What is your most important learning you would like to share ? • Conditions for change • Perseverance; making small changes when you can, as every small step makes a difference • Finding individuals with a interest • Team resilience - keeping going despite the setbacks and the negativity. • Publicity, & raising awareness, getting people on side building the guiding collation
What are your next steps ? • Consolidate and develop role of the frailty nurse • Complete the daily frailty huddle test, using QI methodology to explore the learning • Carry out a few site visits to better understand the practical and operational aspects of a frailty pathway • Commence the visual development of a frailty pathway • Explore potential admission avoidance alternatives • Continue engagement of operational and interest group
NHS Forth Valley Board update Sarah Henderson Consultant Improvement Hub Enabling health and social care improvement
Who is in your team? Within AMU 3 x Frailty Intervention Team Nurses (1 band 7 team lead and 2 band 6’s) Fastrack therapists (physio & OT) Ageing and Health Consultant of the Day Clinical Development Fellow for Frailty Noon Huddle Above plus Discharge Hub Nurses, Psychiatry Liaison Nurses, Social Work, Closer to Home Team (on the phone) & Older Peoples Nurse Consultant
What were your aims at the outset ? • Improve identification of Frailty by screening • Deliver Early Comprehensive Geriatric Assessment • Ensure the person experiences well coordinated care and support attuned to their needs, with the focus of support at home or in a homely setting • Improve the interface and working between health and social care
Screening data
Identification of Frailty
Data – CGAO2 - % Percentage of people over 75 years old discharged from specified ward/unit within 24 hours • • % of patients aged 75 years and over (identified as frail) discharged % of patients 75 years and over discharged directly from CAU/AAU directly from CAU/AAU
Data – CGAO3 - % or number of people admitted to specialist inpatient geriatric bed, who’s length of stay is longer than 7 days
Data – CGA04 - Average length of stay for people admitted to specialist inpatient geriatric bed Currently awaited – Trakcare launched 2 weeks ago and no information available from information services at present
Data – CGAB1 - Number of people over 75, discharged from specified ward/unit, who have re-attended within 7 days Review of data showed coding issue Returns for USS (DVT’s) 8 pts were planned returns 4 frail pts 16 GIM pts Going to go back and plot only frail patients with QI.
What are you most proud of? • Managed to get 3 full-time nurses • Managed to change our whole way of working at the front door. – Screen – Huddle – Primarily look after Frail patients who now all get CGA initiated by a specialist.
What is your most important learning you would like to share ? • Data is really important and dedicated QI/Project support is crucial. • Don’t give up – it takes time and you can’t change the whole world in a month. • Keep going back to your aims to reflect on progress and plan the next steps
