South Ayrshire Health and Social Care Partnership
REPORT
Meeting of South Ayrshire Health and Integration Joint Board Social Care Partnership
Held on 2 February 2017
Agenda Item 6
Title Delayed Discharges
Summary:
The report provides the Board with detail on the current position for South Ayrshire in relation to Delayed Discharges from Hospital Care. The report highlights the current pressures and action being taken to improve the position within the current resources available.
Presented by Tim Eltringham Director of Health and Social Care
The Board is asked to: Note the contents of the report. Approve the range of action being taken. Request a report on progress in April 2017.
Implications checklist – check box if applicable and include detail in report
Financial X HR Legal Equalities Sustainability
Policy X ICT
Directions required to NHS Ayrshire & 1. No Direction Required X Arran South Ayrshire Council, or both 2. Direction to NHS Ayrshire and Arran
3. Direction to South Ayrshire Council
4. Direction to NHS Ayrshire and Arran and South Ayrshire Council
1 SOUTH AYRSHIRE HEALTH AND SOCIAL CARE PARTNERSHIP INTEGRATION JOINT BOARD 2 February 2017 Report by Director of Health & Social Care
DELAYED DISCHARGES
1. PURPOSE OF REPORT
1.1 The purpose of this report is to provide the Board with current information and analysis of the position in relation to Delayed Discharges from hospital in South Ayrshire. The report outlines the recent pattern of delayed discharges and the reasons for them. The report also provides an update on the work being undertaken to manage down the number of delays within the resources available.
2. RECOMMENDATION
2.1 It is recommended that the Integration Joint Board:
Notes the contents of the report. Approves the range of action being taken. Requests a report on progress in April 2017.
3. BACKGROUND INFORMATION
3.1 As the Board will be aware the term delayed discharge is used to describe hospital care being provided to an individual after the time for which they are clinically fit to leave hospital.
3.2 Seeking to minimise any delay to discharge has been a key policy driver for the last 15 years. It is generally recognised that hospital care is likely to be more expensive than alternative forms of care. In addition, once treatment is complete hospital care is less likely to meet the individual’s needs for ongoing care and support in the most effective manner.
3.3 The definition of a delayed discharge is as follows:
“A delayed discharge is a hospital patient who is clinically ready for discharge from inpatient hospital care but continues to occupy a hospital bed beyond the ready for discharge date.”
3.4 The number of delayed discharges is seen as a key indicator of the success or otherwise of integrated service planning and functioning of the health and social care system in a Partnership. Data is collected and reported monthly based on a detailed
2 set of criteria and definitions. The Delayed Discharges Definitions Manual July 2016 summarises key aspects of policy and data collection:
Partnerships have previously worked towards discharging patients from hospital within a maximum time period of 6 weeks, reducing to 4 weeks then 2 weeks in April 2015. However a focus on maximum delay drives activity towards reducing the lengthiest delays, at the expense of facilitating the discharge of those closer to being able to go home. Two weeks is not ambitious enough for the majority of people who should be able to return to the community within 72 hours of being ready for discharge.
It is very clear that being delayed in hospital can be harmful and debilitating – and in the case of older people, can often prevent a return to living independently at home. Reliably achieving timely discharge from hospital is an important indicator of quality and is a marker for person centered, effective, integrated and harm free care. Older people may experience functional decline as early as 72 hours after being clinically ready for discharge and the risk increases with each day delayed in hospital. This increases the risk of harm and of a poor outcome for the individual and further increases the demand for institutional care or more intensive support at home.
It is important that discharge planning starts as early as possible in the patient’s journey. Key agencies such as social work, housing and community support, along with the patient’s main carer, should be involved as early as possible in this process. Professionals should agree a planned date of discharge with the patient and family supported by agreed criteria that will demonstrate readiness for discharge.
The Ready for discharge date (RDD) is the date on which a hospital inpatient is clinically ready to be discharged from inpatient hospital care.
