West High Impact Change Model (HICM) Event

19 October 2018, 10:00-15:00 The Studio, Birmingham Purpose of the Event • To discuss and share innovative practice in implementing the model • To explore some of the opportunities and barriers to using various aspects of the model • To contribute towards a refresh of the model for 19/20 Agenda • 10:00 Introductions and local scene-setting on the journey • 10:10 Managing Transfers of Care – A National Overview • 10:20 Telford and Wrekin CCG & Council • 10:50 • 11:20 Coffee Break • 12:10 Leicester City Council • 12:50 Reflections on the Morning • 13:00 Lunch and networking • 13:40 Workshop – Refreshing the HICM • 14:40 Next Steps • 15:00 Close Introductions & The West Midlands Journey

Aisling Crombie , Deputy Director, Nursing and Quality, NHSE West Midlands & Ian James , Care and Health Improvement Advisor, West Midlands MC1

Managing Transfers of Care A National Overview Jane Lord – Better Care Support Team Slide 5

MC1 LOGOS MacGregor, Calum, 12/09/2018 A ‘delayed transfer of care’ occurs when a patient is ready to leave a hospital or similar care provider but is still occupying a bed.

Behind every Delayed Transfer of Care, there is a person, in the wrong place at the wrong time DTOC – the story so far

DTOC has been a persistent problem over many years (national reports into DTOC since early 2000s) More recently…. • National Audit Office Report (2015) - Discharging older patients from hospital – 5% muscle strength that older people can lose per day of treatment in a hospital bed – £820m gross cost to the NHS of older patients in hospital beds who are no longer in need of acute treatment. • National Strategy to address DTOC – Care Act (2014) • Legislation outlining LAs duty in relation to assessing people’s needs and their eligibility for publicly funded care and support – BCF National Conditions (New condition 4 (2017) • Requirement for Social Care to work with NHS to implement High Impact Change Model to manage delays in transfer of care (expectations published) • iBCF monies – NHS Five Year Forward View Next Steps • Mandate for NHS to work with Social Care to reduce DTOC – CQC Local System Reviews (interface of Health and Care) – Increased collaboration centrally between national partners • Delayed Discharge Programme Board - Strategic (DHSC, NHSE/I, LGA, ADASS, MHCLG, CQC, BCST • Discharge Steering Group - Operations (NHSE/I, DHSC, LGA ADASS, BCST, MHCLG) DTOC – the story so far

• There has been significant improvement in DTOC over the past 18 months – in the face of persisting challenges (workforce, finances/austerity, commissioning complexity) • By far, the most critical and important work has come from YOU (frontline colleagues)

Joint 7,000 6.0% Social Care NHS 6,000 Total 5.0% Ambition 5,000 4.0%

4,000 3.0% 3,000

2.0% 2,000 Number ofNumber days delayed 1.0% 1,000 of beds % occupied consultant-ld

0 0.0%

Underpinning the data are numerous examples nation-wide, of health and care colleagues going above and beyond the call of duty, working together to ensure patients are not delayed unnecessarily in hospital – THANK YOU! DTOC – the story so far

Despite the significant progress… - 4500 patients still in hospital every day (who don’t need to be there) - we have to keep up the work nationally, locally and individually. Nationally - a focus now beyond DTOC to reducing delays through out the entire patient journey • Ambition to reduce DTOC to 4000 beds by the latter part of 2018 • Ambition to reduce extended length of stay • Provide support to local systems National Support

Providing support to systems so that people get the right care, right place and right time and encouraging the development of home first principles Programmes 1. Enhanced – 14 system reviews across 9 areas to really understand why transfers of care remain a challenge 2. Targeted – Tailored Peer Reviews to meet the needs of the system 3. Universal – HICM regional events, Learning from CQC events, Why not home, Hospital Discharge/Home First Practitioner Events Tools (Links included) • Better Care Exchange / Bulletins • LGA Guidance documents • Webinars • DTOC Improvement tool (NHS Improvement) • Quick Guides (NHS Improvement) • HICM (see next slide) • Safer faster better • Focus on improving patient flow • Guide to reducing long LOS High Impact Change Model

