Rapid Process Improvement Workshop RPIW Acute Mental Health

Rapid Process Improvement Workshop (RPIW) Acute Mental Health Multi-Agency Discharge Final Report Out 11 th October 2019

Agenda • Purpose of the RPIW • Current State Overview • Ideas and key themes for Improvement • Proposed Future State • Outline implementation plan • Lessons learnt

What’s the problem we’re trying to solve? Pathway: Concerns: Impact: • Individuals are staying too long in acute mental health settings, which is negatively impacting on their recovery time & journey due to unnecessary delays in the assessment and discharge • When a patient is admitted to a mental health unit, good practice suggests that discharge planning should begin at the point of admission. • Currently it is reported that the process to progress additional and ongoing support for patients where this need has been identified is complicated and protracted and often causes delay for the patient in accessing their recovery support. • Through a collaborative, system-wide approach to working, solutions will include: - Improving the patient, carer and staff experience - Reducing waste and improving efficiency - freeing up acute mental health beds, improving flow and sending less people to private providers out of Hampshire

Current State Overview There are potentially 77 steps in the process from admission to transfer to destination on recovery journey

Current State Overview A real patient journey took 8 months from admission to onward care setting

Staff, Service User & Carer Feedback “Feels like we are trying to spend their own money. ” “Less Detention, More Prevention” “Ask me what I want, not what you think I want” “Urgent out of panel decisions are useful. ” “Not always clear about what is expected in an application and sometimes the goalposts seem to change. ” “Take the money out, not good for patients”

Generating ideas for Improvement • Over 60 ideas for improvement … … grouped into 7 themes

Themes 1. Opportunities on Admission 2. ‘Supporting’ Processes 3. Rehabilitation 4. ‘Funding’ Panel 5. Planned Admission Bed 6. Planned Coordination through CPA 7. Ward Based Social Worker

Ideas & Key Themes for Improvement Idea #1 Opportunities on Admission Repairing the Yellow Brick Road and not getting stranded on the way……. .

Crisis & Contingency Plan/ WRAP/ Personal Profile/ Wellbeing Check One point of information gathering! Trusted Assessor Information Packs Informal 1: 1 meetings Phone App History of Mental Health Act Status – 117 eligible or at risk? Crisis Services HCC Housing Health/ CCG Advocacy/ Other Keeping home life ticking over – not adding stress Triggers for next step Maintain outside life Prep for going home Enhanced support at home Short Term – Step down/ Rehab Longer Term Residential Clear identification of 117 needs Ongoing prevention/ planning e. g. CMHT Guides and flow charts – Keep it simple, accurate, available to all and stick to it! Embedded SW/CCG/ Housing Advice Opportunities on Admission Flow

Family Opportunities on Admission Consent to share – keep asking! Carers Assessment Support Groups Advocacy Accommodation Ask the question. Referral response – 48 hours. “There’s no place like home” Why am I not there now? Benefits & Finances Is there a need? Benefits drop in to ward Home status & how long. Going back? Barriers. Housing drop in to ward Adults Health and Care Safeguarding Apply 3 part test. Use NHS Safeguarding App. Known/ Have a SW? Eligible for SC? – Dummies Guide 117 or 3 – Automatic referral to Social Worker & notify CCG Waiting for everyone for a CPA delays things – Invite agencies to Ward Round and get moving!

Opportunities on Admission Getting on our Ruby Slippers and making it happen 30 Days Housing and Benefits drop in - Melbury Lodge commencing Wednesday 16 th Oct 10 am ‘Start and Stop’ group for a joint triage document that is owned by and follows the patient. Crisis and Contingency/ Wellbeing Assessment/ Passport/ WRAP. Robust flowchart of the main process Simple Guides with embedded documents for ward staff. Adding Apps to patient information packs. 60 Days Housing and Benefits drop in – Elmleigh Test the new assessment document. 90 Days Housing and Benefits drop in – Parklands. Roll out the new assessment document. ASK: A portal is produced for all members of the public to input their own crisis/action plan with all the relevant inf 0.

Opportunities on Admission Dear Wizard (Sponsors) we have one wish CHIE – Can we make this work for us all? The system pulls data from all 3 agencies’ IT systems. Can we make this work better? Automatically completing onward referral forms. Benefits Greater accuracy Faster Easier to track Less staff time and shorter hospital stays

Opportunities on Admission So remember – Use your brain Have courage Keep heart And if all else fails release the flying monkeys!

Ideas & Key Themes for Improvement Idea #2 ‘Supporting’ Processes • Non-value added activity during twice weekly flow calls* and weekly Stranded Patient Teleconference** - * 80 minutes person per week wasted with repetitive information - ** 30 minutes person per week wasted with information that is readily available elsewhere - (Excluding preparation time)

‘Supporting’ Processes • Cease twice-weekly call and replace with commitment by MDT to maintain information on Ri. O Patient Flow Record • Focussed, planned discussion on the weekly teleconference that uses time more effectively to address blockages to progress • Sending advanced agenda information, requiring actions, out earlier to prepare and undertake ready for call.

Ideas & Key Themes for Improvement Idea #3 – Rehabilitation Pathway Within Acute Care – South West. Referring from inpatient to rehabilitation • Problem Definition: Process for staff, carers and service users feels confused currently due to misinformation regarding processes to access rehabilitation and the timeframe for this. This can cause frustration and significant delays within the patient journey. • Definition of Rehabilitation: “A whole systems approach to recovery from mental illness that maximises an individual’s quality of life and social inclusion by encouraging their skills, promoting independence and autonomy in order to give them hope for the future and leads to successful community living through appropriate support. ” (Joint Commissioning Panel for Mental Health).

