South Gloucestershire CCG
Business Case Template 2015/16
Title of Proposal: / Discharge to Assess (D2A) – At scale rolloutProgramme Area: / Urgent Care
Author: / Keirsten Wilson and Kate Lavington
CCG Clinical Lead: / Ann Sephton
CCG Managerial Lead: / Kate Lavington, Kathryn Hudson
Type of Development: / Quality, Invest, Efficiency.
Planned Start Date: / October 2015
Document Version and Date: / V0.11_08.07.15.
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Section 1 – The Proposal
1. Outline of Proposal:Summary
Discharge to Assess (D2A) is a concept whereby patients are transferred from acute hospital at the point where they no longer require acute hospital care through one of three pathways; either at home with support (Pathway 1), in community based sub-acute bed with rehab and reablement (Pathway 2) or in a care home sub-acute bed with recovery and complex assessment (pathway 3). Thereafter any further health or social care assessments are delivered outside of the acute hospital environment.
This business case seeks to outline the costs, benefits, capacity implications, workforce development requirements and implementation plan for the roll out ‘at scale’ of Pathway 1 and some additional capacity in Pathway 3. It is felt that capacity in Pathway 2 will be sufficient when the Elgar provision becomes live (Oct 2015), but this will be continually evaluated and reviewed as part of the overall system as changes are made in the other Pathways. The primary outcomes expected from this work are reduced use of beds, shorter length of stay (LOS), system cost savings and improved overall patient experience.
Nationally, both Pathway 1 and 3 have been expanded with consequent improved outcomes, improved throughput of patients, reduced bed use and costs. Sheffield and Worcestershire have focused on Pathway 1 and 3 respectively and the learning from this work is detailed within this business case as supporting evidence for the changes proposed.
In South Glos, it is proposed that additional resource (workforce, equipment) in Pathway 1 and beds and resource in Pathway 3 (adding 5 dementia specialist bed to the existing 5 general nursing beds) will lead to a reduction of the average LOS currently of 16.9 to 5 (70% reduction) and in Pathway 1 a move from 2.5 discharges per day (M-F) to 5.5 by end of March 2016 across 7 days. The Reduction in LOS from 16.9 to 5 is a target for all pathways; however this will be achieved at different times.
The costs of this have been estimated to be:
Pathway 1 - £862,523
Pathway 3 - £821,000
This roll out and the costs associated with it will require significant reallocation of resources from acute to community services, and associated workforce redesign which will necessitate full engagement and cooperation from all stakeholders and system leaders.
Background
D2A is seen as having significant potential to move medically fit patients from NBT with pace and scale and improve acute flow.
D2A is emerging as a tried and tested model in other health communities, notably Sheffield, Warwick and Worcestershire. Results from here demonstrate that D2A improves outcomes for patients by reducing length of stay in hospital beds where patients quickly become clinically decompensated and those with cognitive impairments can see their confusion increase. D2A is also thought to reduce costs of on-going care packages and care home placements, providing benefit for individuals themselves, Local Authorities and CCGs.
South Gloucestershire Discharge to Assess Model:
Pathway 1 – Home with support – for patients whose needs can safely be met at home – cognitively/physically safe between visits
Pathway 2 – Community Rehab bed – for patients who are unable to return home and require further rehabilitation and reablement
Pathway 3 – Complex assessment – for patients who are unable to return home, have complex needs and may need Continuing Health Care (CHC)
This pathway was initially developed by South Glos and then taken on board by Bristol; see Appendix 1 for their pathway. This mirroring of process within the same provider will mean easier ways of working for NBT, clearer process for patients and front line colleagues.
2. Case for Change:
2a. Local context
The roll out of Discharge to Assess at scale has been identified by all System Leaders as one of the most important projects within the System Flow Improvement Plan to deliver sustainable 4 hour performance within the NBT system. It is seen as having the greatest potential within the SFP plan to move MFFD patients from NBT with pace and scale and improve acute flow.
All partners have committed to ensuring this is in place for Winter 2015-16 (see implementation plan in section 2).
2b. Current Activity
As of June 2015 the following pilot resource is in place for South Gloucestershire;
Pathway / Start Date / Current resource
Pathway 1 / January 2015 / Capacity to support up to 4 discharges per day (M-F). Actual discharges 2.5 per day.