What are your next steps? Screening • Look at our processes for this and see if we can refine these. Can Trak help? Could the ED docs/nurses help?, What can our call handlers pre-screen for us/how reliable are they? Early Comprehensive Geriatric Assessment • Have the team, build links with therapy colleagues, look at collecting some of this information electronically with Trak, work with bed managers to push/wards pull the right patients. Coordinate care • Reflecting on huddles - could members join us in AMU earlier (psychiatry) and feedback at huddle rather than get referrals, building on links with SW and STA beds to be directly accessable (4 beds new Stirling Care Village) • Community work streams for unscheduled care And then…….. Ambulatory unit within AMU for frail patients
Refreshment break
NHS Greater Glasgow & Clyde Board update Dr Lara Mitchell Consultant DME @laramit66043489 Improvement Hub Enabling health and social care improvement
Who is in your team? AHP (Laura Walker) All of the above underpinned by our monthly General ECAN frailty meetings where: Manager (Carolanne Ideas cultivated (Arwel then O’Neill) Geraldine) Tests of change planned and executed Pathways developed Relationships built 20 Consultants DME Health and 5.8 ECAN Consultant social care DME 2 AHP (Fiona Brown/ (me) SW/ Community teams CRT leads) Staff short stay frailty
What were your aims at the outset? FRAILTY SCREENING/ CGA For all individuals >75 years (and >65 years from a nursing home) presenting at ED or IAU to undergo a frailty screen and an initiation of a Comprehensive Geriatric Assessment (CGA) at the front door within 24 hours CARE COORDINATION To ensure coordination of care for frail older patients and the identification of the most appropriate place of care e.g. home with increased support, short stay frailty ward, acute DME assessment bed, non-acute rehabilitation bed or intermediate care bed PATIENT CENTRED/ PATHWAY To improve the individuals’ experience by providing a person centred, coordinated and dynamic approach to supporting individuals with a frailty syndrome using a clearly defined pathway
Have we met those aims? 1. FRAILTY SCREENING Monday to Friday all admissions are screened for frailty in unscheduled care and 100% CGA within 24 hours on monthly testing Number transferred directly to DME bed from ARU 1-3&5 100 90 80 Screening for GROUND FLOOR FRAILTY 70 frailty ground HUDDLE floor 60 50 40 30 20 10 0 Apr-16 Aug-16 Dec-16 Apr-17 Aug-17 Dec-17 Apr-18 Aug-18 Dec-18 Apr-19
Have we met those aims? 2. CARE COORDINATION Creation of a pathway. From our own data, we know double the amount of patients are getting to our wards earlier and we are taking less from the medical wards Number transferred directly to DME bed Number accepted to DME from all sources from Medical wards 600 Short stay ward opens. Short stay ward 120 Frailty team established 500 opens. Frailty 100 team established 400 80 300 60 200 40 100 20 0 0 Apr-16 Sep-16 Feb-17 Jul-17 Dec-17 May-18 Oct-18 Mar-19 Apr-16 Sep-16 Feb-17 Jul-17 Dec-17 May-18 Oct-18 Mar-19
Have we met those aims? 3. PATIENT CENTRED/ PATHWAY To improve the individuals’ experience by providing a person centred, coordinated and dynamic approach to supporting individuals with a frailty syndrome using a clearly defined pathway
Data – CGAO2 - % Percentage of people over 75 years old discharged from specified ward/unit within 24 hours CGA01 CGA02 CGA03 CGA04 CGASL2 % discharged % discharged LoS > 7 Av LoS Patient <24 hours <48 hours days pathway Short stay May- 18 % 29% 38% 13.2 days 26.6% July ARU4 ‘18 18.6% DME 53.7% Sept- 14% 20.6% 51.9% 10.7 days ? (HIS frailty) Oct ‘18
Patients discharged home from ground floor ( non specialty beds) 100 Total Home from IAU / ARU 1-3,5 90 80 70 60 50 40 30 20 10 0 may july sep nov jan mar may july sep nov jan mar may july sep nov jan mar 16 16 16 16 17 17 17 17 17 17 18 18 18 18 18 18 19 19
