Integrated Care Fund Challenge Session Developing Intermediate Care

Integrated Care Fund Challenge Session Developing Intermediate Care Pathway; Proactive Care, TOCALS, Demand & Capacity Schemes

Improving Outcomes for Older People with Effective Intermediate Care • Timely response to acute episodes in the community; ‘Step Up my Care’ & Conveyance Avoidance • ‘Front door Turnaround’ & Admission Avoidance • ‘Discharge to Assess’ Hospital Pathways • Community intermediate care beds • Reablement programmes of care (both domiciliary and residential) • Low level care such as that provided by Third Sector to support transition back to home from hospital • Effective Reablement and Proportionate Commissioning of Long Term Care

Project Introduction • Intermediate Care Review in Carmarthenshire July 2016 q. Broad spectrum of services to support intermediate care but not coordinated and generally social worker led response q. Domiciliary care reablement (led by social care) over used q. Simple therapy led programmes could support the individual to self manage q. Many ‘front doors’ to the CRTs compromised consistent approach to assessment and care planning q. Many ‘front doors’ compromised our ability to measure demand capacity; Workforce? Service Commissioning?

Project Introduction Cont’d • Programme of Realignment Commenced in November 2016 q. Enhance our current 24/7 Careline service to provide an efficient integrated Information, Advice and Assistance (IAA) Service that would also support implementation of ‘ 111’ and its principles. q. Enhance care pathways in relation to admission avoidance; i. e develop our intermediate care pathway and care resource to support this (rapid response and reablement domiciliary care) q. Enable timely discharge from hospital (through strengthening the Transfer of Care Advice and Liaison Service) q. Prevent longer term reliance on statutory services through improving our long term complex care pathway (includes proportionate commissioning of care and support)

Associated ICF Workstreams • Proactive Care: Additional Multidisciplinary Practitioners to Support Intermediate Care Pathway Development in the CRTs - x 3 Social Workers, x 3 Occupational Therapists, x 2 Physiotherapists x 2 Therapy Techs, x 3 Community Nurses - x 1 Information, Advice & Assistance Nurse • Reablement Occupational Therapy: Additional x 3 Occupational Therapists • Enhanced TOCALS: x 2 Unscheduled Care Coordinators, x 2 Discharge Liaison Nurses, x 2 Social Workers and x 3 Occupational Therapists • Demand & Capacity Analyst: x 1 Analyst

Funding arrangements: Budget 17 / 18: £ 1, 443, 263 Funding from ICF: £ 1, 443, 263 Any other funding: N/A Spend 2017 / 2018: £ 1, 275, 228 Projected 2018/19 budget required: £ 1, 624, 923

Project tie-in with ICF objectives • Promotes and Maximises Independence in Frail Older People • Supports Recovery and Recuperation by Increasing the Provision of Reablement Services • Strengthens the resilience of the unscheduled care system • Improves Care Coordination between Social Services, NHS and the Third and Independent Sector through innovating and enhancing schemes which Support Older People

Project key achievements • Integrated 24/7 Single Point of Access; Complies with SSWBA and Supports ‘ 111’ Service • Intermediate Care Pathway; Timely Response for Frail Older Adults with Acute and Sub Acute Presentation • Progressive and Complex Care Pathway; Person Centred Integrated & Outcome Focused Care • Better Understanding of our Demand & Capacity for Care Commissioning and Workforce • Improved Outcomes for Individuals and Organisations

Enquiry Demand at IAA

Enquiry Demand at IAA

Enquiry Demand by Age

Outcome of Enquiry

CRT Pathway Demand Number of Referrals by Locality & Pathway Nov - Jan 17 / 18 250 Number of Referrals per Month 200 150 November December 100 January 50 0 PACC 3 Ts PACC Llan PACC 3 Ts STAAR AG STAAR Llan Locality and Care Pathway by Month STAAR 3 Ts TOCALS

Aggregated Pathway Demand Aggregated % County Pathway Demand Nov - Dec 17 / 18 STAAR PACC TOCALS

Locality Pathway Distribution (%) % Locality Pathway Distribution PACC AG PACC Llan PACC 3 Ts STAAR AG STAAR Llan STAAR 3 Ts TOCALS