This is determined by the consultant/GP responsible for the inpatient medical care and where a multi-disciplinary team, in consultation with all agencies involved, agree that the individual’s care needs can be further assessed or properly met outside a hospital setting.
Where the patient remains inappropriately in a hospital bed, no longer receiving treatment but merely waiting for an appropriate place in the community, then they should be classified as a delayed discharge.
3.5 This advice is used, alongside other planning and policy guidance to inform the approach being taken by the Partnership to reduce delayed discharges.
4. REPORT
4.1 Historical Summary
The definitions outlined in the previous section are used to collect data on delayed discharges over time. Historically, South Ayrshire has tended to have relatively low numbers of delayed discharges. However, over the last 18 months there has been a deterioration in the position. The graph below details the pattern of delays over that period.
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Delayed Discharges in South Ayrshire 2015-16
70
60 Other
50 Healthcare Arrangements
40
Awaiting place availability in a care home 30
Awaiting funding for a care home placement 20
The chart shows that focussed activity to reduce delayed discharges in the early part of 2015 Patients waiting to go home resulted 10 in a reduction to very low numbers over the summer of 2015. That reduction in delayed discharges was, in part, associated with a rise in the number of people requiring care home placements. The chart below illustrates the rise in the number of care home placements made in early 2015. 0 Community Care Assessment Reasons
Number of funded care home placements in South Ayrshire April 2014 to November 2016 920
900
880
860
840
820
800
780
760 4 740
720
Jul-15 Jul-16 Jul-14
Jan-16 Jan-15
Jun-14 Jun-15 Jun-16
Oct-14 Oct-15 Oct-16
Apr-14 Apr-15 Apr-16
Feb-15 Sep-15 Feb-16 Sep-16 Sep-14
Dec-14 Dec-15
Aug-14 Aug-15 Aug-16
Nov-15 Nov-16 Nov-14
Mar-15 Mar-16
May-15 May-16 May-14
The rise in care home placements in early 2015 resulted in significant budget pressures which in part were responsible for the projected overspend in 2015/16. At the IJB Meeting in October 2015 the Board approved a recovery plan which included a plan to reduce the number of care home places on a phased basis.
The pattern of delayed discharges from November 2015 to July 2016 illustrates the impact of restricting the number of funded placements. Throughout the first 6 months of 2016 the number of delayed discharges steadily increased, with the vast majority being for reasons of lack of funding availability.
In August 2016 the IJB agreed to the release of slippage funding from both the Delayed Discharges Funding and the Integrated Care Fund to resource additional placements in the light of concerns about the rising number of delayed discharges.
The release of this funding led to a levelling off of the number of delays and a reduction in September. Since then, however, the number of delayed discharges has seen a rise. This rise has been associated with the lack of capacity within the care home sector. In essence all of the care home places which are available are now occupied.
4.2 Current Number of Delays
As at 22 December 2016, South Ayrshire had 62 delayed discharges. Delays are broadly divided into two groups: Standard delays and “Code 9” delays. The latter are particularly complex situations where there may be the requirement for legal activity under the Adults with Incapacity Act, for example, in order to properly arrange for a hospital discharge.
The table below summarises the numbers of delays in these two categories by hospital location. As the table shows, the majority of delayed discharges are currently at the Biggart Hospital.