Data – CGAO3 - % or number of people admitted to specialist inpatient geriatric bed, whose length of stay is longer than 7 days We are going to look at those patients in longer than 30 days On recent data, we know average length of stay is 6 days for acute assessment
Data – CGA04 - Average length of stay for people admitted to specialist inpatient geriatric bed 29% Short Stay Short Stay Frailty Unit Frailty Unit reduction 30 20% £>3M Opened in LOS Moved increased cost 25 >40 access avoided >1000 extra 20 patients alive at home 15 10 5 0 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18
3 tests of change – the elevator pitch AHP weekends Jan- ECAN weekend Communication with working ( 2 weekends) short stay ward March 2019 a) 159 patients a) 28 patients a) Improved assessed reviewed communication b) 7 discharged home b) More rapid b) 27% discharged home (saved 42 bed days) discharges c) 10 straight to a c) 15% discharged speciality bed (off site on the Monday or tuesday rehab, dementia/ delirium ward, acute assessment)
What are you most proud of? The consultants trust us [ECAN nurses] to make the right decisions – we had a good relationship with THE TEAM them anyway, this work has made it better They look after each other They have great ideas They educate others They have improved the flow and care for the older adult at QEUH Change in culture on They have changed the culture on the the ground floor ground floor Metrics agreed across GGC ! Still need to see it in action
What is the most important learning you would like to share? • Invest in your team- they will flourish • Own your data and work on consistent metrics at hospital level • Feedback and debrief regularly • Be accountable to ‘someone’ • Keep the profile high at a hospital level • Be brave
What are your next steps? Patient led experience feedback to Short stay drive change frailty ward Business case for weekend working. AHP Thank you to HIS frailty collaborative for their support and and ECAN mentorship over the last 18 months. HIS has been a powerful lever for change within our improvement journey
NHS Lanarkshire Board update Yvonne Fielder Service Manager Improvement Hub Enabling health and social care improvement
Who is in your team ? • Alistair McVean Clinical Lead Care of the Elderly • Susan Wilson SCN Ward 20 and Frailty Unit • June Delaney Senior Nurse Care of the Elderly • Agnes, Frances, Gillian, Ian ACE Nurses • Sarah McNally Occupational Therapist • Sekhar Santapur Physiotherapist • Arlene Brown Discharge Hub Team Leader • Jennifer Allan Service Improvement Manager • Karen Goudie Chief Nurse • Pamela Downey Information Analyst • Kerry Paterson/Donna McHenry Assistant Service Managers • Yvonne Fielder Service Manager Care of the Elderly • Heather Knox Executive Sponsor
What were your aims at the outset ? • Deliver a Safe, Effective and Person-Centred Frailty pathway throughout University Hospital Monklands • Embed a robust Frailty detection process for all patients over 65 years • Deliver timely CGA for Frailty positive patients identified at initial assessment • Ensure a ‘Home First’ approach for Frailty positive patients where appropriate, following CGA. i.e. Avoid admission to hospital if possible • Work with H&SCP to develop a Discharge to Assess Model