• It was developed by national partners in 2015 to promote a new approach to system resilience and year around planning for timely discharge • The model identifies eight system changes which will have the greatest impact of reducing delayed discharge

Why refresh the HICM • To take account to new national guidance, address persistent implementation challenges and align guidance to reducing extended length of stay, improving patient flow and early intervention and prevention agenda. Understanding what works

• We are keen to understand and collect an evidence base on what works and why some areas are challenged than others. • We know that local leadership and collaborative working, investment in workforce and investment do have a role to play. • We are also keen to explore whether a combination of national, local and regional support in this area works best Telford and Wrekin CCG & - Challenges, Collaboration & Success

Tanya Miles - Head of Adult Social Care, Shropshire Council Michael Bennet - Head of Commissioning & Care Closer to Home, Telford & Wrekin CCG Challenges Collaboration and Success

Telford and Wrekin and Shropshire Michael Bennett Tanya Miles Local context

• Performance issues within acute hospital • Different economies, needs and approaches • Urgent and Emergency Care Delivery Plan • High Impact Changes • STP Co-ordination • ECIP support Collaborations

• SAED • 6 High Impact Changes • A&E Delivery Group • Frailty Board • Discharge to Assess Steering group • Stranded Patient Reviews • PSDAs/RPIWs/ 6As audit • Demand and Capacity modelling (One Version of the Truth) High Impact Change position at Q2

HIC Actions to achieve MATURE Current RAG 1 Early discharge planning EDD in place within 48 hours Embed flow processes eg SAFER, Criteria Led Discharge, End PJ Paralysis 2 Systems to monitor patient flow Demand and capacity modelling completed Capacity matches demand to support flow 3 Multi-disciplinary/multi-agency Frailty Front Door in PRH in place discharge teams ICT Operational Framework implemented 4 Home First/Discharge to Assess Consistent 60:30:10 discharge ratio 5 Seven-day service Weekend discharges at target levels Community MDT approach at weekends 6 Trusted Assessors Pathway decision 90%+ accurate first time Embed Trusted Assessor for care homes role 7 Focus on choice Fully implement agreed Choice policy Patient Information routinely provided 8 Enhancing health in care homes Care Home MDT in place Complete actions from ECHC self-assessment Red Bag scheme Utilised effectively in pilot areas (Established by Quarter 4) RAG rating key: Not y et established Plans in place Established Mature Exemplary Successes

• System visibility of performance/ progress – Safer/ Red to Green – End PJ paralysis – 60:30:10 – Simple and complex discharges by day • Stranded patients reduced c40 beds • Frailty Team at Front Door embedded • Trusted Assessor to Care Homes reducing DToCs • Integrated Discharge Teams embedded • iBCF monies to drive system change • PDSAs/ Audits to learn from, modify and improve • Honest conversations/ Challenge and Support Success Example: Two Carers in a Car

The Problem The Solution • What can we do to support • 2 Carers and a car’ people with night time needs • Service began as a pilot in the Shrewsbury area in July 2017 and to stay at home, have choice, expanded to 5 contracts in July support their confidence, 2018 comfort and dignity and • Two local domiciliary care providers commissioned ensure we are commissioning specifically services that represent value • For each contract 2 carers travel for money for the council? to any household within the chosen area to provide support 10pm - 7am. • Technology assisted Success Example: Two Carers in a Car

Costs Benefits • Costs £131,400 per year • Reducing support • Shrewsbury contract supports • Coming home from hospital at least 10 people every week • Avoiding over –prescription Admission avoidance – it has supported as many as • • Right support at the Right Time 22 for the same cost. • Flexible contracting- ability to • The total costs of the previous change to days in urgent situations available services for 10 Currently people would have been • Five contracts; used flexibly. £439,000. • A unique service that gives the right support at the right time, • Just for 10 people that’s a cost doesn’t create over-dependence avoidance of £307,600 per and supports quicker hospital year discharges. It also costs less money Success Example – Care Home MDT

• Multi-disciplinary Team targeting six highest admitting care homes with training, clinical support and Rapid Response access for admission avoidance. • Emergency Passport • A document providing a snapshot of an individual’s “normal” function and behaviour to aid paramedics in their decision making • Red Bag Scheme • A transfer pathway designed to support care Homes, ambulance and acute hospital on transition between in-patient and care homes. • It contains standardised documents to ensure staff have immediate access to vital information for any patient being transferred from a care home. Care Home MDT – benefits