Delay Type Hospital Location Code 9 Standard Delays Ailsa Hospital 2 4 Ayrshire Central Hospital 1 2 Biggart Hospital 1 31 East Ayrshire Community Hospital 1 1 Girvan Community Hospital 0 6 University Hospital Ayr 2 9 University Hospital Crosshouse 0 2 Total South Ayrshire Delays 7 55
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The current reasons for delays are summarised in the table below:
Hospital Location Code 9 Awaiting Non Awaiting Awaiting Awaiting Awaiting completion of Availability of Place Place completion of procurement or Assessment Funding Availability in Availablity in social care provision of Residential Nursing arrangements to equipment Home Home live at home
Ailsa Hospital 2 1 1 0 2 0 0 Ayrshire Central Hospital 1 0 1 0 0 1 0 Biggart Hospital 1 5 13 2 9 1 1 East Ayrshire Community Hospital 1 0 0 1 0 0 0 Girvan Community Hospital 0 4 2 0 0 0 0 University Hospital Ayr 2 2 2 4 1 0 0 University Hospital Crosshouse 0 1 0 0 1 0 0 Total South Ayrshire Delays 7 13 19 7 13 2 1
The table shows that the majority of delays are still associated with care home provision. Taking those awaiting a place and non-availability of funding together then almost 40 people are awaiting care home services. The table shows that there are relatively few people awaiting the provision of care or equipment etc. to enable a return home. The number of people awaiting the completion of an assessment is in part a function of the complexity of some assessments. It should also be noted that there is an inherent tension over the need for timeous completion of the assessment but also a need to properly engage with a service user and their families to explore options at a time of major life change.
4.3 Benchmarking
Published data for October 2016 is reproduced in Appendix 1. The table shows the number of delays by category for both Health Boards and for Partnership areas. As the table shows the majority of partnerships are reporting that they have delayed discharges. South Ayrshire is an outlier alongside Dundee in having a significant number the delays reported being as a result of lack of funding.
The table below shows that over recent months there has been a rise across Scotland in the number of delayed discharges.
Principal reason for delay 2: 2016 2016 2016 2016 Jul Aug Sep Oct All delay reasons (Health and social care / patient and family related / code 9 reasons) 1,396 1,472 1,524 1,576 (Source: ISD Scotland)
Analysis of ISD data would suggest that overall there has been a rise in delays associated with both the availability of care at home and in care home places during that period.
4.4 Action to tackle Delayed Discharges
A wide range of activity is underway which is intended to tackle delayed discharges. The range of developments being progressed as part of the Modernisation of Services for Older People and those with Complex Needs are directly or indirectly associated with reducing delayed discharges. While there are specific activities
6 designed to facilitate discharge these are only a part of the range of redesign measures. Activity to reduce attendances at A and E and admissions to hospital through a range of community activity is as important. A number of key initiatives are outlined below:
4.5 Anticipatory Care
Anticipatory Care Planning (ACP) has been adopted in the majority of GP practices in South Ayrshire. A programme of support for ACP work is in progress. In essence, the initiative involves regular multi-disciplinary meetings within GP practices focusing on the development of robust care plans for individual patients. The meetings involve GPs, community nurses, social workers, pharmacists and other relevant professionals. The aim is to develop plans which will help maintain people within their own homes and enable a co-ordinated response to any deterioration to a person’s health and care. One element of the planning is the production of the Key Information Summary (KIS) which can be used by a range of professionals at times of crisis to better understand the care plan and contingency arrangements. The use of a KIS should a person present at A&E is important in order to support a decision to avoid hospital admission.
4.6 Alignment of Care Homes to GP Practices
Within Ayr, Prestwick and Troon agreement has been reached among GP practices to align care homes to individual practices. The initiative will enable a practice to build a relationship with a particular home. It is hoped that one outcome will be to help reduce the number of people admitted to hospital from care homes.
4.7 Integrated Care Team
Additional resources were committed from the Integrated Care Fund in 2016/17 to rehabilitation capacity. Additional AHP and nursing staff have been recruited and the former ICES (Integrated Care and Enablement Service) and Community Ward combined into a single service, the Integrated Care Team (ICT). The work of the team is currently being focussed on both prevention of admission and most critically, early discharge for people who are admitted to hospital. The Team is working closely with both the GP admission ward and receiving wards with the aim of minimising stay in hospital. This intervention at the earliest stage is intended to respond to the concern that after 72 hours older people, in particular, begin to lose confidence in returning home.
The redesign of the ICT service has taken place during the autumn. Additional staff have been recruited and a wide range of protocols have been implemented to support multi-disciplinary team working.
The table below summarises the activity of the ICT over the last few months. Feedback from a wide range of stakeholders including clinical and general management at University Hospital Ayr is very positive about the work of the Team.