Weekly Average LOS in days Geriatric Bed (All CotE Wards) Weekly Average Length of Stay for People Admitted to Specialist Inpatient 10 12 14 16 18 0 2 4 6 8 Oct 18 Oct 18 Nov 18 Nov 18 Nov 18 Nov 18 Dec 18 Dec 18 Dec 18 Dec 18 Dec 18 Jan 19 Jan 19 Jan 19 Jan 19 Feb 19 Feb 19 MAU Nurses Frailty Screening Feb 19 Feb 19 Mar 19 Mar 19 Mar 19 Mar 19 Additonal ACE Resources Apr 19 Apr 19 Apr 19 Apr 19 Apr 19
Ward 20 Weekly Average LOS (excludes Frailty Unit) Weekly Average LOS in days 10 15 20 25 30 0 5 Sep 18 Sep 18 Sep 18 Sep 18 Oct 18 Oct 18 Oct 18 Oct 18 Oct 18 Nov 18 Nov 18 Nov 18 Nov 18 Dec 18 Dec 18 Dec 18 Dec 18 Dec 18 Jan 19 Jan 19 Jan 19 Jan 19 Feb 19 Feb 19 Feb 19 Feb 19 Mar 19 Mar 19 Mar 19 Mar 19 Apr 19 Apr 19 Apr 19 Apr 19 Apr 19
Frailty Unit Weekly Average Length of Stay for People Admitted to Weekly Average LOS in days 10 12 0 2 4 6 8 Oct 18 Oct 18 Nov 18 Nov 18 Nov 18 Nov 18 Dec 18 Dec 18 Dec 18 Dec 18 Dec 18 Jan 19 Jan 19 Jan 19 Jan 19 Feb 19 Feb 19 MAU Nurses Frailty Screening Feb 19 Feb 19 Mar 19 Mar 19 Mar 19 Additonal ACE Resources Mar 19 Apr 19 Apr 19 Apr 19 Apr 19 Apr 19
Ward 20 Discharges Per Week (including Frailty Unit) Total Patients discharged per week 10 15 20 25 30 0 5 Aug 18 Sep 18 Sep 18 Sep 18 Sep 18 Oct 18 Frailty Assess Separate on Trak Oct 18 Oct 18 Oct 18 Oct 18 Nov 18 Nov 18 Nov 18 Nov 18 Dec 18 Dec 18 Dec 18 Dec 18 Dec 18 Jan 19 Jan 19 Jan 19 Jan 19 Feb 19 Feb 19 Feb 19 Feb 19 Mar 19 Mar 19 Mar 19 Mar 19 Apr 19 Apr 19 Apr 19 Apr 19 Apr 19
Frailty Unit (only) Discharges Per Week Total Patients discharged per week 10 15 20 25 0 5 Oct 18 Oct 18 Nov 18 Nov 18 Nov 18 Nov 18 Dec 18 Dec 18 Dec 18 Dec 18 Dec 18 Jan 19 Jan 19 Jan 19 Jan 19 MAU Nurses Frailty Screening Feb 19 Feb 19 Feb 19 Feb 19 Mar 19 Mar 19 Mar 19 Mar 19 Apr 19 Additional ACE Nurse Apr 19 Resources Apr 19 Apr 19 Apr 19
What are you most proud of ? • Enthusiasm • Tenacity • Uncompromising vision (despite the challenges) • Development of (and commitment to) the 12 bedded Frailty Unit • Rapid re-energising and ownership of frailty screening in MAU • Impact on frail patients of a direct move to the Frailty Unit from MAU (avoiding AMRU)
What is your most important learning you would like to share ? What the team said! • Have clear and dedicated leadership ‘The project needed dedicated leadership … with no conflicting priorities’ • Establish a clear and focused MDT from the beginning ‘You need the right team together from the beginning – more than doctors and nurses, the full MDT…’ • Start new improvement projects in the summer before the winter challenges ‘Then we would have had more time to understand the issues, establish the pathway and make it business as usual. We didn’t have time to fully engage the front door teams, so the frailty project remained a bit insular. I think it got a bit lost’ • Understand the data that you need ….. and can access!
What are your next steps ? • 17 Frailty beds from 27 th May 24 bedded Frailty Unit in line with MRRP plans • Embed Frailty screening in MAU • Increase number of patients transferring directly from MAU to Frailty Unit (and MAU to CotE) • Test further changes to the pathway using additional temporary ACE resource • Testing of Discharge Coordinator role (impact on D2A too!)
Frailty Unit (Only) Weekly Pre Noon Discharge Rate % Total Discharges Pre Noon 10% 15% 20% 25% 30% 0% 5% Oct 18 Oct 18 Nov 18 Nov 18 Nov 18 Nov 18 Dec 18 Dec 18 Dec 18 Dec 18 Dec 18 Jan 19 Jan 19 Jan 19 Jan 19 Feb 19 Feb 19 Feb 19 Feb 19 Mar 19 Mar 19 Mar 19 Mar 19 Apr 19 Apr 19 Apr 19 Apr 19 Apr 19
