LOCAL JOINT ACTION PLANS 2006 - 2008
PARTNERSHIP AREA LANARKSHIRE
Lead Responsibility | Project title | Description | Anticipated Outcome | Cost |
Lead responsibility rests with the Chair of the Central Monitoring Group CMG) supported by the Chair of each Locality Area Group (LAG). | The actions identified in the delayed discharge action plan contribute towards delivery of the delayed discharge targets set by the Scottish Executive. They form part of a range of health and social care services designed to support people at home and in community settings, prevent unnecessary emergency admissions to hospital and speed up the assessment process and discharge planning. The projects identified are set against the annual financial allocation (3.1 million pounds) provided to the Partnership by the Scottish Executive. | The Scottish Executive has asked each Partnership to provide a range of information against each project. The information includes: - What impact it will have.
- Who will benefit and how
- What data is collected and how often
- Key risks to achieving satisfactory outcome.
The information should be considered in the wider context of the Delivery Plan, Joint Futures, Unscheduled Care and other Collaborative initiatives. In addition, regard should be taken to increasing demands for health and social care services, a demographic projection that anticipates an increase in the elderly population and increasing pressure on partnership budgets to deliver performance guarantees and meet growing public expectations. | The targets to be achieved are: By April 2007 the Partnership must reduce delays over six weeks by 50% and reduce delays in short- term (acute) beds by 50%. The target in each category is therefore 20 and 10. By April 2008 the Partnership must reduce delays over six weeks to zero and delays in short-term beds also to zero. | The financial allocation for 2006/07 is £3.1 million. The opportunity has been taken to identify the budget by project and LAG. That information is attached to this submission. |
CHAIRPERSON OF L.A.G. | JOINT DISCHARGE MANAGEMENT Central Monitoring Group (CMG) - membership comprises senior managers from NHS Lanarkshire, North and South Lanarkshire Councils. The Group meets monthly and looks at performance over the previous period. A Local Area Group (LAG) operates within each of the three geographic areas of Lanarkshire. It also meets monthly and has a local focus. Each LAG reports to the CMG. NHS Lanarkshire has since April 2006 established two Community Health Partnerships (CHP) that extend over North and South Lanarkshire Councils (this replaces the previous LHCC/Primary Care structure). This has prompted a review of existing joint planning structures including the management of delayed discharges. This may lead to changes to the existing CMG/LAG structure. | - Provides management focus for effective management of delayed discharges.
- Resolves operational and financial issues that cannot be resolved at LAG level.
- Reviews activity information associated with projects specific to that geographic area.
- Supports a weekly multi-agency operational meeting that reviews all patients categorised as delayed discharges. The opportunity is taken to streamline the process of assessment and provision of future care.
| - Monitors progress against targets and takes appropriate remedial action as necessary.
| |
CHAIRPERSON OF L.A.G. | MULTI-AGENCY / MULTI-DISCIPLINARY RAPID RESPONSE TEAMS LOCATED IN EACH ACUTE HOSPITAL | - Facilitate the process whereby patients are assessed and streamed as appropriate.
- The patient will benefit from team and multi-agency working to deliver early assessment, appropriate and rapid care packages and rehabilitation.
- Quantitative data is collected daily and qualitative reports are collated monthly re activity.
- Increased activity and subsequent increased demand on services. The demand on health and social care budgets.
| - Reduce the number of delays in short stay beds.
- Prevent unnecessary emergency admissions
- Speed up assessment process and discharge planning.