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WEEKLY INTERMEDIATE CARE TEAM (ICT) ACTIVITY SCORECARD Week Commencing 03-Oct 10-Oct 17-Oct 24-Oct 31-Oct 07-Nov 14-Nov 21-Nov 28-Nov 05-Dec 12-Dec 19-Dec 26-Dec 02-Jan ACTIVE CASELOAD ICT REHAB - - - - - 119 121 112 106 102 90 100 98 103 ICT MEDICAL - - - - 17 11 8 9 8 13 19 17 13 11 TEC HMHM - - - - - 148 145 151 128 126 140 155 150 146 TOTAL PATIENTS MANAGED IN SERVICE - - - - - 278 274 272 242 241 249 272 261 260 NEW REFERRALS ICT COMMUNITY REFERRALS 10 7 12 7 17 21 17 24 14 14 16 13 10 12 ICT ACUTE REFERRALS 5 10 4 12 14 12 13 18 19 19 18 28 15 20 TOTAL ICT REFERRALS 15 17 16 19 31 33 30 42 33 33 34 41 25 32 TEC HMHM COMMUNITY REFERRALS 0 0 1 3 3 3 7 4 0 6 6 2 3 5 TEC HMHM ACUTE REFERRALS (Specialist Nurse) 2 0 1 4 2 1 2 4 6 3 1 6 3 4 TOTAL ICT & TEC TEAM REFERRALS 17 17 18 26 36 37 39 50 39 42 41 49 31 41 INITIAL OUTCOMES (ICES REHAB ONLY - scottish exec return) Prevented Admissions as result of ICT Intervention 11 10 12 8 15 12 10 10 11 12 7 10 7 10 Early Discharges supported by ICT intervention 2 4 3 6 5 5 10 14 13 10 10 16 13 4 Early Discharge estimated bed days saved 6 12 9 18 15 15 30 42 39 30 30 48 39 12 Prevented Admission estimated bed days saved 55 50 60 40 75 60 50 50 55 60 35 50 35 50 STAFFING Total staff capacity for week - - - - - 89% 90% 77% 72% 77% 80% 72% 65% 76%
Notes 1. This table shows high level scorecard of past weeks. If you wish further detail of current week, please drop down into tab "Referral Detail wk Date" 2. The esimated bed days saved is based on evidence of 3 days for admission prevented, and 5 days for early discharge. 3. Staff capacity has historically been calculated by counting actual staff days in comparison to total staff days that would be available without any form of absence
4.8 MDT Engagement in Hospital Planning Systems
Officers from the HSCP including members of the ICT, social work and home care teams are fully engaged with hospital colleagues in seeking to respond early to the needs of people who need support for discharge. It is hoped that this engagement will help support less risk-averse decision-making than has sometimes been in evidence within hospital settings. At a recent workshop involving a wide range of health and care staff from both the Partnership and Acute Services the importance of having a “default” position of enabling a return home as speedily and safely as possible was further emphasised.
4.9 Biggart Rehabilitation Beds
In November 2015 a test of change involving 8 rehabilitation spaces at Biggart was introduced. The approach has reduced length of stay and improved outcomes for people in these spaces. The length of stay has reduced from over 40 days to less than 30 days following new admission criteria and the establishment of an inclusive goal setting and discharge planning approach. The involvement of family and carers in goal setting has improved over the course of the project and is now apparent in 90% of cases. Work is underway to extend the approach and to test a “home as the default” approach in partnership with community teams. A new Nursing or Allied Health Professional Consultant post has recently been appointed. The postholder will lead changes in Biggart and the community. They will have a key role in the new Combined Assessment Unit at University Hospital Ayr, ensuring that there is a joined
8 up approach across the system. The changes are likely to culminate in a reconfiguration of the rehabilitation service in Biggart during 2017.
