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Borders Action Plan

Borders 2005/06 Action Plan

Borders Delayed Discharge Action Plan 2006 - 2008

The table below indicates the current financial commitments against the Delayed Discharge monies, as managed by the multi-agency Delayed Discharge Steering Group in Borders. The weekly Delayed Discharges Operational Group, and a monthly Executive Review Group (where the Operational Group meets with senior members of staff from NHS Borders and Scottish Borders Council SWD) support this work.

During 2005/06 a value for money review was undertaken by the Delayed Discharge Steering Group, which identified 3 potential areas for disinvestment. Discussions are now underway regarding the timing of this disinvestment - these are marked in the table as being under review. Once this funding is released the Steering Group will agree the most appropriate use of these resources.

The Steering Group are considering a further review of the investments outlined below, during 2006/07. Should this review lead to any changes in investments, then this Joint Action Plan will be amended and updated. Please note that the actual spend outlined in the plan may differ slightly to the planned investments for each initiative, depending on the value for money review/operational issues that arise throughout the year, although the overall total spend will not change.

30th June 2006

Lead Responsibility

Project title

Description

Anticipated Outcome

Cost

NHS Borders

(Primary & Community Services)

Additional funding for Borders Ability Equipment Services (BAES), including environmental control equipment and practitioners and users reference group

· This funding enables the purchase of pressure care equipment, profiling beds, OT equipment, non-core stock and one off requests (including expensive, specialist equipment), which enable timely discharge of patients from hospital, or enable the patient to remain in their own home.

· Performance data is available through BAES and P&CS

· As more emphasis is placed on community care, demand likely to increase. Already reporting an increased demand for profiling beds.

· Prevent unnecessary emergency admissions

· Reduce delays over 6 weeks to zero by April 2008

· Reduce the number of delays in short-stay beds to zero by April 2008

· Prevent unnecessary emergency admissions

· Ensure quarterly sustainable reductions are made

£40,000

NHS Borders

(Mental Health)

CPN G Grade Liaison Post

· This post was created to improve joint working within Borders General Hospital, improving the quality of care for individuals admitted with both physical and mental health needs, and prevent unnecessary transfer to Cauldshiels or delayed discharges. The post also offers support to staff in the Community Hospitals.

· Performance data available through Mental Health.

· Reduce delays over 6 weeks to zero by April 2008

· Reduce the number of delays in short-stay beds to zero by April 2008

· Speed up assessment process and discharge planning

· Ensure quarterly sustainable reductions are made

£35,000

Scottish Borders Council SWD

Rapid Response Service (part funding)

· This funding part funds the 5 Rapid Response teams across Borders offering short-term service post hospital discharge/to prevent hospital admission.

· Performance data is available regularly from the service.

· Increasing the number of people access in the service is a Local Improvement Target for Borders.

· Reduce delays over 6 weeks to zero by April 2008

· Reduce the number of delays in short-stay beds to zero by April 2008

· Prevent unnecessary emergency admissions

· Speed up assessment process and discharge planning

· Ensure quarterly sustainable reductions are made

£66,000

NHS Borders

(Primary & Community Services)

Red Cross Home Care Service

(Red Cross Buddies)

· The service is delivered by volunteers up to a maximum of 45 hours per week averaged over any 4-week period.

· The service assists clients in a variety of ways (including assistance with shopping, short walks, collecting prescriptions, attending social functions and social interaction in the client's home).

· The service receives referrals from the Discharge Liaison Team and the Central/Hawick Rapid Response Services.

· Performance data is available regularly from the service.

· Rapid Response Teams out with Central/Hawick are not yet able to refer to the service, - a development proposal from the Red Cross has been prepared for consideration.

· Reduce delays over 6 weeks to zero by April 2008

· Reduce the number of delays in short-stay beds to zero by April 2008

· Ensure resources are available to fund care home and domiciliary care

· Ensure quarterly sustainable reductions are made

£26,460

Scottish Borders Council SWD

Night Support Service

· The night support service provides regular overnight assistance to service users and their carers, as part of a package of planned care. Two night support workers are on duty within each area every night and travel to services users homes from their bases in the local Community Hospital or BGH.

· The service is currently operating in Kelso and Duns, and is being rolled out across Borders, creating 5 Night Support Service teams.

· Performance data is available regularly from the service.

· Increasing the number of people accessing the service is a Local Improvement Target for Borders.

· Reduce delays over 6 weeks to zero by April 2008

· Reduce the number of delays in short-stay beds to zero by April 2008

· Speed up assessment process and discharge planning

· Ensure resources are available to fund care home and domiciliary care

· Ensure quarterly sustainable reductions are made

£95,000

Scottish Borders Council SWD

Purchase of 12 care home places

· This funds a contribution to the total care home places purchased by Scottish Borders Council.

· Performance data is available regularly through SWD.

· Reduce delays over 6 weeks to zero by April 2008

· Reduce the number of delays in short-stay beds to zero by April 2008

· Speed up assessment process and discharge planning

· Ensure resources are available to fund care home and domiciliary care

· Ensure quarterly sustainable reductions are made

£175,000

Scottish Borders Council SWD

Intensive Care at Home

(part funding)

· This funds a contribution to the Home Care service, to assist in the provision of more intensive care at home packages (i.e. more than 10 hours per week), to help prevent admission to a care home.