Residents • Improved symptom control • Retain control, choice and dignity • Advanced Care Planning, Preferred Place of Care and living well until EOL Families • Involvement, support and satisfaction Staff • Raised awareness and understanding, education and skills enhanced • Improved job satisfaction, teamwork and morale. • Anticipating care needs, being proactive rather than reactive Financial • Currently 8% reduction in costs Challenges

• Domiciliary care capacity • Domiciliary care as part of the Team • Dependency of beds as a solution • Surge for beds high escalation • Predictable peaks in demand that outstrips capacity • Consistent behaviour change • Financial pressures that drive decision-making Summary comments

• Shared realisation of the need to change • Necessity created invention • Working thoughtfully and at pace together • Creating a learning culture • Working through the tensions while delivering the changes • Fragile and Robust Comments and Questions Central Bedfordshire - Managing Transfers of Care from Hospital to Home - Making a link between housing, health and hospital discharge.

Anthony Prior - Operations Manager, Hospital and Community Pathways Rachel Porter & Daniel Smith - Business Intelligence and Performance Analysts Charlotte Gunery - Housing Options Manager, Bedfordshire County Managing Transfers of Care from Hospital to Home & The Crucial Link Between Housing, Health & Hospital Discharge

Central Bedfordshire Council www.centralbedfordshire.gov.uk Wider Housing Initiatives - iBCF

Charlotte Gurney, Head of Service - Housing Solutions

iBCF funded housing officers and achieving positive outcomes for customers

Central Bedfordshire Council www.centralbedfordshire.gov.uk About Central Bedfordshire

Population: 278,935 (June 2018) Households: 104,400 (2011 Census) 73% owner occupied

Project increase: 335,000 in 2031 (CB Key facts and figures 2015)

Both Rural & Town Localities

Major centres of population: Leighton :40,070 : 37,880 : 18,110 : 13,180 Sandy: 12,210

Local Plan 2015-2035 identifies growth of 39,350 dwellings

Central Bedfordshire Council www.centralbedfordshire.gov.uk Context of Housing and Health in Central Bedfordshire

• Important relationship between housing and health • Obvious examples; • Understand the stress of unsuitable housing – impact on physical and mental health • Older people - trips and falls • Rough sleepers – physical and mental ill health • Hospital patients unable to return home • Maximising health, wellbeing and independence through Housing and accommodation • Council’s ambition for the right type of housing

Central Bedfordshire Council www.centralbedfordshire.gov.uk Implications for Central Bedfordshire

In the period to 2035:

• Need for 3650 specialist homes (50-75 new housing- with-care and housing-with-support schemes) • Need for 5400 mainstream housing downsizer homes • The total (9050) represents 23% of planned housing growth • Around 75% of these are for owner-occupation • Delivering these would release an equivalent number of mainly larger family homes

Central Bedfordshire Council www.centralbedfordshire.gov.uk What we have been doing

• Housing Assistance Policy to maximise prevention opportunities – low level housing related support • Inclusion of specialist mental health workers as part of multidisciplinary teams • Investment in Housing officers to integrate and co-locate with health and care services • Housing officers working in hospitals to support discharge and ensure that the person’s health needs are addressed • Implementing Social Prescribing - where GPs, for example will be able to prescribe for housing, debt or welfare benefit advice

Central Bedfordshire Council www.centralbedfordshire.gov.uk Where are we now?

Training: Next Steps: Outcomes: • Housing • Specialised • Closer working Legislation training for relationships • Prevention iBCF funded • Planned moves options Officers from hospitals • Casework • Co location management

Central Bedfordshire Council www.centralbedfordshire.gov.uk Rough Sleeper Outreach Programme

Central Bedfordshire Council www.centralbedfordshire.gov.uk Recruitment • 4 iBCF funded Housing Options Officers • New type of housing officer • Assessment Centre Approach • Value Based Interviews • Team working • Interpersonal skills • Natural empathy

The Rough Sleeper Partnership (RSP) reaches across four local authority areas. The RSP work with existing services and partners to actively identify, engage and effectively provide much needed support to those most vulnerable on the streets, sleeping rough and homeless.

