St Helens Health and Adult Social Care Overview and Scrutiny Panel Winter Plan Briefing Caroline Lees, Assistant Director, Urgent, Planned and Community Health, St Helens CCG 10 th September 2018
Local context CCG CCG CCG CCG St Helens Southport Warrington Halton Aintree CCG CCG CCG CCG Whiston Royal CCG CCG CCG CCG Liverpool
Lessons learnt – System Urgent Care Operational Group 12th April 2018 • Winter Debrief exercise reviewed 8 components • Staffing – Demand – ‘other’ planned resources – Initiatives – Pathways – Escalation – Communication – Organisations: • STHK Trust – WHH – NWB – Community services (DNs, CMs, SPA, WIC/UCCs, IC) – LA, social care hospital and community teams, Care Homes and reablement – Primary care in and out of hours – North West Ambulance Service – Patient Transport Service – NHS 111 –
Lessons learnt – System Staffing: This years actions: Services felt prepared and planned • against demand across the sectors Explore opportunities for shared rotas • Matron led safer staffing reviews • for ED across community / Trust Specialist staff to support escalation • Alternative to agency – Direct • areas recruitment e.g. GP in ED. Earlier booking of agency. • Challenges: Increasing recruitment ahead of winter • (reablement / ED). 16 additional staff to Stretched GP provision supporting • date across St Helens & Halton multiple demands A&E specialty in-reach is a job planned • Sickness / Vacancies/ Annual leave • and resourced activity management Bed occupancy planning (step up step • Agency issues • down). Increase in acuity reduced resilience and • capacity Staffing in care home and domiciliary • care sectors / intermediate care varied across the patch Unforeseen demand e.g. Christmas Day • Staffing escalation areas •
Lessons learnt – System Demand: This years actions • • Higher attendances than previously known – Increase AEC capacity Acute and – (e.g.400+ at SHK), not foreseen Community – standard approach, IV Community v Trust pressures, e.g. IV (can limit – (DVT and cellulitis pathway priorities, in-reach potential for admissions avoidance) Flu/pneumonia/respiratory; GP referrals – UTI/dehydration) PTS supporting more on the day referrals – Front door streaming (ECIP) project – (needs planning for this year) PTS advanced planning in 18/19 Increase NWAS calls but less conveyance – – Decrease in 111 dispositions to ED (linked to NWAS increase in clinical call handlers – – CAS) Paediatrics – Increase in demand for on the day discharges – Capacity and Demand Review (Venn) – and larger % of urgent referrals Step up / down capacity (see plan) High number of Flu cases – – Planned escalation not always enough to cope System review of EMI capacity – – Good system effort around DTOC End of Life and advanced care planning – – Increased acuity reported – Recommendations: • High demand for EMI care homes and POC – Understanding 7 day service priorities / re- – profiling rotas and service provision potential (UCOG project)
Lessons learnt – System Initiatives: This years actions • • /recommendations: – Ambulance Response Programme (ARP) ARP Improvement Plan in place – ED front door Streaming review led – Primary Care Streaming in A&E – by ED Clinical Director – PTS Admissions Avoidance Car – broaden – – Admissions Avoidance Car reach? – Additional Re-ablement Can we have Hub and Spoke Model – around in-reach to support all areas? supporting DTOCs/POC Case Management of Care Home – MADE/SAFER Start – Admissions with MDT – NWB – Clinical Bed Managers has ‘Step up’ capacity is a priority – improved discharge and flow ED in-reach resourced effectively – – Winter Funding Initiatives (GP in WIC, Paeds, etc) – Community Response / Enhanced Care Home Service in- reach well received
Summary Debrief Lessons learnt – System Pathways: This years actions : • • – Ultrasound Pathway works well – Clear Communication of Pathway and service changes to internal / – Children’s Croup PW at WIC external teams – Direct Reablement Referrals Ambulatory Emergency Care / worked well – Further work on Single Point of – Trusted Assessor Models Access / Direct referrals where – Good comms on discharge possible to avoid delays pathways – Trusted Assessor Models – wider – Good engagement from external roll out underway partners – DTOC ongoing / stranded – Early issues adjusting to IASH patients process
