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Councillors and committees

Agenda item

Delayed Transfers of Care/ Enablement and ACT Team

Report of the Strategic Director, Care, Wellbeing and Learning

Minutes:

The OSC received a report and presentation advising them of progress to date to reduce hospital discharge delays, an update on the in house Enablement Service and the new Achieving Change Together team and its remit.

 

Three targets were set for the delayed transfers of care for Gateshead by the Government, they are:

 

·         An overall transfer target that delays do not exceed an average more than 8.2 per day per 100,000

·         NHS transfers do not exceed an average more than 5.6 per day per 100,000

·         Social Care transfers do not exceed an average more than 2.6 per day per 100,000

 

The latest data available is as at November 2017; the data is published monthly but is always two months behind. The latest data shows considerable progress across all three targets, with each target being exceeded. Specifically the latest figures for:

 

·         All delays are 3.67 well below the target of 8.2. This has improved significantly on the same point from last year (13.04)

·         NHS delays are 3.93, well below the target of 5.6. This has improved on the same period last year (6.29)

·         Social Care delays are 1.24, well below the target of 2.6. This is a significant improvement on the same period last year (6.42)

 

If this data is looked at in terms of being a number of people, the rates per 100,000 would equate to (rounded to the nearest whole number)

 

·         For overall delays; approximately 6 people on average per day. The target requirement was fewer than (approximately) 13 people on average per day.

·         For NHS delays; approximately 4 people on average delayed per day. The target requirement was fewer than (approximately) 9 people on average per day.

·         For Social Care delays; approximately 2 people on average delayed per day. The target requirement was fewer than (approximately) 4 people on average per day.

 

The OSC were advised that the following key areas that have aided improvement in reducing delays are outlined as follows:-

 

Social care

 

A long established social work assessment team are based at the QE hospital, and in the last year the team structure and focus have been reviewed to ensure that resources are being used to their maximum benefit, with the team now only focussing on discharges.

 

Emergency Residential/Nursing Care Trusted Assessor

 

The OSC were advised that the Council does not have many problems in accessing Residential and Nursing Care homes beds at short notice and can normally get an admission, once assessed, within 48 hours.

 

At present, before an admission takes place, the registered manager or the responsible officer at the care home must carry out an assessment at the hospital. This is to ensure that the home can manage the persons’ needs and have the right levels of staff available. However this can delay admission into the care home.

 

As part of the winter planning for 2018 it was highlighted that there may be a need at some point in the winter period to transfer people from hospital with a long term care need into a residential/nursing care within a very short timescale.

 

All thirty care homes were invited to be included in an emergency trusted assessor model, where at a time of crises, homes would accept referrals based on the assessment of the Council Officer and would agree to take the admission as soon as possible; with the aim of two hours if possible. Referrals can be made seven days per week including out of hours if required. A total of eighteen homes agreed to be included if required with these homes having around ninety vacancies that could be used as and when needed.

 

The OSC were advised, that there had not been a need to use this approach but it is available should it be required.

 

Bridging Service

 

The Committee were advised that one of the main reasons for delayed discharges was people waiting for a long term package of home care to start in the community. Due to the workforce issues the home care market is facing, not only in Gateshead but the rest of the country, providers don’t always have the resources to enable packages to start as soon as someone is ready to leave hospital.

 

To enable people to leave hospital as soon as they were ready for discharge, it was agreed to pilot over a three month period a new approach with the independent sector providers. They agreed to have a small team of salaried staff who will deliver support to enable people with a long term care needs to be discharged and receive support for a short period of time whilst waiting a long term package of care.

 

The OSC were advised that the Pilot was evaluated and overall proved very successful. It enabled over 50 people to return home on the day they were fit to leave hospital. The overall satisfaction from service users and their families was really high with the vast majority rating the service good to excellent.

 

The Council agree that the service was required all year round and have commissioned the service with three providers (Clece Care, Comfort Call and Dale Care) from September 2017 to March 2019.Over 100 people have been supported within the first three months since the service has been reintroduced with the majority moving to a long term package within two weeks of receiving the bridging service.

 

The OSC also received an update on the Enablement service and the Achieving Change Together (ACT) team and on the joint work between CCG/Trust/Council has also assisted in reducing reported delays.

 

RESOLVED -

i)

That the information be noted

 

ii)

The OSC were satisfied with progress so far and the future plans in place to continue to work towards reducing Delayed Transfers of Care

 

iii)

The OSC endorsed the continued work of Enablement including the new services being provided

 

iv)

The OSC noted the development of the Achieving Change Together team

 

 

 

 

 

                                                 

 

Supporting documents:

 

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