## Adult Services Pathway Transformation

Mark Lobban, Director of Commissioning  Social Care, Health and Wellbeing, KCC Steven Phillips, Director, Newton

## Transformation (Approach) Transformation (Phasing) Transformation (Phasing) Transformation (Phasing) What The Work Looked At

realise a 5-15% improvement within each wave of 

## Findings Can Patients Arriving At A&E Be Treated Elsewhere?

Mr F, 72:
•
A gentleman with a known history of falls, has fallen for the 4th time and hurt his back - no 
preventative falls service has been provided to this point

## Could Preventative Support Have Been Provided Prior To Attendance? Findings Could The Treatment Provided In Hospital Be Provided Outside Of The Hospital For Any Patients?

Mrs V, 88:
•
A lady ready to leave hospital after 9 days, delayed for a further 28 days (so far) whilst
agreement is sought over the funding arrangements for her Nursing home. Acquired
pneumonia in hospital

## Findings When Patients Are Discharged From The Hospital, Are The Correct Options Available And Selected?

Mr G, 81:
•
IDT correctly planned to discharge patient into a community hospital bed with physical
therapy - no capacity available. Then discharged to a basic short term bed by the Ward without therapy and Mr G eventually ended up in a residential home

## For Sus Referred To Social Services, Are The Correct Options Available And Routinely Accessed?

| Attendance   | Admission   | Location   | Discharge & Social Care   |
|--------------|-------------|------------|---------------------------|
20%
44%

## Findings Community Nurse (Band 6) Quotes On Work They Are Doing: Is There Opportunity To Better Coordinate Services For Citizens Receiving Both Community Nursing And Social Care Provisions?

"The specialist diabetes nurses used to train residential staff to deliver insulin - that doesn't happen anymore and we do the work"

## Are Packages Of Care Appropriate In Community Nursing?

"Of course [low level wounds] could be managed by Care workers"

| Attendance   | Admission    | Location   | Discharge & Social Care   |
|--------------|--------------|------------|---------------------------|
| 35%          | 36%          | 20%        | 44%                       |
| DN not Req.  | DN Skill Mix |            |                           |
| 26%          | 30%          |            |                           |

## Findings Summary Of Where The System Benefit Arises

% case notes reviewed 
% of total financial 
where a pathway 
Averages across areas
savings identified 
improvement was 
attributable to this area
identified
ED attendances
35%
3%
ED admissions
36%
42%
Acute settings of care 
20%
21%
44%
17%
Acute discharge and local authority intake (together)
56%
12%
Community nursing (overlap with LA provision and correct work/skill mix) CCG Commissioning
4%
Total
41%
100%

*Note for the financial modelling confidence weightings have been applied to the total opportunities identified based on practitioner input and Newton delivery experience. Additionally variable costs of alternative pathways have been modelled. These confidence factors vary between 10% 
and 75%.

## Key Messages

•
By focussing on the correct care pathway for citizens, significant patient / service user and financial benefit can 
be realised (~7-10% of budget assessed)
•
Opportunities are driven by a variation in front line decision making
•
The findings have identified two main areas where resources could be saved:
–
Avoidance of admissions to acute hospitals
–
Discharge planning, whilst maximising independent outcomes
–
Redeploying community nursing resource is a priority to realise the whole system opportunity

## Key Messages

•
By focussing on the correct care pathway for citizens, significant patient / service user and financial benefit can 
be realised (~7-10% of budget assessed)
•
Opportunities are driven by a variation in front line decision making
•
The findings have identified two main areas where resources could be saved:
–
Avoidance of admissions to acute hospitals
–
Discharge planning, whilst maximising independent outcomes
–
Redeploying community nursing resource is a priority to realise the whole system opportunity

## Case Example - Acute Demand Case Example - Acute Demand Case Example - Acute Demand Case Example - Acute Demand Case Example - Acute Demand Case Example - Acute Demand