Lessons learnt – Acute Winter Planning Workshop (February 2018) • Following questions where asked : • What went well? • What didn’t go well? • What could we implement next year? • An action plan was developed and themes identified to take forward improvements • The actions have been aligned to 10 Patient flows and ECIP Concordat workstreams
No Theme/Programme 10 Patient Flow Principles 1Admission Avoidance Admission, transfer, discharge 2Bed Management - Outliers project Specialities 3Bed Management - Winter Plan Emergency Departments/ Specialities Acute Medical Units, Ambulatory Emergency Care, Ambulance Handovers ECIP Concordat Admission, transfer, discharge, Specialities Emergency Departments, Primary Care Streaming, 4 Frailty 5Education and training Specialities 6Medway Developments Emergency Departments 7Winter Plan - Safer start Emergency Departments/ Specialities 8Winter Plan - Elective Activity Specialities Acute Medical Units, Ambulatory Emergency Care, Ambulance Handovers Admission, transfer, discharge, Specialities Emergency Departments, Primary Care Streaming, 9Workforce Planning - all year Frailty 10Workforce Planning - Winter Emergency Departments/ Specialities 11Workforce Planning -Nursing new model of care Specialities 12Emergency Planning Emergency Departments/ Specialities St Helens Cares Therapies Project (Urgent Care Work 13 stream) Specialities 14Discharge Planning Admission, transfer, discharge
Logic model: Improving Patient Flow Patient Outputs Outcomes ECIP Impacts Flow Concordat Attendan Current Capacity and Demand All patients will be triaged within Improvem Profile ce/ Workstream 15 minutes of arrival Review of Streaming ent areas admissio Ambulance opportunities and redesign Patients seen by a clinical decision- 1. ED Capacity n Making Handovers process/model maker within 60 minutes (1 hour) things and Demand Standardised Process for Fit to Sit of arrival better for Primary ambulance arrivals 30% of the 'daily take' are sent to patients Care 0-4+ days Length of stay analysis AEC Streaming by condition 100% patients sent to AEC will be Emergency Capacity and Demand analysis of initially assessed within 15 Reduce resource within AEC Department minutes of arrival delays in New model/pathway designed s the NEL 100% patients sent to AEC will be 2. Increase patient Utilisation & Workforce Plan medically assessed within 60 Ambulatory pathway developed AEC minutes of arrival Reduce medical outliers on Emergency Opportunities SAFER Care Bundle refreshed surgical wards Care/ Acute across all 14 medical wards 100% patients with Length of stay Improved 3. Hospital Assessment less than or equal to 48hrs on Board Round and Huddles in 5 Star s Flow & Patient AMU place Patient Pathways Visual Control (Red2Green) in Care Reduce average time to bed Specialities place allocation 4. Stranded Review Team in place Reduce average time of wait for Patient 95% of Admission, Standard Operating procedure patient to be moved Process Patients Transfer, produced, testes and finalised transferred, Increase average daily discharges Discharge discharged Programme of Stranded Patient in total/ pre midday/pre 10am 5. Clinical or admitted Reviews rolled out Achieve 92% bed occupancy Criteria for Dischar within 4hrs Analysis of length of stay by Frailty of arrival Discharge ge speciality and condition Reduce % Delayed Transfers of care Roll out plan for early adopters Mental Reduce Number of Patients with Evaluation of CCDs undertaken Health average length of stay > 7 days CCDs rolled out to broader specialities
Winter plan 18/19 Areas to address for urgent and emergency care: NHS England directives. Realistic capacity planning (significant focus upon the Acute Sector) • Reducing hospital length of stay and ‘super stranded’ patients, to reduce patient harm and • bed occupancy The national ambition is to lower bed occupancy by reducing the number of long stay patients (and long stay – bed days) in acute hospitals by 25% Ensure delayed transfers of care are not more than 3.5% – Delivery a bed occupancy rate of 92% – Zero tolerance of minors breaches • Managing Monday Surge (Acute Focus) • Eliminating corridor care • Timely ambulance handovers • Continued focus on Urgent and Emergency Care transformation •
Winter plan 18/19 • Creating more capacity – Demand and capacity planning needs to have been conducted and tested before the end of October (Venn) – Commission additional home-care packages now to support ‘discharge to assess’
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