The Rough Sleeper Outreach Team includes three dedicated Mental Health Crisis Workers employed by East Foundation Trust and Central North West London Foundation Trust. Central Bedfordshire Council www.centralbedfordshire.gov.uk Hospital Discharge Protocol

The Homeless Reduction Act – Duty To Refer came into effect on 1 st October 2018. The protocol basics: - Ensure referrals are sent at least 48 hours prior to discharge - LA provides a single point of contact in housing - All referrals acknowledged within 1 working day - Housing maintains case control/oversight until a satisfactory discharge resolution is reached - Housing makes referrals to other teams or statutory or voluntary agencies in order to achieve a resolution.

Central Bedfordshire Council www.centralbedfordshire.gov.uk Hospital Discharge Protocol

Count of Applicants Name by Outcome 7

6

5

4

3

2

1

0 Hostel Housed Non engagement Not Homeless TA (blank)

• 11 referrals received between April – Aug 2018 • 9 gave 48 hours’ (or more) notice for discharge (average of 1 weeks notice given)

Central Bedfordshire Council www.centralbedfordshire.gov.uk Case Study Scenario MR MB had moved into a poorly What we did…. maintained caravan on a piece of This enabled the Housing officer to liaise with the care land after a relationship breakdown. coordinator and the family. The isolation from family and friends and his living conditions Working together whilst Mr MB was still in hospital a full housing caused his mental ill health to assessment was completed on Mr MB and he was supported to apply for worsen. Mr MB was taken into welfare benefits and referred to agencies for future support. hospital and when he was not occupying the caravan the land owner took the opportunity to remove it making Mr MB homeless as he had no home to return to. ELFT made an early referral to housing under the discharge protocol The outcome….

Feedback…. A suitable permanent privately rented property was The referral for Mr MB was made found for Mr MB. 48 hours after admission and this enables all professionals and the The LA paid a rent deposit for the accommodation and family to work together to ensure upon discharge MR MB moved straight into his new that Mr MB did not have to go into home. temporary accommodation on his release.

Central Bedfordshire Council www.centralbedfordshire.gov.uk Case Study Scenario What we did…. MR AR rented a room in a private property. He had The hospital made a referral to the LA a week before been very ill for some time Mr AR planned discharge date, this enabled housing officers to complete a and his landlord had taken housing assessment. on some care responsibilities. It was identified that Mr AR would need a placement in a supported housing scheme that could continue to support him after his prolonged In March 2018 Mr AR was illness. The LA supported Mr AR in making applications to a number of hospitalised sepsis. The supported housing facilities. landlord advised Mr AR that he did not feel able to provide ongoing care and gave him a notice to leave. The outcome….

Feedback…. The early referral from MR AR was offered a supported housing placement but it was the hospital enabled both not going to e available on his release. health and housing professionals to work The LA were able to arrange alternative transitional together to ensure that accommodation for 4 days before Mr AR moved into supported Mr AR was supported housing. and could continue to receive the care he required.

Central Bedfordshire Council www.centralbedfordshire.gov.uk Managing Transfers of Care from Hospital to Home

Anthony Prior Operational Manager Hospitals & Community Pathways Rachel Porter Business Intelligence & Performance Analyst

Central Bedfordshire Council www.centralbedfordshire.gov.uk Central Bedfordshire Context

• Multiple Acute NHS Trusts

• NHS Trusts all out of Local Authority Boundary

• 2 CCG’s & Competing Priorities

• Highly Fragmented Care System

• Variety of Community Service Provider Contracts

• BLMK STP Footprint Bedfordshire//

Central Bedfordshire Council www.centralbedfordshire.gov.uk Central Bedfordshire Council www.centralbedfordshire.gov.uk Team Transforms to Service

Integrated Hospital Discharge Hospital Data & Intelligence Person Tracker Service Launched DTOC Tracker Implemented Officer (Oct 2017) Implemented (Sept (Oct 2017) (Dec 2017) 2018)

Central Bedfordshire Council www.centralbedfordshire.gov.uk Central Bedfordshire Council www.centralbedfordshire.gov.uk Change 2 Systems to Monitor Patient Flow

Robust patient flow models for health and social care, including electronic patient flow systems, enable teams to identify and manage problems (for example, if capacity is not available to meet demand) and to plan services around the individual.