4.10 Re-ablement
The redesign of the Care at Home Service is ongoing. It is anticipated that the final proposals for the new management structure and care pathways will be implemented over the next 3 months. In the meantime in-house resources have been redirected to the further strengthening of the Re-ablement Service. This service is being focussed on the needs of those people requiring discharge from hospital. While it is acknowledged that capacity across both the in-house and private sector has been stretched, in the majority of cases a service has been provided. Very few delayed discharges are the result of a lack of care at home. It will, however, be necessary to keep the current arrangements under review. An emerging need is for speedier responses to needs emerging from early intervention by the ICT, for example.
4.11 Impact of Service Changes
4.11.1 Delayed Discharges
At this stage, the impact of the range of activity on the crude numbers of delayed discharges has yet to be seen. As was referenced earlier there are currently significant problems in relation to the capacity of care homes in South Ayrshire. Emerging data suggests that as a proportion of the population aged over 65 more people are accommodated in care homes than in both East and North Ayrshire. The reasons for this and the impact of the new ways of working will be examined over the coming months in order to develop a model of the likely demand and capacity for care homes in South Ayrshire in years to come.
4.11.2 Reduction in number of people needing care home
There is some evidence that the numbers of people needing care home support is beginning to reduce a little. The chart below compares the number of people placed in 2016 as compared to 2015. While placements in 2016 have been impacted on by the lack of vacancies and the lack of funding availability, even if a further 40 potential placements had been made the total would be 224 which is almost 40 fewer than in the same period in 2015.
9 Numbers of Placements in Care Homes in 2015/16 and 2016/17 400
353 350 334
312
300 293
263 249 250 225
197 200 2015/16 184 Admissions 163 154 150 141
121 114
100 87 78
56 47 50 29 13
0 Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar
Conversely, the number of number of discharges from care homes is 34 lower than in 2015. In large part this difference has contributed to the current lack of capacity for people currently waiting in hospital.
4.11.3 Further Service Modelling and Commissioning
In conjunction with the work to begin to redesign services in line with the Modernising of Care programme it is recognised that there is a need for further analysis of the system within South Ayrshire. A number of data systems and means of recording metrics are in development and need refinement in order to improve both strategic planning and commissioning and operational service delivery. As indicated earlier there is a need for further benchmarking in relation to care home demand, for example. Further modelling of the capacity required within care at home as an alternative to care home provision is needed. Workforce planning and availability are likely to be significant factors. It is anticipated that more robust future strategic and commissioning plans will take some months to develop.
5. STRATEGIC CONTEXT
5.1 The action outlined in this report contributes to the following IJB Strategic Objectives as set out in its Strategic Plan:
We will support people to live independently and healthily in local communities. We will prioritise preventative, anticipatory and early intervention approaches. We will proactively integrate health and social care services and resources for adults and children. We will support and develop our staff and local people. We will operate sound strategic and operational management systems and processes.
6. RESOURCE IMPLICATIONS
10 6.1 Financial Implications
6.1.1 The delivery of services associated with the minimising of delayed discharges consumes a significant proportion of the Partnership’s resources. This paper does not address directly the financial implications of tackling delayed discharges and does not at this stage advocate additional resources to respond to the issues raised. Clearly, however, given the service demand and the pressure on resources these issues will be kept under constant review.
6.2 Human Resource Implications
6.2.1 There are no direct Human Resources implications arising from the content of this report.
6.3 Legal Implications
6.3.1 There are no direct Legal implications arising from the content of this report.
7. CONSULTATION AND PARTNERSHIP WORKING
7.1 The range of activity associated with tackling delayed discharges is the subject of regular engagement between a wide range of stakeholders.
7.2 The Chair and Vice Chair of the IJB have been consulted on the content of this report.
8. EQUALITIES IMPLICATIONS
8.1 There are no immediate equalities implications arising from the content of this report.
9. SUSTAINABILITY IMPLICATIONS
9.1 There are no immediate sustainability implications arising from the content of this report.
10. CONCLUSIONS
10.1 Delayed discharges are clearly a cause of concern within the health and care system. At present South Ayrshire HSCP is experiencing a historically high number of delays in large part associated with a lack of care home capacity. A wide range of activity is underway which aims to either maintain people within their own homes or support and early discharge home. A key aim is to reduce as far as possible the numbers of people needing care home provision. A range of further analysis is needed in order to inform future strategic and commissioning plans.