| |
CHAIRPERSON OF L.A.G. | MULTI-AGENCY / MULTI-DISCIPLINARY EARLY SUPPORTED DISCHARGE TEAMS FOR EACH LOCAL AREA | · Facilitate early discharge and community rehabilitation. · Patient benefit as rehabilitation programme will be delivered at home. This will enable delivery of optimum functioning and care management throughout process. · Quantitative and qualitative data is collected and analysed routinely | · Reduce the number of delays in short stay beds. · Improve the process of assessment and discharge planning. | |
CHAIRPERSON OF L.A.G. | FALLS SERVICE | · Early identification of patients who are at risk due to falls. · Benefit to the patient from team and multi-agency working to deliver early assessment and rapid access to appropriate diagnostics and investigations. · Quantitative and qualitative data is routinely collected and analysed. | · Prevent unnecessary emergency admissions. · Improve assessment process and discharge planning. | |
CHAIRPERSON OF L.A.G. | PSYCHIATRIC NURSE LIAISON SERVICE | · Early identification of patients presenting with psychiatric symptoms in acute areas. This enables advice and support to be provided to staff caring for these patients, and where necessary facilitating transfer of patients to appropriate area. In addition, psychiatric staff input into Adult with Incapacity (AWI) process. · Patients will benefit by having their needs addressed more quickly and in an appropriate care setting. · Quantitative and qualitative data is captured routinely and analysed. | · Improve assessment process and discharge planning. · Reduce the number of delays in short stay beds. · Reduce delays over 6 weeks. | |
DIVISIONAL DIRECTOR OF NURSING | CARE MANAGEMENT PILOTS (X 3) CLYDESDALE EAST KILBRIDE COATBRIDGE | · Facilitate the process whereby patients with complex health/social care needs will be monitored closely by appropriate professional staff. An assessment of need will be undertaken rapidly and systems put in place across agencies to access appropriate services. · Patients with complex care needs related to long-term conditions who have an acute episode of care will be actively supported on discharge. · Data information needs are currently being assessed. | · Reduce the number of delays in short stay beds. · Prevent unnecessary emergency admissions. · Improve assessment process and discharge planning. | |
CHAIRPERSON OF L.A.G. | REHABILITATION IN COMMUNITY HOSPITALS | · Early identification of patients from rural area with rehabilitation needs that can be met within community hospital. Provide an alternative to acute emergency admission. § Patients living in local rural areas will have acute care, assessment and rehabilitation undertaken locally. Consultant staff will attend Multi Disciplinary Team meetings in Community Hospitals. § Quantitative and qualitative data is routinely collected and analysed. | - Reduce delays over 6 weeks.
- Reduce the number of delays in short stay beds.
- Prevent unnecessary emergency admissions.
- Improve assessment process and discharge planning.
| |
MOTHERWELL LOCALITY GENERAL MANAGER | LIAISON NURSING SERVICE WITH NURSING HOMES | § Provide support to Care Homes re patients with complex needs. Provide education to Care Home Staff. § Care Home residents can now be managed appropriately within Care Home avoiding unnecessary admissions. § Quantitative and qualitative data is routinely captured and analysed. | · Prevent unnecessary emergency admissions. | |
GENERAL MANAGER - HAIRMYRES HOSPITAL | R.A.D.A.R. (Rapid Access Diagnostics and Rehabilitation) | § Underpins a process whereby patients have rapid access to assessment and support as an alternative to direct hospital admission. § Patients over the age of 65 will benefit from Outpatient assessment and rehabilitation by a multi-disciplinary / multi-agency team. § Data information needs are currently being assessed | · Prevent unnecessary emergency admissions. | |
Risks There are risks associated with capacity and demand and the availability of staff with the required skills/competencies to deliver services. The Partnership recognises the need to promote flexibility in staff utilisation but with the necessary mechanisms to support staff during a period of significant management and service change. It does represent opportunities for staff internally but also externally and the retention of scarce resources is often difficult to achieve with neighbouring NHS Boards/Local Authorities competing for the same staff. Pressure on budgets continues with capacity demands and priorities to achieve service improvement. | |
Next Steps The Partnership acknowledges that the budget of £3.1 million pounds allocated by the Scottish Executive to support actions to address delayed discharges has remained broadly unchanged since release of the original financial allocation. Those initiatives have supported the delayed discharge action plan over that period and whilst there has been perceived added value from each initiative there has not been a robust evaluation from which clear conclusions can be drawn. There have also been some initiatives that are historically based that would benefit from review. There is a commitment to undertake that piece of work to be completed by the end of calendar year 2006. This will inform utilisation of delayed discharge funding in 2007/08. In addition, NHS Lanarkshire and North and South Lanarkshire Councils have been working together to improve and develop services for older people as part of the strategic and operational plan for older people. Services have been improved and developed through this process including proposals to integrate day services and enhance home care provision. Evaluation of those and other services and identification of good practice will inform future priorities and service delivery. This will also inform the dialogue around future allocation of resources. |
Intermediate Care and Delayed Discharge Initiatives
1 Intermediate Care
Since 2001 Lanarkshire health and care partners have worked together to develop a range of services that facilitate earlier and supported discharge, prevent avoidable admissions and reduce delays to discharge. 'Picture of Health' proposals to enhance community based services and continued progress against Joint Future action plans will extend the scope of services that operate at the interface between hospital and community. Services such as Early Supported Discharge and Falls Teams are increasingly described as Intermediate Care in recognition of a specialist element delivered in the community but which is beyond the scope of the traditional primary care or social care team.
