The Scottish Government

Lead Responsibility

Project title

Description

Anticipated Outcome

Cost

Acute Division

Acute Outreach and Rapid Response Enhancement:

The Supported Discharge services provide rehabilitation in patients' own homes to allow for earlier discharge. The teams are now in place and report monthly on activity and annually on outcomes and patient satisfaction. Further expansion of the teams into new areas is now limited by resources

1/2/3/4/6

£800k

Local Authorities

Additional Community Care Places:

Following reviews of capacity and demand each authority has a commissioning plan to respond to local need and this includes additional places and a range of accommodation options including housing based alternatives. This is reported monthly. Capacity is not an issue although current funding is required to sustain existing practice and will be challenged as further demand for places is generated. Capacity planning will be reviewed in 2006/7 in light of the new targets, the impact of free personal care and the agreed Scottish Care rate. Funding for care home places is a significant risk for the partnership.

1/2/3/5/6

£1350k

Local Authorities

Care Packages for 1 Year Plus Delays:

In order to reduce the longest waits a small ring fenced resource has been created. This has been allocated to named individuals and if no longer required will be aborbed into the overall care home provision

1/5/6

£250k

Local Authorities

Homecare:.

All authorities have increased funds for home-care in response to demand and this has included allowing NHS staff to directly order care for hospital discharge. Funds are also availble for overnight home-care. This is reported via LITs. Home care budgets in all authorities are under considerable financial pressure and in some areas waiting lists are operating.

1/2/3/5/6

£1210k

Local Authorities

Information for carers:

Information is now provided by all agenices on the discharge process, options for future care and support to maintain living at home.

1/2/4/6

£25K

Acute Division

Joint Training:

An organisational development post has been created to focus on joint training for staff involved in discharge across all agencies. In 2006/7 work will focus on arrangements with the new CHCPs

1/2/4/6

£25k

Local Authorities

Enhanced Social care Infrastructure:.

This has allowed the further development of care management and intensive home care solutions. This is reported via LITs

1/2/3/5/6

£600k

Local Authorities

Improved Access to Equipment and Adaptations:

Investment in increased numbers of requests for nursing equipment and aids to daily living and in particular the increased numbers of high value items. Direct ordering by hospital staff. The possible introduction of a wider range of items for this is currently under consideration. This is reported via the LITs. West Dumbartonshire is joining the current joint store with GCC and East Dum in 2006/7.

1/2/4/5/6

£250k

CHCPs

Community Health Supports:

A service has been established to support home based enteral feeding. This allows earlier discharge from hospital and helps prevent admission. This is now eatbslihed and is reported via routine management systems

2/3/5

£50k

Acute Division

Integrated Hospital Discharge Teams ( Glasgow City Council and Acute Divisions):

Health and social care resources focused on discharge have been brought together into single integrated teams, led by a Head of Discharge. This has allowed a focus on discharge within hospitals and has assisted in the development of shared processes and target setting. The IDMs report monthly against the targets. In 2006/7 the teams will further review practice in light of the new organisational structures within NHS Glasgow and GCC

1/2/3/4/6

£250k

Local Authorities

Improved Locality Based Discharge Arrangements (Other LA's):

This additional investment has addressed capacity issues and ensured effective relationships and practices across the partnership area. Waiting times for assessment and allocation and monitored monthly and each authority meets the IDM monthly to discuss the targets and agree an action plan.

1/2/3/4/6

£100k

Acute Division

New and Improved IM & T Solutions:.

Currently information is held on different systems. A project has been initiated to dvelop a shared reporting system that also meets legislative requirements for data protection and confidentiality.

1/2/4/6

£100k

Acute Division

Improved Health Supports to Care Home Residents:

Glasgow has a GP practice for care homes and a range of other support staff. In 2005/6 a service review was undertaken and recommendations for action produced to improve performance and equity. A steering group is now taking this work forward .

3

£250k

Acute Division

Falls Prevention Programme:

In 2006/7 the community based falls service will roll out to cover all of NHS Glasgow. This provides direct referral for all older people and activity and waiting times are monitored monthly.