Ward 20 (including Frailty Unit) Weekly Pre Noon Discharge Rate % Total Discharges Pre Noon 10% 20% 30% 40% 50% 60% 0% Aug 18 Sep 18 Sep 18 Sep 18 Sep 18 Frailty Unit Separate on Trak Oct 18 Oct 18 Oct 18 Oct 18 Oct 18 Nov 18 Nov 18 Nov 18 Nov 18 Dec 18 Dec 18 Dec 18 Dec 18 Dec 18 Jan 19 Jan 19 Jan 19 Jan 19 Feb 19 Feb 19 Feb 19 Feb 19 Mar 19 Mar 19 Mar 19 Mar 19 Apr 19 Apr 19 Apr 19 Apr 19 Apr 19
What are your next steps (cont.)? • Support Pharmacy and AHP colleagues to review workforce for Frailty • Continue to work with H&SCP colleagues to further develop D2A • Advanced Nursing Practice for CotE – possibilities +++ • Support identification and management of Frailty in the community to optimize quality of life and prevent unnecessary hospital admission • Frailty dataset from TRAK • Patient and staff experience
Falls Data (Ward 20 including Frailty Unit) Ward 20 Total Number of Falls 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Total Number of falls Median
Ward 20 (including Frailty Unit) Patient Observation Costs By Month 2018-2019 10,000.00 9,000.00 8,000.00 7,000.00 6,000.00 5,000.00 4,000.00 3,000.00 2,000.00 1,000.00 0.00 April May June July August Sept October Nov Dec January February March
NHS Lothian Board update Gillian Cunningham General Manager Medicine Services SJH Improvement Hub Enabling health and social care improvement
Who is in your team? Consultant Geriatricians Integrated REACH Discharge Nurses Hub The Site Discharge Co- Management ordinators Team Project and Multi – Analytical Disciplinary Support Ward Teams AHPs
What were your aims at the outset ? • To improve the process of identification of frailty at the front door and carry out screening and assessment at earliest opportunity. • Co- ordinate whole system ‘end to end’ integrated care which improves experiences and outcomes for people living with frailty who present to unscheduled care. • Understand the patient population aged 65+/75+ who are discharged from Medicine and ensure they are put on the right pathway at the earlier point of their acute illness
St John’s Hospital – Setting the Scene Projected % change in population ≥75 years old, 2016 - 2026 Clackmannanshire +48% +46% Midlothian +41% +41% Orkney Islands +40% +40% Highland +38% +35% East Lothian +35% +34% +33% Scottish Borders +33% +33% Falkirk +33% +31% South Ayrshire +31% +31% East Dunbartonshire +30% +28% Dumfries and Galloway +28% Scotlan +27% East Ayrshire +27% +27% d East Renfrewshire +26% +26% North Lanarkshire +23% +23% Na h-Eileanan Siar +22% +21% Inverclyde +19% +16% Aberdeen City +10% Glasgow City +3% 0% +5% +10% +15% +20% +25% +30% +35% +40% +45% +50%
St John’s Hospital – Setting the Scene • We do not have a specialist frailty unit on site • Frailty is managed throughout medicine on the acute site and within the community via community based teams - REACH frailty nurse and AHP model in Medical Admissions Unit screening and commence CGA - Geriatrician within each medical ward - Integrated multi disciplinary discharge hub - REACT services inc hospital at home, rehab at home and reablement GP Downstrea m Medical Discharg Ward Medical e Home ED Admission s Downstrea Discharge Hub m Rehab Admissio Supporte Ward n d Avoidanc Discharge e REACT
