Buckinghamshire Integrated Care Partnership CCG Governing ... · We need to design new pathways for...

Buckinghamshire

Integrated Care Partnership

CCG Governing Body

Executive Summary

Winter Plan

Key lessons from 18/19

2 Your community, Your care : Developing Buckinghamshire together

Over 50 members of the Bucks ICP and neighbouring organisations attended the winter wash up for 18/19. Feedback from the event was shared widely across the ICS, with the key messages of: • Collaboration is key – structured and regular communication is needed, as are trusted

relationships to resolve challenges • Communications across the system – consistent communications to staff and patients

across the ICP will keep messaging simple, and avoid conflicting messages • Weekend flow is vital – we need to build robust services that functions 7 days a week • Structured approach to escalation – we need calm, consistent and equitable escalation

via OPEL, and to review the approaches taken to increase system bed capacity • Engagement of the charitable sector – we want to work with the charitable sector to

enable patients to remain at home safely and leave hospital when they no longer need acute care

• Saving patient and staff time – designing systems that are timely, simple and reduce duplication and distress caused through over complexity

Priorities for winter 19/20


For both adults and children: • Reduce A&E attendances • Reduce NEL admissions • Facilitate timely discharge

The Bucks ICP plan aligns to these three objectives and the delivery of a home first approach

Clinical areas of focus


As a integrated system, these are the key areas we have committed to developing • Paediatrics

• Increased medical and nursing coverage in ED and the paediatric decision unit (PDU)

• Rapid access to consultant support via additional hot clinics • Frailty

• Falls and frailty vehicle to support patients calling 999 and 111 • Silver phone for immediate consultant advice for primary care,

including paramedics • Mental health

• Providing bespoke mental health support away from ED, for acutely unwell patients

• Safe havens across Buckinghamshire, in areas of high need

BOB UEC Funding

• The ICS has been allocated £320,598 for winter transformation schemes

• Monies have been allocated on a capitation basis, which gives Bucks £94k

• The AEDB has agreed two schemes to be funded from this allocation

• The implementation of MiDoS for SCAS, an enhanced version of the DOS, and a way of reducing conveyance – cost £16k (£50k cost across STP)

• The delivery of a falls and frailty vehicle 5 days a week for 22 weeks, with the service aligned to the days of peak demand. This will be delivered as an ICS with input from BCC and BHT with SCAS to maximise admission avoidance opportunities.

5 Your community, Your care : Developing Buckinghamshire Together

BCF Winter Funding


Scheme Name Estimated output Expenditure Description

Brokerage support in

hospitals – waiving

charges to patients

c13 referrals per month £83k From November 18 to March 19, 87 referrals received – 7 day

response offered to SMH and Wexham hospital sites

Flu vaccinations –

increasing uptake by

independent sector

providers and wider Bucks

population

All care home and

preferred home care

providers contacted and

frontline social care staff

targeted; information to

general population

£15k Increase uptake and immunisation against flu of non-health

population to improve general system resilience – 8 clinics held in 18-

19, earlier start and wider scope in 19-20 to increase inclusion

Intermediate nursing care

home beds - 3

To support reablement

services, to offer

intermediate care home

beds

£234k To reduce targeted individuals coming out of hospital to regain their

skills and independence and reduce long term care costs

Residential Placements

(flexible across all service

groups and models)

OR 71 nursing

78 residential

£1,671,318 Based on average cost of £821 for a new nursing placement over 6

months

Based on average cost of £901 for a new residential placement over 6

months

Home Care and Dom Care OR 86,134 hours £1,671,318 Based on average £19.40 per hour; 221 people if 15 hours each per

week for 6 months

Personalise Care at Home

– Live in care

OR Between 46-76 sets of

24/7 care for 6 months

£1,671,318 24/7 live in care for 6 months

Operational structure for 19/20


Day Support

Monday

• SMH check and challenge • Wycombe >7 day review • Forward planning

Tuesday

• SMH check and challenge • NSIC LOS review • Buckingham >7 day review • Directors call