Central Bedfordshire Council www.centralbedfordshire.gov.uk Tracking Delayed Transfers of Care

‹ National, regional & local priority focus on reducing Delayed Transfers of Care & Non Elective Admissions

‹ Multiple Sources of Acute Trust DTOC Data

‹ Variety of Validation/SITREP Procedures

‹ Published data in arrears

‹ Financial Penalty

‹ DToC Tracker development

‹ Early Warning System

Central Bedfordshire Council www.centralbedfordshire.gov.uk Central Bedfordshire Council www.centralbedfordshire.gov.uk Central Bedfordshire Council www.centralbedfordshire.gov.uk Central Bedfordshire Council www.centralbedfordshire.gov.uk Unlocking the Data

Complex Simple front end data

Easy to use Trackers built using Shared access

Recruited Hospital Based within the Data & Hospital Discharge Intelligence Service Officer

East Of Shared learning & development across a DTOC system Network

Central Bedfordshire Council www.centralbedfordshire.gov.uk Tracking People HOME from HOSPITAL

‹ Development of Person Tracker

‹ Case management reporting & notification

‹ Length of Stay monitoring

‹ Capacity monitoring

‹ Information sharing & engagement – Primary Care

‹ Discharge destination reporting & commissioning cycles

Central Bedfordshire Council www.centralbedfordshire.gov.uk Monitoring Patient Flow

Information Discharge Assessment Person Sharing with Planning and DTOC Activity Notification Tracker Primary Transfer of Monitored Care/Partners Care

Central Bedfordshire Council www.centralbedfordshire.gov.uk Central Bedfordshire Council www.centralbedfordshire.gov.uk Reducing Social Care Delays

Central Bedfordshire Council www.centralbedfordshire.gov.uk Reducing Social Care & NHS Joint Delays

Central Bedfordshire Council www.centralbedfordshire.gov.uk Thank you,

For a demonstration of our tools and further discussion please come and see us in the breakout area

Central Bedfordshire Council www.centralbedfordshire.gov.uk Leicester City Council - Team of Teams: leading and delivering on the High Impact Changes in Leicester

Ashraf Osman - Leicester City Council Adult Social Care, Mark Pierce - Senior Strategy and Implementation Manager, Leicester City CCG Team of Teams: Leading & Delivering on the High Impact Changes in Leicester Leicester City (of Diversity)

Diversity in Leicester 2011 2001 • White: 51% 64% • Asian/British: 37% 30% • Black/British: 6% 3% • Mixed: 4% 2% • Other: 3% 0.5%

Compared with 2001 • there are generally fewer White British residents in 2011 (although big increases in White Other)

• there are more Asian / Asian British residents (notably 0-4, 20-39 years and over 50 years)

59 Deprivation in Leicester

• Leicester is the 21st most deprived of 326 Local Authority areas.

• 44% of Leicester’s population live in the most deprived fifth of areas (quintile 1).

• Only 1% of Leicester’s population live in the least deprived fifth of areas (quintile 5 )

60 Years of life spent in good health

• Across Leicester, men live between 52 and 69 years in good health

• Worst years of good health in New Parks East, Braunstone West and City Centre

• Best years of good health in South Knighton, Clarendon Park and Western Park

• Across Leicester, women live between 52 and 70 years in good health

• Worst years of good health in St /St Peters, Saffron and Spinney Hills

• Best years of good health in South Knighton, Evington and Western Park

61 DTOCs 2013-16

62 63 64 Leicester City 65+yrs Emerg. Adms lasting 6 hrs+

65 Leicester City Em. Adms 6hrs+ for 85yrs +

66 Agreed Shared Behaviours and Values – Ashbridge Mission Model (adapted)

67 68 The Health Transfers Team

• About 2 ½ years ago Leicester City were outliers in DTOC • Health Transfers was formed after restructuring to improve performance • Team part-funded by BCF • Has Reablement Care Management Team and Hospital Discharges as part of the staff complement • Changed the operating model • Ward attached staff – every ward have the mobile number of the member of staff attached to them • Attend some Board Rounds and participate in Red 2 Green 69 How we (The System) built the team

• The team operates on the following principles • Everyone occupying a bed in hospital has a bed in the community – their own bed at home – lets get them there!! • People (especially older people) lose their independence quickly (and sometimes irreversibly) in hospital settings • People recover better in their own environment • 2 questions are asked by HT staff of all patients. Can the patient return home and if they can why cant they return today.