Hospital Conveyance Avoidance • Conveyance Rate 78% • STAAR Pathway Implemented fully in October • No Reduction in Conveyance over last 5 months • GGH Demand Increased by 5% between November and February • PPH Demand Increased by up to 13% between November and February • Increased Ambulance Conveyance in January 44%

Conveyance Avoidance • STAAR Enquiries Generally Sub Acute i. e post injury or illness • Rarely Acute Referrals from GP / WAST / 111…. . If Any! • GMS Infrastructure Fragile and Imploding; Demand Outweighs Capacity for Home Visits • Default to Hospital Admission • 55% of all emergency admissions are frail older adults and a significant amount of bed occupancy days (78%) related to frailty. • Evidence suggests that around 30% of emergency admissions can be prevented.

Key Outcomes Realignment of CRTs • Eliminated Occupational Therapy waiting list • Reduced number of individuals requiring reablement domiciliary care • Reduced the number of individuals in the community waiting for assessments for care and support by up to 75% • Reduced the number of reviews outstanding by 81%

‘Front Door Turnaround’ • An average of 52% of all patients assessed by TOCALS at the ‘front door’ are discharged home within a 72 hour period with 48% of these being discharged within the same day of presentation. • Quarter 3 17 / 18 Number of Assessments Conducted by TOCALS - GGH 180 - PPH 160 • Quarter 3 17 / 18 Number of Emergency Admissions - GGH = 825 - PPH = 750

‘Front Door’ Turnaround • Value for Money? • Skill Retention / Peer Support • Further Analysis Needed and Consideration of Options • TOCALS + Initiative Doubled the Number of Discharges at the ‘Front Door’ • Rapid Response Domiciliary Care

‘Discharge to Assess’ Pathways • Recruitment of additional Occupational Therapists and Social Workers not Completed until December • Marginal Reduced Length of Stay GGH • Increased Length of Stay in PPH • ‘Work List’ Industry – ‘Only do what only you can do’ • ? Band 6 Discharge Liaison Nurses • ? Band 7 Unscheduled Care Coordinator Roles • Benefit to Community Services? Value for Money?

Key case study / studies Mr Jones, 82 years old, Type 1 Diabetes Unstable Blood Sugars and Poorly Managed Diabetes STAAR Response – Adjusted Insulin Regime by Community Nurse and Rapid Response Domiciliary Care Provided until Stable Mrs Jones, 97 years old, Lives alone, Recurrent Falls, Care and Support Plan in Place Fell at home, Conveyed to ED with Hip Injury Presented with Painful Hip and Deteriorated Mobility TOCALS Facilitated Discharge to Step Down Bed for Pain Management & Functional Gain Discharged Home following a Short Stay with No Increased Needs

Sustainability plan • This Programme Takes Up the Greatest Proportion of the ICF Allocation for Older Adults • Evidence Base is Clear in Relation to Impact of Robust Intermediate Care Services • ICF 18 / 19 Over Committed • Joint Consideration of Future Priorities and Impact of Delivering Efficiencies on Outcomes

Reflection and Considerations • Realigned CRT and Associated Pathways Works – But Conveyance? ? Admission Avoidance Optimal? Reduced Length of Stay? • Culture Change Doesn’t Happen Overnight…. . !! • Evaluate Impact over Q 1 and Q 2 2018 / 19 • Historically ICF Reporting Against the ‘Means’ i. e Individual Schemes • Need to Report our Aggregated Scheme Performance against the ‘Ends’ i. e Impact of Total investment on Outcomes for Individuals and Organisations • Analyst Role Critical to ‘Whole System’ Reporting • Health Board Resource now Producing USC Data Set • National Pilot for ‘Whole System’ Outcomes Framework

Action Plan • Joint Review of Existing Investment into Intermediate Care Pathway w/c 26 th February with Service Leads and Acute Sector Colleagues • Explore Opportunities to Enhance STAAR Pathway Utilisation • Strengthen Links with ART and Review the Role of the Proactive Care Nurse • Review Short Term Domiciliary Care Resource i. e British Red Cross, Reablement Dom Care, Rapid Response • TOCALS Resource Absorbed into CRT and TOCALS Provided on Duty Rota Basis? • Role of the DLNs / Unscheduled Care Coordinators? • Cost Benefit Analysis being Undertaken • Workforce Review