· Performance data is available regularly through SWD.

· Increasing the number of people receiving 10+ hour and 20+ hours of home care is a Local Improvement Target for Borders.

· Reduce delays over 6 weeks to zero by April 2008

· Reduce the number of delays in short-stay beds to zero by April 2008

· Prevent unnecessary emergency admissions

· Speed up assessment process and discharge planning

· Ensure resources are available to fund care home and domiciliary care

· Ensure quarterly sustainable reductions are made

£31,000

Scottish Borders Council SWD

Out of Hours Home Care

(part funding)

· This funding helps support the out of hours home support service, which provides dedicated out of hours home care assistant response where urgency is required and the out of hours service is not able to provide an immediate response.

· Performance data is available regularly through SWD.

· Reduce delays over 6 weeks to zero by April 2008

· Reduce the number of delays in short-stay beds to zero by April 2008

· Prevent unnecessary emergency admissions

· Speed up assessment process and discharge planning

· Ensure resources are available to fund care home and domiciliary care

· Ensure quarterly sustainable reductions are made

£27,000

NHS Borders

(BGH)

Provision of OT and Physio input into A&E

· This funding provides 21 hours of Senior 1 OT time in A&E and out of hours follow up via phone calls (i.e. 3/7 days), to help prevent admission and enhance timely and safe discharge.

· Performance data is available regularly through the BGH.

· Reduce delays over 6 weeks to zero by April 2008

· Reduce the number of delays in short-stay beds to zero by April 2008

· Prevent unnecessary emergency admissions

· Ensure quarterly sustainable reductions are made

£20,000

NHS Borders

(Primary & Community Services)

Assessment Training

· Funding to train Community Hospital nursing staff to be Care Managers to speed up assessment.

· Performance data is available regularly through P&CS.

· Reduce delays over 6 weeks to zero by April 2008

· Reduce the number of delays in short-stay beds to zero by April 2008

· Speed up assessment process and discharge planning

· Ensure quarterly sustainable reductions are made

£8,000

NHS Borders

(BGH)

Discharge Liaison Team

(part funding)

· This funding has enabled the Discharge Liaison Team to extend their role into Mental Health wards and the Community Hospitals across Borders.

· This enables a more effective management of patients through hospital admission, as well as providing earlier intervention for patients requiring complex discharge planning.

· Performance data is available regularly from the team, and in addition delayed discharges are reviewed twice weekly.

· Reduce delays over 6 weeks to zero by April 2008

· Reduce the number of delays in short-stay beds to zero by April 2008

· Speed up assessment process and discharge planning

· Ensure quarterly sustainable reductions are made

£35,000

NHS Borders

(Primary & Community Services)

Voluntary and Commercial Sector

· This funding is used to assist patient, public and voluntary sector involvement in Delayed Discharge groups / meetings (e.g. payment of travel expenses)

· Ensure quarterly sustainable reductions are made

£2,500

Scottish Borders Council SWD

Welfare Benefits Income Maximisation

Currently under review

· Funds Welfare Benefits Adviser hours to assist with increased take-up of welfare benefits - to assist discharge from hospital.

· Performance data is available regularly through SWD.

· Reduce delays over 6 weeks to zero by April 2008

· Reduce the number of delays in short-stay beds to zero by April 2008

· Speed up assessment process and discharge planning

· Ensure quarterly sustainable reductions are made

£29,000

Scottish Borders Council SWD

Free home care for 4 weeks post hospital discharge

Currently under review

· This funding contributes to the care home service, providing assistance to all those eligible for free home care for 4 weeks post hospital discharge.

· Performance data is available regularly through SWD.

· Reduce delays over 6 weeks to zero by April 2008

· Reduce the number of delays in short-stay beds to zero by April 2008

· Speed up assessment process and discharge planning

· Ensure resources are available to fund care home and domiciliary care

· Ensure quarterly sustainable reductions are made

£13,000

Scottish Borders Council SWD

Financial and systems management support

Currently under review

· This funding assists Social Work supporting role in the production of performance information and increased pro-active management of delayed discharges.

· Reduce delays over 6 weeks to zero by April 2008

· Reduce the number of delays in short-stay beds to zero by April 2008

· Speed up assessment process and discharge planning

· Ensure quarterly sustainable reductions are made

£20,000

NHS Borders

(Primary & Community Services)

Delayed Discharges Operational Group Budget

· This funding is managed by the Delayed Discharge Operational Group, to expedite individual patients whose discharge has been delayed, and to provide increased capacity into the Discharge Liaison Team, as required throughout the year.

· Reduce delays over 6 weeks to zero by April 2008

· Reduce the number of delays in short-stay beds to zero by April 2008

· Speed up assessment process and discharge planning

· Ensure resources are available to fund care home and domiciliary care

· Ensure quarterly sustainable reductions are made

£31,040

Total commitments = £654,000

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Page updated: Monday, October 2, 2006