Medicine Data – CGAP1: % Patients Screened Following Admission to % Admissions to MAU Screened 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% 08/01/2018 15/01/2018 22/01/2018 29/01/2018 05/02/2018 % of Admissions Screened 12/02/2018 19/02/2018 26/02/2018 05/03/2018 12/03/2018 19/03/2018 26/03/2018 02/04/2018 09/04/2018 16/04/2018 23/04/2018 30/04/2018 07/05/2018 14/05/2018 21/05/2018 28/05/2018 04/06/2018 11/06/2018 18/06/2018 25/06/2018 02/07/2018 09/07/2018 16/07/2018 23/07/2018 30/07/2018 06/08/2018 13/08/2018 20/08/2018 27/08/2018 Number of Admissions 65+ to MAU 03/09/2018 10/09/2018 17/09/2018 24/09/2018 01/10/2018 08/10/2018 15/10/2018 22/10/2018 29/10/2018 05/11/2018 12/11/2018 19/11/2018 26/11/2018 03/12/2018 10/12/2018 17/12/2018 24/12/2018 31/12/2018 07/01/2019 14/01/2019 21/01/2019 28/01/2019 04/02/2019 11/02/2019 18/02/2019 25/02/2019 04/03/2019 11/03/2019 18/03/2019 25/03/2019 0 20 40 60 80 100 120 140 160 Number Admissions to MAU Increase in MAU reducing overall service in hours Monday-Friday REACH being a Limitation of REACH team Reduction in % screened admissions
Data – CGAP2a: % Patients Screened Within 24 Hours of Admission Percentage Patients Screened in 24 Hours 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% 05/03/2018 12/03/2018 19/03/2018 26/03/2018 02/04/2018 09/04/2018 16/04/2018 23/04/2018 30/04/2018 07/05/2018 14/05/2018 21/05/2018 28/05/2018 04/06/2018 11/06/2018 18/06/2018 25/06/2018 02/07/2018 Week Commencing Admission Date 09/07/2018 16/07/2018 23/07/2018 30/07/2018 06/08/2018 13/08/2018 20/08/2018 27/08/2018 03/09/2018 10/09/2018 17/09/2018 24/09/2018 01/10/2018 08/10/2018 15/10/2018 22/10/2018 29/10/2018 05/11/2018 12/11/2018 19/11/2018 26/11/2018 03/12/2018 10/12/2018 17/12/2018 24/12/2018 31/12/2018 07/01/2019 14/01/2019 21/01/2019 28/01/2019 04/02/2019 11/02/2019 18/02/2019 25/02/2019 04/03/2019 11/03/2019 18/03/2019 25/03/2019 Increase in MAU reducing overall service in hours Monday-Friday REACH being a Limitation of REACH team Reduction in % screened admissions
Hours Data – CGAO1 - % Patients Discharged From Medicine Within 24 % Patients Discharged Within 24 Hours 10% 15% 20% 25% 30% 35% 0% 5% 08/01/2018 % Patients aged 65+ and 75+ Discharged home within 24 15/01/2018 22/01/2018 29/01/2018 05/02/2018 12/02/2018 19/02/2018 26/02/2018 05/03/2018 12/03/2018 19/03/2018 26/03/2018 02/04/2018 09/04/2018 16/04/2018 23/04/2018 30/04/2018 07/05/2018 14/05/2018 21/05/2018 28/05/2018 04/06/2018 11/06/2018 18/06/2018 25/06/2018 02/07/2018 Week Commencing 09/07/2018 hours 65+ 16/07/2018 23/07/2018 30/07/2018 06/08/2018 13/08/2018 20/08/2018 75+ 27/08/2018 03/09/2018 10/09/2018 17/09/2018 24/09/2018 01/10/2018 08/10/2018 15/10/2018 22/10/2018 29/10/2018 05/11/2018 12/11/2018 19/11/2018 26/11/2018 03/12/2018 10/12/2018 17/12/2018 24/12/2018 31/12/2018 07/01/2019 14/01/2019 21/01/2019 28/01/2019 04/02/2019 11/02/2019 18/02/2019 25/02/2019 04/03/2019 11/03/2019 18/03/2019 25/03/2019 therefore aim to wards quickly to Identified as an to downstream progress frailty opportunity to screening may Patients move facilitate flow MAU capacity at front door Challenge of alternative be missed pathways therefore identify work
Hours Data – CGAO2- % Patients Discharged From Medicine Within 48 Patients Discharged Within 48 Hours 10% 15% 20% 25% 30% 35% 40% 0% 5% 08/01/2018 15/01/2018 22/01/2018 % Patients aged 65+ and 75+ Discharged home within 48 29/01/2018 05/02/2018 12/02/2018 19/02/2018 26/02/2018 05/03/2018 12/03/2018 19/03/2018 26/03/2018 02/04/2018 09/04/2018 16/04/2018 23/04/2018 30/04/2018 07/05/2018 14/05/2018 21/05/2018 28/05/2018 04/06/2018 11/06/2018 18/06/2018 25/06/2018 02/07/2018 Week Commencing 09/07/2018 hours 65+ 16/07/2018 23/07/2018 30/07/2018 