Pathway 2 / November 2013 / 29 community reablement beds in care homes, 20 beds in Thornbury Community Hospital
Pathway 3 / April 2015 / 5 beds in care homes (general nursing only)
4 blue beds (residential care only)
2c. Evidence base:
Pathway 1:
Sheffield discovered that on average frail patients were spending 4 times longer in hospital than initially estimated by geriatric medicine consultants involved in their care. An analysis of 23 patients found an additional cost of £470,000 to the hospital from these delays. Causes of delay included services being involved in discharge being unable to respond quickly enough and transfers across the hospital whereby vital information was lost.
The Sheffield Frailty Unit consequently changed its practices and moved the assessment of intermediate and social care needs into the patients’ home and as a result there has been a 37% increase in patients who can be discharged on their day of admission or the following day. It has also led to improvements in bed occupancy moving from a mean of 312 in January 2012 to 246 in September. The Trust was then able to close 2 wards, totalling 68 beds¹.
Pathway 3:
In Worcestershire they found that 80% of the emergency admissions who were staying for longer than 2 weeks were over 65 and that emergency admissions staying more than 2 weeks were equating to 55% total bed days. This was leading to sub-optimal outcomes and high levels of delayed transfers of care (DToC) and staff stress.
Their reaction to this was to develop a Community Enablement and Recovery team and increase their Reablement, use Winter funding to spot purchase and improved assessment culture and process. This helped but not enough and so a pilot was created with local nursing homes which led to an average EBD saving of £5,830 per patient and reduced length of stay in Acute by 31 days which freed up 19.1 EBDs.
2d. Approach
Pathway 1:
Pathway 1 has been identified by the Enabling Discharge subgroup of the System Flow Partnership as thepreferred priority for further roll out.
The additional capacity required to make this pathway the default for all South Gloucestershire patients within NBT would allow for patients to be discharged the same or following day that they become medically fit and all assessments to do with their onwards care to be delivered in the community.
Pathway 1 has been prioritised for development because:
- It will facilitate the largest number of complex discharges of the three pathways; thereby increasing throughput of patients and turnover of beds;
- There is most clinical sign up to this pathway within NBT for this pathway, for instance some clinicians in NBT continue to have concerns about transferring patients to pathway 2 and pathway 3 beds in care homes, because of the impact on continuity of care;
- It avoids choice issues, where patients and their families decline a pathway 2 or pathway 3 bed because they do not want to move to a particular care home albeit on a temporary basis and pathway 1 is most often the pathway of choice by patients and their families;
- It is expected that visible success will be seen sooner.
The proposed additional resource into Pathway 1 equates to £862,543 of staff and equipment, to smoothly facilitate exit of patients in a more timely and complete manner, transport costs and medical/equipment same day delivery. There isa 22.35 WTE forecast requirement across clinical and social care teams which is estimated will lead to a reduction of 5880 bed days and a reduction of LOS by 70%.
This business case seeks agreement for annual funding as specified for Pathway 1 which will allow partners, led by Sirona, to work together to flex capacity and resource across the year as required to meetthe variable demands, including the known peak in winter.
Pathway 3:
To date the utilisation of pathway 3 has been variable with some periods of high use and some of voids. There has been concerns over criteria for access to Pathway 3 and consequently, the +ve checklist is no longer to be the determinant. The CHC Nurse Assessor will make the decision whilst a different solution is found.This operational issue, plus other clinical and choice issues has meant that a decision to maximise the use of the current 5 beds by end of July 2015 should be prioritised first.
From August 2015 onwards it is proposed that an EOI process for some additional 5 beds be undertakento meet the demand for dementia specific beds. It is appreciated that there may be a case for additional resource in Pathway 3 however it is important to take into consideration the associated need to review ways of working with Local Authorities and the lack of current resource of this provision in the county. There is also a new Care Home Commissioning Framework in October 2015 which will need time to bed down and may change the picture considerably.
The intention is therefore to have constant review of throughput in all pathways to ensure that impact on the total D2A system is captured and evidenced and subsequent changes to capacity requirements in Pathway 3 will be proposed thereafter.
Calculation of the Capacity Required
Impower were commissioned over a two week period to produce a demand and capacity model for transfers of care from North Bristol trust which would enable scenario and sensitivity testing.
The model uses the number of admissions per day that will become subject to complex discharge (based on averages) and the average length of stay of patients as “White” patients and as “Red” patients to calculate the number of complex discharges a week.