Wednesday • Amersham >7 day review • SMH MADE/DPTL*

Thursday • SMH check and challenge

Friday • SMH check and challenge • ICP LLOS directors call

Other

• Daily System call • Twice weekly Frimley

Medically Stable huddle

Winter team 19/20: ICP: Frances Woodroffe – Winter Director BHT: Helen Byrne – Director of Site and Patient Flow BHT Clinical Lead: [waiting for a name and title] CCG: Nicola Newstone – Head of Urgent Care CCG: Dal Sahota – Clinical Director Urgent Care BCC: Tom Chettle – Head of Service Oxford Health: Donna Clarke – Service Director SCAS: Mark Begley – Head of Operations FedBucks: Asma Ali – Services Director FedBucks Clinical Lead: Gemma Jones – Clinical Director, Urgent Care Voluntary sector: TBC South Bucks Managerial Lead: Ian Sadler – Commissioning Manager South Bucks GP Liaison: Dr Sonia Tariq South Bucks Clinical Lead: Dr Nicola Turner

*MADE = multi-agency discharge event DPTL = discharge patient tracking list

Admission and discharge gap


Every day it is a challenge to discharge as many patients as are admitted When there are not enough discharges, this causes patients to wait in ED for beds This is not the care anyone would want for a loved one Nationally there is a focus on reducing the overall length of time patients spend in Emergency Department, and avoiding patients going to ED unless clinically essential We need to work with our community to encourage appropriate use of our Emergency Department To enable a smooth and timely journey through the hospital, we need to enable safe and timely discharge and care in the right setting We need to design new pathways for patients, working across the Integrated Care Partnership, to provide the right care, in the right place for patients

How we can close the gap:

• Robust implementation of SAFER & increased consultant coverage at the front door

& hot clinics – 24 beds (equivalent to 5% LOS reduction)

• Non weight bearing -15 beds

• Alcohol detox – 5 beds

• Community based IV Antibiotics - 7 beds

• Integration of hospital and social care discharge team and delivery of Single Point of

Access – 15 beds

• Adherence of choice policy + brokerage to support self funders – 4 beds

• Protect assessment areas from bedding – 5 beds

• Delivery of medical day unit – 6 beds

• Front door frailty – 8 beds

• Total – 89 beds

Measures of success:

• Reduction in the number of patients waiting in ED >12 hours

• Reduction in the percentage of patients with a LOS >20 days

• An additional 9 extra weekend discharges


Areas of focus for improving patient care and experience

Real time patient flow


Live dashboards now give visibility of flow across BHT. Delivery of a ICP reporting system to replace Alamac goes live in September, and a ward dashboard in October.

Ensuring the safety of our patients

• ED: SHINE in place – emergency department safety checklist

• Safe staffing huddle twice daily

• Ward patient safety huddle

• Director of flow- reviewing safe placement of patients in escalation and plus

one

• Safe care element of health roster – live view of staffing taking into account

numbers and needs of patients

• Allocate on arrival staffing (2 Registered Nurse & 4 Health Care Assistants)

• Intentional rounding

• Acute & Community Flu immunisation plan

• Norovirus plan

• CCG/BHT joint quality visits to core services

• Normal practice of monitoring SI, incidents, complaints


An integrated approach to discharge

• Spending time in a hospital bed when you are not acutely unwell is harmful

• Existing discharge process are complicated and cause unnecessary delays

in patients leaving hospital

• There is clear focus in the ICP to work collaboratively in improving

discharge pathways to simplify and speed up process by:

– Integrating hospital and social care discharge teams

– Delivery of single point of access for professionals to refer patients who

do not require acute hospital care – avoiding admission and enabling

discharge

– Bringing forward the planning of discharge to take place in parallel to

the patient becoming medically ready

– Implementing national best practice for patient flow including the

SAFER patient flow bundle


A system approach to escalation

• Nationally a system call OPEL (Operational Pressures Escalation

Levels) is in place to provide consistency and structure to identifying

• We want to work across the ICS to align our thresholds for

escalation

• As an ICP we are working to review the existing OPEL structure and

ensure the actions across both BHT and system partners are

appropriate, timely and sufficient to mitigate risk.