3

£250k

Acute Division / CHCPs

Further Enhancement of Rehabilitation, Transitional and Intermediate Care Services:

Teams have been established in the community for older people, the physically disabled and for older people with mental health problems. In 2005/6 a service review of rehabilitation was undertaken and in 2006/7 this will be taken forward including a review of the roles and relationships between community and hospital teams providing services to older people and the disabled.

1/2/3/4/6

£500k

TOTAL INVESTMENT

£6010k

Resources from NHS Glasgow's other allocations

Acute Division

Falls Prevention Programme:

The falls programme will be further developed to provide exercise programmes for longer periods, exercise in care homes a more comprehnsive osteoporosis service, a hospital falls service and falls upport to care homes. The impact of each element will be reported to the falls steeing group. The recruitment of sufficient AHPs will be key to this development.

1/2/3/6

2006/7

£300k

2007/8

£500k

Acute Division

Developing a consistent approach towards hospital discharge:

The integrated discharge teams received additional resource to provide more comprehsive cover by discharge coordinators and of supported discharge services. This investment should be fully effective during 2006/7 and will be reported as described above.

1/2/3/4/6

2005/6

£625k

Local Authorities

Reviewing hospital screening services:

Additional resource has been allocated to ensure that each authority has sufficient capacity to undertake its own screening and assessment of hospital referrals. Waiting times for assessment and allocation are reported monthly.

1/2/4/6

£250k

Acute Division

( planning role )

Challenging Behaviour Cases

Additional resource has been made available to help fund care packages for adults with challenging behaviour. Traditionally these types of packages take lengthy periods to develop and to resource and these cases can be amongst the longest delays.

1/5/6

£300k

Chronic Disease Management

NHS Glasgow has a range of Local Enhanced Services providing additional care to patients with heart disease, stroke and diabetes. In 2006/7 a service for COPD will be established . This is known to be amongst the main reasons for emergency admission to hospital amongst the elderly.

Current LES are not provided to the housebound. A project will be undertaken in 2006/7 to develop alternative solutions for the house-bound including enahcned community transport and a domiciliary service

3

£675k

£75k

Acute Division ( planning role )

Palliative care

Additional resources have been made available to hospices to enahcne palliative care and also to community services to support patients at home whever possible.

3/5

£1,250K

Lead Responsibility

Project title

Description

Anticipated Outcome

Cost

CHCP

Levern Valley Older People's Team

The Team provides rapid assessment, crisis response and active rehabilitation for physically frail older people and older people with mental health problems. The aim of the Team is to prevent unnecessary admission to hospital and to facilitate complex discharge.

1/2/3/4/6

£318K

(£130K from former NHSAC DD Allocation)

Lead Responsibility

Project title

Description

Anticipated Outcome

Cost

NHS acute services

Faster Discharge Initiative

Initiative to reduce length of stay for patients in orthopaedic wards who are deemed as medically fit for discharge. These patients will now be allocated as a priority to MATCH physiotherapist. Data being gathered to monitor impact of this initiative.

2, 6

Within existing resources

Renfrewshire CHP

Northcroft Care Management Pilot

The pilot introduces a new model of pro-active care management through the development of district nursing and health visiting roles to enable preventative and anticipatory multi-agency intervention, thereby preventing avoidable admissions to hospital. Two nurse care managers are seconded to project which will be subject to monitoring & evaluation by a multi-agency steering group. Outcomes will inform "roll out" of care management model in Renfrewshire

3,6

Renfrewshire CHP/Renfrewshire Council

Intermediate Care

A community-based model of intermediate care will bring together key partners to enable older people to maintain their health and independent living skills and manage chronic conditions within the community. It will promptly identify and respond to older people's health and social care needs helping to avoid crisis and inappropriate hospital or care home admissions. It will also enable timely discharge to appropriate care settings promoting effective rehabilitation and a return to independence. An integrated service model is planned which will involve the adaptation of existing resources and the development of new models of care as part of a 'whole systems approach'.