1
1
1
1
2
1
2
2
1
1
Care Navigator
1
2
1
1
1
1
1
Carers Assessment
1
2
1
2
1
1

## Preventative

Families / Unpaid Carer
1
1
1
1
1
1
Postural Stability Clinic
2
1
2
2
1
1
1
Specialist Services
1
2
2
2
1
1
1
0 Hour GP Services
1
1
1
1
1
1
1
Advocate Services
1
2
1
2
1
1
1
Community Geriatrician
1
1
1
2
1
1
1
Multidisciplinary Meeting
1
1
1
1
1
1
1
Equipment Support
2
2
1
1
1
1
House Clearance
2
1
1
2
1
1
Kent Enablement Service
1
1
1
1
1
1
1
Learning Disabilities Team
1
1
2
1
1
1
1
Mental Capacity Act
1
1
1
1
1
1
1
Occupational Therapist Clinics
1
1
2
2
1
2
2
2
1
1
2
1
1
2
Occupational Therapist Technician Psychiatric Liaison
1
1
1
1
1
1
1
Re-ablement Beds
1
1
1
1
1
1
1
Telecare
1
1
2
1
1
1
1
Ambulatory Care Pathways
1
1
1
1
1
1
2
Coastal Beds
2
2
1
1
1
1
1
Community Matrons
1
1
1
1
1
1
1
Community Pharmacy
1
1
2
2
2
1
1
Day Centre
1
1
1
1
1
1
1
Day Hospital
1
1
2
1
1
1
1
District Nurses
1
1
1
1
1
1
1
Domestic Violence Support
1
1
2
1
1
1
1
Early Supported Discharge
1
1
1
2
1
1
1
Fast Track
1
1
1
1
1
1
1
1
1
1
2
1
1
1
Health and Social Care Village 

## Community Bed

Home Self Management
1
1
1
1
1
1
1

## Or At Home

Home with ICT
1
1
1
1
1
1
1
Home with Care Package
1
1
1
1
1
1
1
Hospice
1
1
1
1
1
1
1
Integrated Care Centre
1
1
1
1
2
1
1
KMPT Mental Health Services
1
1
1
1
1
1
1
Outpatients Physio
1
1
2
1
1
1
2
Post ITU Rehab
1
1
2
2
1
1
1
Red Cross
1
1
1
1
1
1
1
Social Services
1
1
1
1
1
1
1
Specialist Nurses
1
1
1
1
1
1
1
Stepdown Bed
1
1
1
1
1
1
1
Continuing Health Care
1
1
1
1
1
1
1
KCC Care Home
1
1
1
1
1
1
1
NHS Care Home
1
1
1
1
1
1
1

## Residential/

Nursing Home
1
1
1
1
1
1
1
Private Care Home
1
1
1
1
1
1
1

## Nursing

Residential Care
1
1
1
1
1
1
1
Specialist Placement
1
2
1
2
1
1
1

Ward Staff Team Leader:
"I don't know half of what's on there, the girls on the ward don't stand a chance"
Matron:
"Were all talking different languages and patients are totally confused"
Pathway Team Manager:
"Social Care can often only share previous care package details verbally and not in print, thus picking the most appropriate care is made far harder."
It is not expected that every professional would know every service, but it is clear that the ward staff are not the best people to discuss postacute services with the citizen and their family System needs to be designed so that the correct option is the easiest option

Vision: "A united team having open discussions to achieve the best outcomes for patients in a timely manner"
KCC Hospital Team Acute Hospital
2

- The progress of each case is tracked and each client on 
the board is discussed at the daily washup meeting
- Meeting focuses on how to get each client home safely - Promotes peer review and ensures senior support as 
required
Feedback from WHH team:
"The new process provides more support for us"
"It's changed the way we think"
"Makes us work more similarly and be more consistent in the way we work"

Improving the decision making process and availability of alternative services (e.g. 

Hilton recovery service) has helped to dramatically reduce the number of inappropriate STB & LTB placements Integral to this improvement has been a change of culture, processes, practice and awareness of performance. This has now been rolled out across the 7 Acute hospitals in Kent with excellent results

"The daily wash-up process provides us with a mechanism to ensure we are applying an evidence-based method of approaching cases and achieve the best outcome for service users"54%
Figures correct as of Apr '16

## Change Model

Each example of best practice observed during the review had followed a broadly consistent approach to implementing the change, highlighting the importance of the change model 

1.
Identifies, quantifies, and prioritises the opportunity
2.
Set up for success
3.
Top down alignment: Aligns the work with each organisation's vision and incentives
4.
Bottom up change: Co-designs solutions with front line users
5.
Measures the performance
6.
Tests the solutions in a live area, then redesigns and iterates as required
7.
Standardises the new approach and only then rolls out at scale in implementation
8.
Rationalises the subsequent menu of service and removes superseded options

## Have We Been Successful?

All Long Term Care Home Placements