06/08/2018 13/08/2018 20/08/2018 75+ 27/08/2018 03/09/2018 10/09/2018 17/09/2018 24/09/2018 01/10/2018 08/10/2018 15/10/2018 22/10/2018 29/10/2018 05/11/2018 12/11/2018 19/11/2018 26/11/2018 03/12/2018 10/12/2018 17/12/2018 24/12/2018 31/12/2018 07/01/2019 14/01/2019 21/01/2019 28/01/2019 04/02/2019 11/02/2019 18/02/2019 25/02/2019 04/03/2019 11/03/2019 18/03/2019 25/03/2019 therefore aim to wards quickly to Identified as an to downstream progress frailty opportunity to screening may Patients move MAU capacity facilitate flow at front door Challenge of alternative be missed pathways therefore identify work
Discharges Data – CGAO3- % Patients With Length of Stay 7+ Days inc. Delayed Percentage of Patients 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 0.0% 08/01/2018 15/01/2018 Percentage of Patients 65+ and 75+ with a Length of 22/01/2018 29/01/2018 05/02/2018 12/02/2018 19/02/2018 26/02/2018 05/03/2018 12/03/2018 19/03/2018 26/03/2018 02/04/2018 09/04/2018 16/04/2018 Stay 7+ Days on Discharge 23/04/2018 30/04/2018 07/05/2018 14/05/2018 21/05/2018 28/05/2018 04/06/2018 Discharge Week Commencing 11/06/2018 18/06/2018 25/06/2018 02/07/2018 65+ 09/07/2018 16/07/2018 23/07/2018 30/07/2018 06/08/2018 13/08/2018 20/08/2018 75+ 27/08/2018 03/09/2018 10/09/2018 17/09/2018 24/09/2018 01/10/2018 08/10/2018 15/10/2018 22/10/2018 29/10/2018 05/11/2018 12/11/2018 19/11/2018 26/11/2018 Integrated Hub 03/12/2018 10/12/2018 Launched 17/12/2018 24/12/2018 31/12/2018 07/01/2019 14/01/2019 21/01/2019 28/01/2019 04/02/2019 11/02/2019 18/02/2019 25/02/2019 04/03/2019 11/03/2019 18/03/2019 25/03/2019 service capacity Follow through admission unit Challenges of: requirements Complexity of of CGA from Community discharge
Delayed Discharges Data – CGAO3- % Patients With Length of Stay 7+ Days exc. Perecentage of Patients -10.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 0.0% Percentage of Patients 65+ and 75+ with a Length of Stay 08/01/2018 15/01/2018 22/01/2018 29/01/2018 05/02/2018 12/02/2018 19/02/2018 26/02/2018 05/03/2018 12/03/2018 19/03/2018 7+ Days on Discharge Excluding DDs 26/03/2018 02/04/2018 09/04/2018 16/04/2018 23/04/2018 30/04/2018 07/05/2018 14/05/2018 21/05/2018 28/05/2018 04/06/2018 11/06/2018 Discharge Week Commencing 18/06/2018 25/06/2018 02/07/2018 65+ 09/07/2018 16/07/2018 23/07/2018 30/07/2018 06/08/2018 13/08/2018 20/08/2018 75+ 27/08/2018 03/09/2018 10/09/2018 17/09/2018 24/09/2018 01/10/2018 08/10/2018 15/10/2018 22/10/2018 29/10/2018 05/11/2018 12/11/2018 19/11/2018 26/11/2018 03/12/2018 10/12/2018 Integrated Hub 17/12/2018 24/12/2018 Launched 31/12/2018 07/01/2019 14/01/2019 21/01/2019 28/01/2019 04/02/2019 11/02/2019 18/02/2019 25/02/2019 04/03/2019 11/03/2019 18/03/2019 25/03/2019 admission, 7 day Need to create follow through provide earlier opportunity to intervention, planning and of CGA from working
Data – CGAO4- Average Length of Stay inc. Delayed Discharges Average Length of Stay (Days) 10 15 20 0 5 08/01/2018 15/01/2018 22/01/2018 Average LoS Patients 65+ and 75+ with a Length of Stay 29/01/2018 05/02/2018 12/02/2018 19/02/2018 26/02/2018 05/03/2018 12/03/2018 19/03/2018 26/03/2018 02/04/2018 09/04/2018 16/04/2018 23/04/2018 30/04/2018 07/05/2018 14/05/2018 21/05/2018 7+ days on Discharge 28/05/2018 04/06/2018 11/06/2018 Discharge Week Commencing 18/06/2018 25/06/2018 02/07/2018 09/07/2018 65+ 16/07/2018 23/07/2018 30/07/2018 06/08/2018 13/08/2018 20/08/2018 27/08/2018 75+ 03/09/2018 10/09/2018 17/09/2018 24/09/2018 01/10/2018 08/10/2018 15/10/2018 22/10/2018 29/10/2018 05/11/2018 12/11/2018 19/11/2018 Integrated Hub 26/11/2018 03/12/2018 Launched 10/12/2018 17/12/2018 24/12/2018 31/12/2018 07/01/2019 14/01/2019 21/01/2019 28/01/2019 04/02/2019 11/02/2019 18/02/2019 25/02/2019 04/03/2019 11/03/2019 18/03/2019 25/03/2019 service capacity Follow through admission unit Challenges of: requirements Complexity of of CGA from Community discharge