REPORT AUTHOR AND PERSON TO CONTACT
Name: Tim Eltringham Phone number: 01292-612419 Email address: [email protected]
11 BACKGROUND PAPERS
South Ayrshire Health and Social Care Partnership approved Strategic Plan for 2016- 19.
South Ayrshire Health and Social Care Partnership approved Annual Performance Report for 2015-16.
24.01.16
12 Appendix 1
Delayed Discharges in Scotland at October 2016 (Source ISD Scotland)
Principal reason for delay 2: Awaiting Patient and Total Total Awaiting place completion of Code 9 Assessment Funding Transport family related (excluding (including NHS Board area of treatment1 availability care reasons reasons Code 9) Code 9) arrangements All Lengths of Delay Scotland 202 22 432 521 - 56 1233 343 1576 Ayrshire & Arran 16 10 20 20 - - 66 28 94 Borders 1 - 13 9 - 1 24 7 31 Dumfries & Galloway - - 23 9 - 1 33 7 40 Fife 12 - 36 32 - 1 81 33 114 Forth Valley 8 - 27 22 - 2 59 25 84 Grampian 12 - 65 59 - 5 141 28 169 Greater Glasgow & Clyde 46 2 56 17 - 6 127 59 186 Highland 8 - 33 39 - 21 101 52 153 Lanarkshire 39 - 40 94 - 14 187 20 207 Lothian 44 - 105 141 - 1 291 34 325 Orkney - - 1 - - - 1 - 1 Shetland - - 1 - - - 1 - 1 Tayside 13 10 12 70 - 4 109 31 140 Western Isles 3 - - 9 - - 12 19 31 Local authority of Residence 1 Aberdeen City 3 - 32 25 - 1 61 10 71 Aberdeenshire 3 - 29 10 - 3 45 8 53 Angus 3 - 1 7 - - 11 6 17 Argyll & Bute 2 - 4 9 - 3 18 2 20 City of Edinburgh 34 - 71 94 - 1 200 24 224 Clackmannanshire - - - 2 - 1 3 2 5 Comhairle nan Eilean Siar 3 - - 9 - - 12 19 31 Dumfries & Galloway - - 23 9 - 1 33 7 40 Dundee 1 8 - 24 - 4 37 15 52 East Ayrshire 3 - 2 - - - 5 11 16 East Dunbartonshire 3 - 9 1 - - 13 2 15 East Lothian 3 - 17 21 - - 41 1 42 East Renfrewshire 4 - 2 - - 1 7 2 9 Falkirk 6 - 23 11 - - 40 15 55 Fife 13 1 36 33 - 1 84 34 118 Glasgow City 22 1 29 11 - 5 68 39 107 Highland 7 - 30 31 - 18 86 50 136 Inverclyde 1 - 1 1 - - 3 1 4 Midlothian 3 - 5 9 - - 17 4 21 Moray 6 - 3 21 - 1 31 10 41 North Ayrshire 8 - 6 14 - - 28 6 34 North Lanarkshire 25 - 6 52 - 7 90 12 102 Orkney - - 2 1 - - 3 - 3 Other 2 - - 1 - - 3 - 3 Perth & Kinross 7 1 11 40 - - 59 9 68 Renfrewshire 1 - - - - - 1 6 7 Scottish Borders 2 - 13 9 - 1 25 7 32 Shetland - - 1 - - - 1 - 1 South Ayrshire 7 10 16 7 - - 40 11 51 South Lanarkshire 24 1 38 44 - 7 114 13 127 Stirling 1 - 4 9 - 1 15 8 23 West Dunbartonshire 1 - 6 - - - 7 4 11 West Lothian 4 - 12 16 - - 32 5 37
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