Rehabilitation Pathway OUR AIM: To clarify the most effective processes and to correct information within the service in order to provide a clear and streamlined rehabilitation pathway at Melbury Lodge. #rightplacerightpace

Rehabilitation Pathway

Rehabilitation Pathway ACTION PLANNING Quick Wins 1. Already set up links to HCC to provide drop-ins at Melbury re: housing and benefits- awaiting start date. 2. Relationship built and agreement to explore links with CCG /HCC and Advocacy 3. Clarify/outline and disseminate the process for discussing complex cases with CCG/HCC. 30 Day Plan 1. Visit rehab units in trust- obtain criteria for referral, outline beds available to specific areas/current SOP? 2. Obtain referral forms for supported housing providers. 3. Change MDT report templates for funding to add in; - outcomes for the person, markers for change and indicative (baseline) timing- Anna, Bernie and Nat to lead. 4. Present Rehab Pathway to Senior Leadership Team at Melbury- 5 th November 2019. 5. Anna to liaise with in trust rehab re: referral forms for intrust Rehab- prior to review of their SOP. Recommendation for Anna to be involved.

Rehabilitation Pathway ACTION PLANNING 60 Day Plan 1. Team Leads from all areas within Acute Care Pathway South West to disseminate the Rehab pathway at team meetings. 2. Pilot the rehab pathway at Melbury Lodge- Anna and Nat o lead- taken to each Flow meeting and ward rounds and professionals meetings. 3. Pilot of the MDT report templates to be completed. 4. Nat and Anna to review the process for liaising with HCC/CCG regarding complex cases. 90 Day Plan 1. Anna to clarify changes to rehab intrust SOP and how this impacts on rehab pathway. 2. Review the rehab pathway and makes changes- Anna and Nat in consultation with MDTdiscussion at leadership on 7 th January 2020. 3. Review of the MDT report templates and make changes- Anna, Nat and Bernie.

Rehabilitation Pathway OUR RECOMMENDATIONS • We have 1 referral process/form for all trust rehab units- which utilises RIO and sends off an nhs. net email to appropriate team • We have someone to coordinate the funding applications within the CMHT who can link with those leading the rehab pathway • Kingsley (possibly OT Team Manager) should be involved in the review of Hollybank and other intrust rehab units SOP

IDEAS & KEY THEMES FOR IMPROVEMENT Idea #3 ‘Funding’ Panel #not OC S S E PR P B L T E RAF N D A F IR ST LU E SK Y TH IN K IN G

PURPOSE OF PANEL • Governance around decisions that are made. • CCG/HCC are accountable and responsible for all packages of care they agree – assurance that safe and appropriate care is being agreed and public money is being allocated in the right way. • Ensure that the least restrictive options are being sought. • Guarantee the reviewing of placements/packages of care and following the person after they are discharged from hospital to ensure recovery goals are being achieved. • Social care, Southern Health and the CCG are working together which fosters relationships and benefits the person needing support. • Sharing of possible safeguarding alerts and issues so high quality suitable services are offered to individuals.

DISBAND PANELS!! Took a day to debate the pros and cons with mixed feelings and emotions! Trust Frustration Fear Building relationships

W O L L F E G N N I PA V O H R P UG IM RO ESS TH OC PR

NO DECISION ABOUT ME WITHOUT ME

ALL AGENCIES WORKING WITH ME IN COLLABORATION TO SUPPORT ME • • • What are we trying to achieve? How will we do it? When? Who is responsible? What will success look like?

IMPROVED FORMS Multi agency meeting planned for 21 st October 2019 to redesign the form Consult via steering group and widely: report back on 30 day catch-up workshop Responsibility: CK Process will not delay my discharge when I am ready! Success: Stakeholder Feedback Application decision made at first presentation to panel

HELP TO GET HOME HUB • • Fortnightly Multi-agency in-reach to ward including: CCG commissioning assessor HCC representatives Shared Knowledge and CAB collaborative working to Advocacy help me move on from hospital Wellbeing Centre Advisor Responsibility: CK, NH, CA, JG and DP Success: Attendance from organisations trialled over 90 days. Evaluation of experience from patients, carers and staff. Develop form to monitor topics requested.

Proposed Future State • Improved patient, carer and staff experience • Reduced staff time on non-value added activity • Streamlined process and collaborative working across organisations • Value adding current processes that puts the patient at the centre with early identification of need, timely access to required support and recovery journey • Improved access to in-patient care close to home and reduction in private acute bed usage

Measuring Impact • Potential reduction in: - Staff time spent in non-value added activity time - Time wasted on repetitive information sharing with no additional benefit - Delayed Transfers of Care (DTOCs) - Number of patients accessing high levels of support - Length of time away from home/right place to continue recovery journey (length of stay) • Improvement in service user and carer experience and feedback • Improved morale, wellbeing and satisfaction of staff

Car Park • Community Provision - Prevention and proactive action is better/more effective than crisis response and can also help people leave hospital • Overarching I. T. provision • Senior Management calls/meetings – Why? • More support from Advocacy • Standardised Consent to Share • MHA - Tribunals are archaic and not person centred

Lessons Learned • Don’t underestimate what we can do • Consider all the information/knowledge but don’t get caught up in it • Keep it simple • All organisations have contributed to the complexities of the current process and therefore all organisations are part of the solution • Positive outcomes are maximised when we work together rather than in isolation • A focussed week together fosters and improves relationships both internally and across organisations INSERT PHOTO

Thank you to: • Our service users, carers and Experts by Experience for their feedback, openness and honesty • Our Colleagues who have kept the services running whilst this week has taken place • Our attendees who have made the time and put in so much effort during the RPIW • Our Facilitators for their time, and particularly to Paul for his endless supply of sweet treats!

And Finally… A word from our Sponsor…