• This is particularly relevant for days of greatest risk and escalation,

where anticipatory action can prevent the system reaching OPEL 4


Ensuring the well being of our staff

• Clear messaging to all staff to look after their personal wellbeing and take their breaks

• Staff and wellbeing service in place – over winter this can be delivered in situ in ED and other critical clinical areas and be accessible and available for staff to drop in and be signposted elsewhere if required

• Regular walk-abouts by executives and other senior leaders across all acute and community sites to troubleshoot and ensure visible and easy access to the leadership team – the team are constantly aware of the system position, and respond in particular to teams under pressure

• Flu vaccinations offered on site to all staff, peer vaccinators in place to further enhance coverage

• ‘Go Engage’ programme to support collaborative and successful team work

• Before you got home checklist to be rolled out, particularly focused in key patient flow areas

• How can we better support our primary care staff?


CHC and End of Life CHC

• We have integrated our placement commissioning team with Bucks CC to identify placements

so patients can move from hospital in a timely way, thus improving flow

• We are implementing a Nursing Needs Assessment for hospital patients to reduce the number

of patients who require a CHC checklist before they leave the hospital and move into a

nursing home

• We are increasing capacity and implementing LEAN processes within the CHC team to

ensure timely turnaround of CHC applications

• We will be piloting an out of hospital pathway for some patients who have had a CHC

checklist and it shows a full (Decision Support Tool) assessment is required. This will allow

discharge of patients from hospital sooner in a more home-like environment

End of Life

• We have the Airedale /Immedicare 24/7 nurse video consultation system in place in 37 of the

largest care homes with the highest rates of hospital admission, covering 50% of the 4,000

care home beds in Buckinghamshire. This reduces the need for hospital admission, improves

quality of care for residents and has led to fewer hospital admissions from care home

residents dying in hospital

• We are exploring ways in which end of life providers can increase capacity for supporting

people to die in their own homes rather than in hospital


South Bucks

• Paediatric advice line purchased for South Bucks patients to reduce attendance

– audited and impact on ED attendances and OP demonstrated

• From 1st July Buckinghamshire will be starting D2A Dom care in zone 1 (4hrs per

day) and 2 (7hrs per day) and 1 bed in Parkfields for Buckinghamshire CCG

patients in Wexham Park Hospital.

• D2A will be increased to a maximum capacity from January 2020 of 10hrs per

day in Zone 1 Dom care; 15hrs per day in zone 2 Dom care and 3 beds in

Parkfields.

• Further discussions with Wexham Park Hospital regarding the Cardiology and

Respiratory work streams

• Monmouth Team coding challenges to reduce price

• Develop dashboard to include tracking metrics – HRG level

• Real time access to the Bucks admissions and attendances to WPH is now

available and graphs are produced by CSU


Glossary OPEL (slide 2)

• Operational Pressures Escalation Levels. A graded (OPEL 1-4) set of actions to assist health and care systems in managing patient flow

NEL admissions (slide 3)

• Non-elective: care/admissions that are not pre-planned

Hot clinics (slide 4)

• Rapid access clinics aimed at reducing admission rates

Silver phone (slide 4)

• Direct access by phone to a consultant geriatrician

Safe havens (slide 4)

• Professional out of hours support for those in mental health crisis

DoS (slide 5)

• Directory of Services, an NHS online directory of thousands of health services, accessible by health and social care professionals

Intermediate nursing care home beds (slide 6)

• Intermediate care services are provided to patients, usually older people, after leaving hospital or when they are at risk of being sent to hospital

MADE- Multi-Agency Discharge Event (slide 7)

• MADEs are a collegiate exercise, consisting of members across health and social care, to highlight and challenge system partners to reduce delays (internal and external) and support safe and timely discharges

ICP LLOS directors call (slide 7)

• ‘Long Length of Stay’ discussion between senior system partners to escalate issues and expedite planning

Choice policy (slide 9)

• A series of steps communicated to the patient about their expected length of stay, and planning for timely and effective discharge

SAFER (slide 12)

• Five elements of best practice to achieve good patient flow and outcomes

CHC LEAN processes (slide 15)

• A set of working practices to create the best value from available resources


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