NHS Lanarkshire has secured support from NHS Education for Scotland (NES West Region) for a four-year project to develop, implement and evaluate a multi-professional competency framework to support practitioners working in a range of Intermediate Care services. Endorsed by NHS Lanarkshire's Workforce Development Steering Group, the project will build capacity in CHPs to meet Delivering for Health targets for Shifting the Balance of Care. The NES Intermediate Care project is one of the work streams being led by a multi-agency team that is scoping the development of a Managed Care Network for Older People across Lanarkshire. This team reports to NHS Lanarkshire's Modernisation Board Programme 6 and to the Older People's Care Groups of North Lanarkshire and South Lanarkshire Health and Care Partnerships.
2 Delayed Discharge
The Lanarkshire Partnership receives an annual allocation of £3.1 million from the Scottish Executive, ring-fenced to support a reduction in delayed discharge and to meet related Local Delivery Plan and Joint Future targets. Despite incrementally challenging targets there has been no increase in allocation since 2004/05. To date this budget has been released annually to three Local Area Groups (LAG's) that report spend and performance against the Partnership Delayed Discharge Action Plan through the multi-agency Delayed Discharge Central Monitoring Group (CMG). The establishment of Community Health Partnerships and joint accountability arrangements for delayed discharge make it timely to review the remit, reporting arrangements and utility of the existing delayed discharge groups.
The Lanarkshire Partnership has acknowledged that maintaining progress against increasingly challenging delayed discharge targets will require critical review of established initiatives in terms of their impact and value for money. Such a review would support the Partnership in developing, for 07/08 and beyond, a revised Delayed Discharge Action Plan that delivers sustained progress through a range of initiatives that implement A Picture of Health and Joint Future Strategy.
3 Proposed Review
The Chair of the Central Monitoring Group has proposed that the Intermediate Care Project Team is well placed to support the Central Monitoring Group in undertaking a review of delayed discharge initiatives. This proposal has support in principle from Central Monitoring Group officers from partner agencies.
The first phase of the proposed review will be a stock take of existing Intermediate Care and Delayed Discharge initiatives across Lanarkshire and preparation of a report that describes caseload, anticipated impact, resources allocated, staffing / skill mix and prospective data used to evidence impact / outcome / quality / resource utilisation for the services.
The second phase will include a facilitated partnership event to explore the extent to which each initiative adds value, contributes towards Shifting the Balance of Care and delivers a sustained reduction in Delayed Discharge. Outputs from this event will inform a final report that will present recommendations on
· A shared definition of Intermediate Care services
· Aligning varied elements of Intermediate services provision
· Opportunities for redesign of existing services
· Optimising use of resources
· Alternative initiatives to address gaps / remaining challenges
· Harmonising data on activity, quality and impact
· Streamlining performance management arrangements
4 Review Team
The review will be led by Moira Forsyth, supported by the Intermediate Care Project co-ordinator and by the multi-agency Managed Care Network Project Team, and directed by the Central Monitoring Group Chair.
5. Timescale and Reporting
Phase one will be completed by end of Dec 2006. The stock take report will be presented to the Central Monitoring Group in January 2007 before circulation for comment to Modernisation Board Programme 6 and North Lanarkshire and South Lanarkshire Health and Care Partnership Groups.
The partnership development event will be held early Feb 07. Participants will be drawn from the above groups and will include representation from service users and carers and Area Partnership Forum.
The final report and recommendations will be circulated to the groups outlined above by end of Feb 07.
The Lanarkshire Partnership's delayed discharge action plan 07/08 will be informed by the review and by the proposals which emerge from the redesign / development event.