1, 2, 3, 4, 5, 6

Gerontology nurse specialists

An audit of emergency admissions to hospital from care homes indicated care staff require increased training and support to deal with more complex medical conditions. The introduction of gerontology nurse specialists provides in-reach specialist support to care homes giving clinical nursing support and facilitating education and development of staff in order to prevent unnecessary emergency hospital admissions. They will also have an interface role between primary and secondary care enabling care co-ordination and rapid access to multi-disciplinary assessment and diagnostic services.

3

Renfrewshire CHP/Renfrewshire Council

Evaluation of MATCH services

This hospital-based multi-agency team brings together health and social work teams including rapid response and hospital to home. This existing model has been evaluated and recommendations will lead to refocusing of service and the day hospital as key parts of the intermediate care tier of services.

1,2,4,5,6

Renfrewshire Council/ Renfrewshire CHP

Joint community equipment store

To improve efficiency, speed of access and quality of service by establishing joint arrangements for procuring, storing, delivering and fitting OT aids and equipment

4, 6

NHS Acute Services

Unscheduled Care Collaborative

Identifies patient pathways, particularly in relation to older people. Outputs will inform quantitative outcomes to reduce inappropriate or unnecessary hospital admissions

3,6

Alzheimers Scotland

Alzheimers Nurse specialist

Post is based within hospital and works closely with ward staff to reduce delayed discharges and improve discharge planning of people with dementia, including those admitted with physical illnesses. Impact of this initiative will be audited by Alzheimers Scotland

4, 6

Renfrewshire CHP

Interface Pharmacist

Research indicates that around 10% of hospital admissions are due to issues such as poly pharmacy, over-prescribing and drug side effects. The interface pharmacist will work closely with the gerontology nurse specialists to ensure older people gain maximum benefit from their medication, promote effective prescribing and medication compliance and ensure effective communication with the GPs in relation to discharge and transfer of care.

3

Renfrewshire Council

Developing use of telecare support systems

Community alarms have proved effective in avoiding unnecessary admission. This service is being evaluated with a view to further expansion, increasing the capacity of home care staff to respond to crisis on a 24 hours basis and better integration with community nursing evening and overnight services to provide overnight rapid response services and prevent unnecessary emergency admissions to hospital.

5

Renfrewshire Council

Eligibility Criteria

Introduced for community care services in April 2006 in order to target services towards those in greatest need

5, 6

NHS Acute Services

Implementation of Directions on Choice Protocol

Embedded in practice in order to minimise delayed discharges.

1, 2, 4, 6

Renfrewshire Council

Overnight home respite pilot project

Introduces overnight respite at home for carers on a planned basis and in emergencies such as carer illness, thereby preventing admission to hospital or care homes

3, 5

Renfrewshire Council

Modernising Home Care Strategy

Changing management structures, assessment/review arrangements and increasing availability of evening and weekend services

5

Renfrewshire Council/ Renfrewshire CHP

Joint commissioning strategy for older people 2005 - 2008

Shifting balance of care from continuing care services by establishing a range of integrated community services for frail elderly and emi. Implementation plan will incorporate short term financial flexibility to address unforeseen pressures in achieving delayed discharge targets

1 - 6

Renfrewshire Council

Very Sheltered Housing

In partnership with housing providers, it is planned to provide extra care housing for older people and to support them to remain in their communities through the creation of specially adapted housing and support services including health staff, home carers, and community alarms

Lead Responsibility

Project title

Description

Anticipated Outcome

Cost

West Dunbartonshire Council

Additional Assessment Capacity

We will use this funding to employ an additional Social Worker to assist with preventing admission and reducing discharge times. This costs £35,000 per annum (in addition to existing Social Workers doing this kind of work) and assists the Council to achieve the Local Improvement Target of reducing delayed discharges in line with Scottish Executive targets over 2006/07 and 2007/08. Data on average assessment times is collected for quarterly analysis. Data on numbers of clients affected by Delayed Discharge of more than 6 weeks is collected on a monthly basis. Data on numbers of avoided admissions is collected on a quarterly basis.

Risks are that the resources allocated overall in the assessment of need (including this additional post) are insufficient to meet high levels of clients being presented for discharge or approaching potential hospital admission.