It then uses the outcomes of the rehab audit to determine what proportion of patients will require each specific outcome including the rise in patients during the first week as more patients are discharged and then the drop off as the backlog clears. It works by assessing what the difference in workload for each of the community providers will be if we reduce the length of stay or alter the number of patients in the system
Limitations
The data used in the model were collected from a number of different providers, using different currencies and used in the model by Impower over 2 week period. For this reason a lot of proxies and assumptions were made. The results of modelling should therefore be taken as an indicative guide as to the possible outcome of a particular scenario. There are further limitations in that the only areas that can be adjusted are the length of stay of patients and the total number of patients leaving the system as a whole making it difficult to look at the impact changes to small areas of the system or to specific geographies.A further limitation is created by the use of audit data to assign patients to each pathway. This data is based on the likely outcome for a patient based on previous ways of working. As the Discharge to assess pathways develop, the case-mix of patients suitable for each pathway may change resulting in amended proportions suitable for each pathways. The model should be updated as the pathways are developed to reflect this.
The table below show the current discharges per week under each pathway. This is based on the annual average of 9 discharges a day and a post-acute LOS of 16.9 days.
D2A Pathway / S Glos / Bristol / Other / Total
Pathway 1 / 11 / 12 / 7 / 29
Pathway 2 / 4 / 4 / 2 / 10
Pathway 3 / 6 / 6 / 4 / 16
Outside D2A pathway / 3 / 3 / 2 / 7
Total / 23 / 25 / 15 / 62
The post-acute Length of stay has been reduced in the below example to 5 days to reflect the changes made to pathway 1 and the resulting increased discharges. The numbers show the number of patients requiring each pathway based on the proportions indicated in the audit. The numbers shown indicate the new resources needed to cope with the increase in the first week following the change. It then models the number of the next three weeks as the initial backlog is dealt with and we return to a new “Steady state” shown below. This shows the numbers we would expect to see requiring each pathway on an on-going basis following the change.
The modelling also suggests that demand may be much higher in winter and planning assumptions should include a level of resilience in order to deal with increased demand. Figures modelled for the steady state using January data are shown below are indicate the increase in capacity needed.
3. Benefit Criteria
What are the direct, indirect, financial and non-financial benefits of this scheme and when/where will they occur? How will they be monitored?
- Increased number of beds and bed days released within Pathway 1 - proposed additional 5,880 bed days released at NBT with 17.5 actual beds saved (based on a 92% utilisation rate)
- improved outcomes for patients by reducing length of stay in hospital beds where patients quickly become clinically decompensated and those with cognitive impairments can see their confusion increase
- reduced costs of on-going care packages and care home placements for individuals themselves, LAs and CCGs
- a clearer split between ‘simple’ and ‘complex’ discharges and who owns and drives both – Simple discharges would encompass pathways 1 and 2, with complex discharges centring around pathway 3. Simple discharges can be identified and referred to referral hubs by ward nurses/therapists, whilst complex discharges will require specialist caser management and input from the Integrated Discharge Service.
- Number of patients discharged via D2A (by pathway)
- Number of D2A patients on LHPD (by pathway) within operational standards (‘a’ codes)
- Number of D2A patients on LHPD (by pathway) who exceed operational standards (‘b’ codes)
- % patients discharged from D2A within 6 weeks (by pathway)
- % patients assessed by social care/community health within set timeframes (by pathway)
- Positive change in elderly mobility score for patients discharged via pathways 1 and 2
- Positive change in on-going care needs for patients discharged on all D2A pathways (split by pathway)
- Reduced length of stay (by pathway)
- Positive patient and family experience (by pathway)
4. What Outcomes will this proposal support?
The increased development of the Discharge to Assess pathway will support the following outcomes:
(NHS Outcomes Framework – look at)
- improved outcomes for patients by reducing length of stay in hospital beds where patients quickly become clinically decompensated and those with cognitive impairments can see their confusion increase
- reduced costs of on-going care packages and care home placements for individuals themselves, LAs and CCGs
- increased number of discharges through increased use of pathway 1 (additional 29 per week backlog; 13 per week additional in steady state
- avoidance of the current complex choice issue and provide a clear route for patients and staff to follow
- a clearer split between ‘simple’ and ‘complex’ dischargesto support NBT and partners in delivering a high
Support delivery of CCG Strategic Plans
It will also support the achievement of the following South Gloucestershire CCG priorities:
Priority 2. Working with partners (NHS providers, South Gloucestershire Council, and other CCGs), improve the patient flow through local hospitals for both planned and unplanned care
Priority 3. Continue implementation of urgent and emergency care strategy, working closely with key partners.
