potentially easier than Aintree, who are challenged by managing discharge and on going support for our patients from 3 different boroughs, with 3 different social services, equipment providers and community services. We firmly believe that we have a high quality service that will continue to grow and adapt to meet the future needs of the NHS.

18. Thank you Any questions? For further information please contact: Angela McAvoy Aintree University Hospitals Therapy outpatient department Lower Lane Liverpool L9 7AL ANGELA.MCAVOY@aintree.nhs.uk