• Worked with CCG, LPT and UHL to build the team • Provided Joint training • Improved relationships including with the CSU • Instilled a “systems culture” within the team • Team is flexible and adaptable with a “can do” attitude 70 HT Performance

71 Discharge Home to Assess pilot

• Aims to reduce the number of DSTs done in hospital • Collaboration between CCG, ASC, Acute Discharge Team, CHC, Community nursing, GP Practices, Reablement and domiciliary care providers • Case management of selected patients by Care Management Officer • QI approach to learning lessons • Identified some gaps in communication

72 Trusted Assessorship

Now gradually rolling out within systems. Already established TA routes out of hospital are: • ICRS – All wards use TA to refer patients to ICRS

• Health Transfers team – TA in some areas such as assessment beds, Dom Care Agencies, Some Hospital Wards and community hospitals

73 The Integrated Crisis Response Service

• In-House providers of a 24/365 rapid response (max 2 hours) to social care crises for a maximum of 72 hrs. • Co-located with community nursing and therapy at the Neville Centre. Joint Board Rounds • Bridging POCs • Safe & well checks • Rapid response to fallers in the community – working with EMAS, Dom. Care Providers and Leicester Care 24 • Responded to 1,774 fallers in 17-18 out of which 8% (142) were conveyed into hospital. • 6822 referrals in 17-18. 85% still at home.

74 System Leadership…

• … comes from everyone! • We consciously and deliberately talk about being a “team of teams” • We talk values and behaviours quite a lot • Trust takes time to build and is all about doing things together – walking wards/ going out to care homes, looking at data. • We try to encourage front line teams to lead on creating answers. • Saying “thank you” a lot

75 The Book…

76 77 Hearing from each other: Sharing your most successful HICM achievement

Round table discussions – with roaming lead speakers and facilitators Reflections on the morning

Aisling Crombie - Deputy Director, Nursing and Quality, NHSE West Midlands Ian James, Care and Health Improvement Advisor, West Midlands Lunch and Networking Refreshing the HICM June 2018 – April 2019

Fiona Russell - Senior Advisor, Local Government Association Introduction • HICM was introduced in 2015 as a improvement toolkit to help health and social care systems consider a implementing a series of Changes in order to reduce DTOC and improve patient flow. • This year, there is a ambition to refresh the model to better links with emerging national agendas on improved patient flow, community support and reducing length of stay. HICM Refresh Questionnaire • Below is a link for the HICM refresh questionnaire, This is a further opportunity for you to provide feedback as a means of informing the refresh of the HICM. It should take around 10 mins to complete. http://survey.euro.confirmit.com/wix/p1866998059.aspx • For reference the HICM can be found here Purpose of the workshop • To find out how you use the model and your views on how this could be improved? • To find out what has been most useful / least useful when implementing the model and considering the impact it has had • To find out what you what you think the gaps are in the current model and how you think it should be improved and why

The views from this workshop will directly feed into collecting the evidence base for revising the current HICM. Stage 1 Spend 20 minutes considering the following questions

Q1. How do you use the HICM and what is missing?

Q2. What Change has had the most / least useful in improving patient flow and why?

Use prompt questions provided that are on the tables Stage 2 Spend 20 minutes considering the following questions

Q3. How do you think the HICM could be improved?

Please make use of the prompt questions for this question provided on each table. Next Steps • Understanding the key themes from each of the nine HICM refresh workshop

• Set up of a National Reference Group of practitioners to act as a sounding board for the development of the refreshed HICM.

• Aim is to publish refreshed model by April 2019 Conclusions and Next Steps

Aisling Crombie - Deputy Director, Nursing and Quality, NHSE West Midlands Ian James, Care and Health Improvement Advisor, West Midlands