Contributes to 1,2, 4 and 6

£35,000

West Dunbartonshire Council

Care Home Places

Expenditure incurred in placing clients in Care homes who are placed there from a Delayed Discharge bed or as a means of avoiding hospital admission. By accepting people into Care Homes this reduces admission to hospital and allows an earlier release from hospital that would otherwise have been possible. Data on numbers of clients affected by Delayed Discharge of more than 6 weeks is collected on a monthly basis. Data on numbers of avoided admissions is collected on a quarterly basis. Risks to the success of this lie in availability of Care Home places and the ongoing financial effect of accepting such clients into a Care Home. At present the ongoing cost of such cases for West Dunbartonshire is £1.2m per year. The more of such clients who remain in a care Home after leaving hospital, rather than returning home then the bigger the financial burden on the Council becomes. At present there is clear evidence that in most cases once a client is admitted to a Care Home they are staying there and producing an ongoing commitment for the Council which is in excess of the delayed discharge funding available.

Contributes to 1,2,3, 4 and 6

£180,000 from Delayed Discharge funding

Susan Spicer

Joint Future Development Manager

Lomond Care Team (LCT), including

· Extension to weekends

· Overnight Nursing

Developments to the Integrated Care Team which is an inter-agency, multi-professional team, responding rapidly to:

· Prevent unnecessary admissions to hosptial

· Support early supported discharges from hospital

· Provide additional weekend interventions (in partnership with District Nursing teams)

· Referal and outcome data is collected. Numbers of prevented admissions and supported discharges are reported monthly for collation to LA's for SEHD rapid response returns. Annual report to Joint Partnership.

· The team has been successfully responding to the referrals as stated; there is an unknown element this year due to the NHS systems changing practice, with some services being delivered from different sites and cross boundary changes which may or may not have an effect on referrals.

For West Dunbartonshire (Lomond) population we would expect the teams in their entirety to deliver in line with last year's figures (ie. The outcomes are not merely produced from the additional funds):

• Prevent approx 298 admissions to hospital per annum
• Support approx. 179 early supported discharges from hospital
• Weekend interventions approx 64 per annum
• Overnight approx 137 prevented admissions per annum.

£114,000 from Delayed Discharge funding

Lynne McKnight

Intensive / Augmented Homecare packages

· Alternative to residential care placements (limited residential placements availability within council area)

· Recording through social work information system

· Reported on quarterly basis

Anticipate working in partnership with health colleagues to contribute to overall reduction in delayed discharges and increased volume of prevention of admission to hospital

£91,080

Lynne McKnight

Intensive home care places in conjunction with Step Up Step Down facilities

· Prevent unecessary hospital admission.

· Facilitiate support on discharge from hospital

· Support client during carer emergency

· Reported on quarterly basis

Improved success of speedy dischages and prevention of admissions providing intensive support during crisis period and supplemented carer support

£37,030

Lynne McKnight

Overnight care in the community

Home carer working partnership with Overnight Nursing Service

· Prevent unecessary hospital admission.

· Facilitiate support on discharge from hospital

· Support client during carer emergency

· Weekly returns from timesheet

· Reported on quarterly basis

Anticipate 137 admission prevented per annum

Support 52 discharges per annum

£25,000

Older Person's Development Group

Delayed Discharge commissioning plan

The Delayed Discharge plan in Inverclyde is seen as a continuum, building on the original commissioning plan, reviewed on an ongoing basis and incorporating service redesign with process mapping to ensure the patient journey is streamlined from home to hospital and back to home. The plan reflects the Framework for Joint Services : Better Outcomes for Older People and has further outcomes identified within the Local Improvement Targets for 2006-07.

A number of actions are being progressed to ensure the delayed discharge targets are achieved, but these are not seen as "projects", but as progression and development of mainstream services for older people. There are well developed performance management arrangements in place that enable monitoring to progress routinely.

One part of the service is dependent on the other, therefore it is not possible to separate out the anticipated outcomes to each part of the service development with complete accuracy.

Early intervention teams

Process mapping identifying gaps and overlaps in teams has been carried out and the results will inform the development of an Intermediate model of care as a starting point to ensure rehabilitation remains an active, ongoing and constructive part of the assessment process.

Community nursing staff will work in partnership with independent sector providers to enable service development within the care home sector.

