Medway Home First LinkedIn

…we are caring and compassionate …we deliver quality and value …we work in partnership

Home First


EnablementReablement

Rehabilitation=

Supporting Independence


Our Goal

Our pledge was to speed up hospital discharge times and improve patient outcomes We promised to support patients who might need assistance at home by arranging an independence programme within two hours of discharge

Our offer was to provide assessment of needs in the patients’ own home, setting of goals and provision of support at home; promoting independence and reducing the need for ongoing long term care in the future


What our Home First model aimed to deliver:

•Assessment for reablement and improving independence within an environment familiar to the patient. This is ‘context specific’ and the patient’s immediate and longer term needs can be more appropriately evaluated in their own home

•Assessment of the issues which may have precipitated the acute admission and anticipatory plans put in place while the patient is still able to be at home

•Removal of steps, processes and delays in the discharge process which consume valuable resources and do not add value for the patient

•A reduction in length of stay


What our Home First model aimed to deliver cont:

•A reduction in the risk associated with vulnerable patients remaining in a hospital environment and deconditioning

•Increased discharge rates on the wards

•Freeing up of hospital beds reducing medical outliers

•Increased patient flow throughout the hospital


Our Achievement

We developed a multi-agency partnership initiative working across the whole health and social care system to reduce unnecessarily prolonged lengths of stay in an acute hospital Facilitating more timely and effective hospital discharges, achieved by the community providing holistic assessment, equipment and on-going enablement and support in the patient’s own home or intermediate care facility Facilitating up to 35 discharges onto Pathway One per week, including weekends.


Quotes to consider …

Systems need to remove barriers and perverse incentives created by contracts and organisational boundaries via planning and working collaboratively (Ian Sturgess)

Understand and successfully operate the existing business – Alignment (Ian Sturgess)

Home First Principle (Ian Sturgess)

No patient should enter hospital and never return to their home again (Liz Sergeant)


Who were we missing with our existing discharge processes and what did we need to do?

Those we were unaware of who could potentially go home with no support in place.

Those waiting for placement into residential and nursing homes. These should follow the ‘home first principle’ and not enter the hospital never to see their home again.

Those that returned to the community via various pathways. We needed to be more joined up and respond quicker to referrals – simplify for the wards who to go to and when.

Resources were already in place for various hospital and community pathways. We needed to realign them so they were in the right place and able to respond at the right time.


Overcoming the challenges

Reducing confusion: Implement SAFER Board rounds and provide the wards with 4 discharge options

Timely TTOs: Need to be in line with Home First timescales

Transport delays: Utilising existing community resources

Reablement availability short term: Every one is entitled to reablement and not labeled in hospital as being unable to be rehabilitated

Commissioners nominated providers on block contract to deliver independence programs for up to 6 weeks


Overcoming the challenges cont.

Home first – sending the right message: Joint communications plan (for staff and public)

Better use of resources - Review and movement of existing community and acute resources into new pathways. Seek and utilise available wrap around voluntary services

Long term - the vision is to support patients to have 24 hour care at home for a short period of time whilst being assessed, as part of independence programme, or whilst awaiting care home placement


Mobilisation …


• Pathways designed• Not precious or territorial of existing teams and

processes • Created a Single Point of Access (SPA)

• Developed triage criteria• Calculated, reallocated and/or procured staffing

required• Procured enablement agency support


• Provided a presence at board rounds• Ensured adequate arrangements for equipment

provision• Ensured adequate transport provision

• Researched and arranged wrap around support such as telecare

• Communicated the pathways and initiative to all stakeholders – continuously


• Designed contingency and escalation plans• Flexibility and preparedness to tweak all aspects

frequently behind the scenes where required – ensuring the pathways remained the same for those accessing it

• KEPT IT SIMPLE


Pathway Two

SAFER Board round discussionPatient medically optimised but requires further MDT assessment / rehabilitation and is unsafe to be left between visits. Requires further support but no longer required to be delivered in an acute hospital.This could be significant support in the home or admittance to a community bed facility

SAFER Board round discussionPatient is unable to live independently at home and requires long term social support / placement or the patient is in the terminal phase of illness


What have we achieved so far..

Over 800 discharges on Pathway 1 between April and

September


What have we achieved so far..


MEDWAY

Home First

Medway Home First LinkedIn

Documents

Transcript of Medway Home First LinkedIn