Priority 8. Continue with the implementation of the new model of care, focusing on capacity available within the community
It will also contribute to two of the 5 key priorities in the South Gloucestershire CCG Five Year Plan:
Priority 2. Improve the number of people having a positive experience of health care provided in hospital, in the community and in general practice – with a focus on transitions
Priority 4. Reduce the amount of time people spend avoidably in hospital
Support delivery of NBTStrategic Plans
This work is required to ensure the Trust meets its objective of an 92% bed occupancy to increase resilience to deal with surges in non-elective activity, hence maintaining flow, protecting delivery of the Trust’s elective care programme and also the quality of care provided for all patients from admission to discharge. A reduction in occupied bed days for medically fit patients will ensure patients receive health and social care input in the most appropriate care setting for their needs.
Support delivery of SGC Strategic Plans
This work closely aligns with South Glos Councils priority to increase the independence of its population and reduce long term dependency on domiciliary care. The Joint Care Home Commissioning Framework in October 2015 will set out the future direction of travel for the care home market in the county and a ‘fair pricing’ model is being sought for April 2016, all of which will have significant impact on the local care home market and this provision.
Support delivery of SironaStrategic Plans
This clearly aligns within Phase 2 of the South Gloucestershire 3Rs programme (Rehabilitation, Reablement and Recovery) and Sirona and NBT are the preferred providers for delivery of rehabilitation.
5. What will success look like?
Including how will the evaluation be carried out to judge success?
Overall success:
-Full Clinical engagement at NBT and at Sirona
-Full engagement within SG Social Care teams
-Reduction in LOS across all pathways
-Named responsible individuals within key teams for each discharged patient
-Increasing similarity between initial EDD and actual
-Clear document and information sharing routes through from admission to discharge
-Sufficient patients exceeds operational standards
-Reduction hospital stay related illnesses
Pathway 1:
-More joint working between Health and Social Care teams
-Overall reduction in care package cost
-Flexible transport options for discharge with more than 1 exit time
-Same day deliveries of equipment and medication
-Satisfied patients and families
-Improved on-going care needs and costs
-Improved elderly mobility scores
-4 discharges per day (across 5 days) by end of July 2015
-5.5 discharges per day (across 7 days) by end of March 2016
Pathway 3:
-Full and appropriate use of current beds
-Successful EOI process and identification of additional resource
-Full use of an additional 5 beds
-Clearer monitoring of occupancy, LOS and associated target setting for throughput
-Greater efficiency of bed use as Pathway 1 and 2 bed down.
6. Impact on Other Service Areas
Local Authority, Community Services, Prescribing spend etc.
North Bristol Trust
The pathways will reduce LOS and support the planned % bed occupancy reduction target of 92%.
-EWB rollout
-BBRs
-New assessment documentation
-IDS
-Revised use of Elgar
-Optimisation of internal flow and enabling of 4 hour ED target, and support admitted RTT delivery
South Gloucestershire Council
-Impact (both in terms of availability and price)in care home market of block purchasing an additional 5 dementia beds
-On-going support needs eg. Domiciliary care
-Potential greater use of assistive technology to support people on pathway 1 / coming out of pathway 1 – cost / benefits of equipment plus capacity to install
-In pathway 1 ensuring that we are able to proactively map and manage the flow of individuals from and between provision – understanding what Sirona are doing, Brunelcare are doing, rapid response and enabling DP recipients / self-funders to access timely support
Sirona
-Additional District Nurse resource is required to support D2A Pathway 1 and has been costed as part of proposed funding requirements (7/7 provision);
-Impact on Mediquip Equipment provision –required move from 3% Same Day delivery (as % of total activity) Q4 2013/2014 to 9% Q4 2014/15 (D2A pathway 1 pilot period);
-Recognition for need of increased Management resource for Community Rehabilitation Services (has been costed as above- 5/7 provision);
-Recognition that further exploration required around improved Rehabilitation/ Reablement Interface- close collaboration with SG LA.
Section 2 – Implementation Plan and Key Performance Indicators