Appropriate referral processes.

Improved joint working between health, housing and social care staff.

Further development of Single Shared Assessment.

Links to Flows 2 and 5 Unscheduled Care Collaboratives to prevent emergency admissions, and where admissions occur, ensure discharge planning starts at the most appropriate stage.

Within existing resources

Training for roll out of Discharge Protocol to approx. 250 staff.

Monitoring use of newly agreed Discharge Protocol

Streamline processes within acute hospital and ensure referrals for assessment are made at an early stage.

Application of choice guidance for care home provision within the process.

Reduction in people being delayed over 6 weeks.

Reduction in Occupied bed days.

Reduction in length of delays.

Within existing resources

Designated assessment staff attached to the Assessment wards in the Larkfield Unit.

A designated Social Worker and social work assistant working within the Larkfield Unit, building links with NHS staff and with care providers in the community.

This development will be evaluated and requirements for additional assessment and care management services will be quantified.

Speeding up the assessment process and discharge planning.

Reduce occupied bed days within acute services.

Additional resource requirements will be quantified throughout 2006-07.

Service redesign and Delayed Discharge monies.

Appointment of a Gerontology Nurse Specialist and Staff Grade Doctor

Development of a team of staff to reinforce links between inpatient services and community services.

Working with the day Hospital as a hub to look at specialist support to people in the community. Offering advice, training and assessment as required in all settings including patient's own homes, care homes and Intermediate care.

Developing a continuum of care across inpatient services, GP practices and community services.

Developing a quality assurance process through the Joint Inverclyde Quality Advice and Assurance Group.

Providing assessment in a location that suits each individual patient therefore

reducing inappropriate hospital admissions.

£80k from Delayed Discharge monies

Development of an Intermediate Care model

Working with the above staff group and an Independent Sector provider to develop an initial joint model of Intermediate Care within a care home setting as part of a ward closure from outdated NHS Continuing Care facility.

Appointment of appropriate AHP staff to support this model, ensuring they progress through the assessment process.

Ensuring people are supported and prepared for discharge as an ongoing process through the system.

People attain their optimum potential.

Ensuring rehabilitation takes place at the right time for people who need it.

Resource release through service redesign as an initial stage to implementation of the wider redesign plan.

Commissioning services with the independent sector.

Work will progress in a number of areas, as detailed in joint care group service redesign plans, working with the independent sector to ensure that new services meet the needs of the changing population and services in Inverclyde.

A new care home will open in August 2006 and development of specialist beds within this facility will enable closure of NHS Continuing Care beds for both frail Older People and Older People with Mental Illness.

Useage of residential care home beds will be monitored and negotiations regarding re-design/reinvestment will be taken forward with the providers.

Community infrastructure will be developed to ensure that services can sustain people in their own homes, and this will be provided through a range of internal and external providers.

Releasing resources for re-investment in appropriate community services.

Service redesign.

Reduction in and re-designation of NHS Continuing Care beds.

Progress joint plans drawn up for service redesign for Older people and Older people with Mental Illness by reducing NHS Continuing Care bed numbers, disinvesting and reinvesting at an appropriate level in community services to ensure they will prevent inappropriate admissions and support speedy discharge.

Making the optimum use of new care home places by working in partnership with the provider rather than increasing the number of standard care home places and in effect not changing the balance of care.

Ensuring resources are available to fund care home and domiciliary care.

As NHS Continuing Care beds reduce, there is always a danger that people will be inappropriately admitted to acute NHS beds.

Clear protocols will have to be developed to ensure a continuum of care is available for people in all care groups, especially older people with mental health needs.

Service redesign

Further development of joint equipment store

Protocols for single management of a joint equipment store will formalise current arrangements.

Additional funding has been made available for equipment and adaptations.

Quicker access to a wide range of equipment at the point of discharge as required.

Reduction in length of delays.

£50,000

Training for carers of people ready for discharge.

Medical wards make training available for carers of patients who will have specific needs on discharge. This is provided on a one to one basis as and when required to ensure carers are confident in being able to provide care as required.

Reduction in re-admissions/failed discharges, and increased support to carers.

Within existing resources.