Data – CGAO4- Average Length of Stay exc. Delayed Discharges Average Length of Stay (Days) 10 12 0 2 4 6 8 08/01/2018 15/01/2018 22/01/2018 29/01/2018 Average LoS of Patients 65+ and 75+ with a Length of 05/02/2018 12/02/2018 19/02/2018 26/02/2018 05/03/2018 12/03/2018 Stay 7+ days on Discharge Excluding DDs 19/03/2018 26/03/2018 02/04/2018 09/04/2018 16/04/2018 23/04/2018 30/04/2018 07/05/2018 14/05/2018 21/05/2018 28/05/2018 04/06/2018 11/06/2018 Discharge Week Commencing 18/06/2018 25/06/2018 02/07/2018 09/07/2018 65+ 16/07/2018 23/07/2018 30/07/2018 06/08/2018 13/08/2018 20/08/2018 27/08/2018 75+ 03/09/2018 10/09/2018 17/09/2018 24/09/2018 01/10/2018 08/10/2018 15/10/2018 22/10/2018 29/10/2018 05/11/2018 12/11/2018 19/11/2018 26/11/2018 03/12/2018 10/12/2018 Integrated Hub 17/12/2018 24/12/2018 Launched 31/12/2018 07/01/2019 14/01/2019 21/01/2019 28/01/2019 04/02/2019 11/02/2019 18/02/2019 25/02/2019 04/03/2019 11/03/2019 18/03/2019 25/03/2019 admission, 7 day Need to create follow through provide earlier opportunity to intervention, planning and of CGA from working
Data – CGAB1- % Patients Readmitted Within 7 Days Percentage of Patients Readmitted Within 7 days 10% 12% 14% 16% 18% 0% 2% 4% 6% 8% 01/01/2018 % Patients 65+ and 75+ Readmitted within 7 days of Discharge 08/01/2018 15/01/2018 22/01/2018 29/01/2018 05/02/2018 12/02/2018 19/02/2018 26/02/2018 05/03/2018 12/03/2018 19/03/2018 26/03/2018 02/04/2018 09/04/2018 16/04/2018 23/04/2018 30/04/2018 07/05/2018 14/05/2018 21/05/2018 28/05/2018 04/06/2018 11/06/2018 Discharge Week Commencing 18/06/2018 25/06/2018 02/07/2018 65+ 09/07/2018 16/07/2018 23/07/2018 30/07/2018 06/08/2018 13/08/2018 75+ 20/08/2018 27/08/2018 03/09/2018 10/09/2018 17/09/2018 24/09/2018 01/10/2018 08/10/2018 15/10/2018 22/10/2018 29/10/2018 05/11/2018 12/11/2018 19/11/2018 26/11/2018 03/12/2018 10/12/2018 17/12/2018 24/12/2018 31/12/2018 07/01/2019 14/01/2019 21/01/2019 28/01/2019 04/02/2019 11/02/2019 18/02/2019 25/02/2019 04/03/2019 11/03/2019 18/03/2019 25/03/2019
Data – CGAB2- % Patients Readmitted Within 30 Days Percentage of Patients Readmitted Within 7 days 10% 15% 20% 25% 30% 0% 5% 01/01/2018 % Patients 65+ and 75+ Readmitted within 30 days of Discharge 08/01/2018 15/01/2018 22/01/2018 29/01/2018 05/02/2018 12/02/2018 19/02/2018 26/02/2018 05/03/2018 12/03/2018 19/03/2018 26/03/2018 02/04/2018 09/04/2018 16/04/2018 23/04/2018 30/04/2018 07/05/2018 14/05/2018 21/05/2018 28/05/2018 04/06/2018 11/06/2018 Discharge Week Commencing 18/06/2018 25/06/2018 02/07/2018 65+ 09/07/2018 16/07/2018 23/07/2018 30/07/2018 06/08/2018 13/08/2018 75+ 20/08/2018 27/08/2018 03/09/2018 10/09/2018 17/09/2018 24/09/2018 01/10/2018 08/10/2018 15/10/2018 22/10/2018 29/10/2018 05/11/2018 12/11/2018 19/11/2018 26/11/2018 03/12/2018 10/12/2018 17/12/2018 24/12/2018 31/12/2018 07/01/2019 14/01/2019 21/01/2019 28/01/2019 04/02/2019 11/02/2019 18/02/2019 25/02/2019 04/03/2019 11/03/2019 18/03/2019 25/03/2019
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