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Helen bessant
- 1. Helen Bessant Clinical Team Leader sandwell.icares@nhs.net @icares_SWBH Integrated Care Services – iCares
- 3. Agenda • Why Own Bed Instead? – national context – local context • What do we do? – service structure / work • How are we doing? – outcomes so far • Where are we going? – future plans
- 5. Context – existing NHS Sandwell services • Sandwell / City Hospitals – Acute • Intermediate Care – two high intensity wards • Intermediate Care – medium intensity 22 beds in two local BUPA homes • Community Services – ICARES / District Nurses / specialist services
- 6. Winter initiatives • Winter pressures • CCG purchased more ‘spot purchased’ beds • Open more IMC beds / flex existing bed stock
- 7. Own Bed Instead ethos
- 8. Own Bed Instead • OBI will provide short term re-enablement in the patient’s own home for people who are medically stable, and have predictable health needs but who consent to rehabilitative support to regain function and confidence
- 9. Own Bed Instead • Hospital • Intermediate Care (IMC) wards • BUPA IMC beds • OWN BED INSTEAD • Community services
- 10. Aims of OBI • Maximise independence • Reduce need for bed provision • Reduce length of stay in any bed • Support timely discharge • Reduce number of people needing long term care • Provide an integrated service at home • Reduce admissions to hospital
- 11. Own Bed Instead Team • Virtual team comprises: • ICARES – physiotherapist and occupational therapist (and project lead for ICARES) • IBEDS – nurse case manager (and project lead for IBEDS) • Social Services (Social Worker, STAR team and lead officer) • Community Alarms (for night support)
- 12. Agewell is - • A membership organisation for individuals aged 50+, professionals and partner organisations • Provide a range of innovative community and home-based interventions: • To re-connect older people with their communities tackling social isolation • To help older people regain their confidence after a fall or to prevent a fall in those at risk • To encourage a proactive approach to ageing so individuals enjoy a happier, healthier and more independent older age
- 13. Agewell Services A Voice for Older People – Consultation & Engagement Capacity to Care - Bespoke Befriending Service - Home Based Exercise - Community Navigator - Edna’ Army working in Sandwell & City Hospitals' Productive Ageing – Community Based Exercise Programme – Health Promotion, Keeping Safe and Well, Self Care. - Future Proof (Planning for the future)
- 14. BEDS TEAM All referral s to be added to S1 - AA unit - OBI triage caseload Allocate a bed & contact JDT (3147) to ensure STAR+ has started Rapid Response Therapy Service (RRTS) / Hospital Wards Identify patient is suitable Alert beds team – is there a free bed? Negotiate suitable community alternatives if not Complete OBI referral form STEP UP - iCares AA Identify patient is suitable Alert beds team – is there a free bed? IMC Step Down Identify patient is suitable & this is planned as part of discharge Complete OBI referral form Own Bed Instead Pathway
- 15. OBI Criteria for Admission Service Specification outlines: • 10 beds – Sandwell, 10 beds – Birmingham • 7/7 • 4 weeks ‘admission’ • Medically stable with predictable needs • Consent to rehab approach • Sandwell resident • Safe environment
- 16. What do we do? • IBEDS team co-ordinates admission • STAR services / night support starts immediately • Therapists visit and commence intensive, tailored programme • Nurse visit for basic nursing assessment • Weekly team meeting to review goals / aims
- 17. Case study - ‘Madge’ • OBI: 27-Dec-2014 – 28-Jan-2015 • Age: 84 years old • Referral from: Stroke team • Previous level of function: fully independent with mobility, transfers and ADLs • Rehab journey • Outcome
- 19. Outcomes : Reason for Admission 0 2 4 6 8 10 12 14 16 18 20 Number
- 20. Referrals and Admissions Referrals (75) Admitted (54)
- 22. Needs on Discharge Increased (9) Reduced (6) Maintained (3) None (13)
- 24. Patient Satisfaction Score < 69% (2) > 70% (18)
- 25. Patient Comments • ‘I couldn’t fault the service’ • ‘We couldn’t have had it better’ • ‘You provide a very good service’ • ‘I felt I was treated very well’ • ‘The staff were all very friendly’
- 26. Outcomes • Length of stay – average 25 days X X X X X X
- 27. Progress so far • KPIs added to SystmOne as questionnaire • Spreadsheet created for length of stay • Nurse has been released from IBEDS • Two therapists have made 7 day working work
- 28. Benefits for patients • Seamless service • Services can be flexed up/ down depending on patient need • Service has been appreciated by the patients • Hospital admission is avoided
- 29. Benefits for the service • Less re-admissions than other IMC bases • Reduced length of stay than in IMC beds • Virtual ward concept works even in complex environment • New model of a reducing therapy intensity seems to lead to good outcomes
- 30. Next Steps • Pilot continuing to February 2016 • Recruitment of band 6 OT and PT and band 3 rehab support worker • Formal evaluation underway • Ensure questionnaire S1 is bedded in for KPIs • Continue with patient questionnaires on discharge • Decommission IMC beds as contracts come up for renewal • OBI will be permanent feature of Sandwell health economy • Improve the patient leaflet
- 32. Questions? • Your thoughts, comments, questions? • Any experiences of similar schemes?
Editor's Notes
- Introduce self and service – good news pilot in NHS
- ICARES – combination of teams/ services
- Here is Sandwell in closer detail Made up of 6 distinct towns each with their own personalities 320,000 population within about 30 square miles Sandwell is a real mix of deprivation and open spaces and some challenging modern architecture 60% of the population live in deprivation with 30% of children living in poverty You can expect to die younger than the national average 21% of the population rate themselves as having a long term illness Sandwell doesn't have a hospice building – a virtual team People don't tend to travel between the towns but rather out to neighbouring shopping areas
- Structure to meet medical and rehab needs of Sandwell
- News of winter pressures – see Daily Mail cutting March 23 2015 So what has been commissioned previously to meet winter’s bed demands? Purchase of Spot Purchased beds – risk of random purchase so pts are lost in the system with no support (tho locum staff were recruited to manage these beds, AND it depleted the bed stock accessible for the normal flow of pts into permanent 24 hour care = system silted up with delayed transfers of care)
- So what can we do to make our services less dependent on creaking structures and flexible to meet their specific needs?
- An audit of 145 IMC commissioned beds in Sandwell and W B’ham in Sept 2014 – identified 26% pt could have gone home if extra services were available to them – so commissioners started work on developing a model to provide those services – to go home to ‘their own bed’ with additional support = ‘own bed instead’ of nhs bed Definition – short term, in own home, rehab model
- So where does OBI fit into the health economy in Sandwell……………………? Designed to meet needs of patients with less intensive needs………………………..
- ……….so what are we aiming to achieve? OBI is achieving many aims simultaneously!
- The MDT is complex and cross agency – and this is the exciting element of OBI…………….! NHS - ICARES and IBEDS (ie integrated beds)are in community group (ie directorate) in Sandwell and W B’ham Hospital but have separate managers Social Services = Sandwell Assist - STAR = Short Term Assessment and Re-enabling service = local Social Services home care with rehab approach Night support co-ordinated by Sandwell Alarms, with Sevacare agency managing for the calls out of hours
- And out most recent addition, not planned in the original service spec is the link with voluntary agencies with Agewell…………………
- ………………….see paper clipping of Edna and her army!
- What is the process then to ‘admit’ someone to OBI……………here is the pathway showing processes involved to ‘step up’ and ‘step down’ - ie admit from hospital or bed, or keep them in their own home – again showing its complexities……………..
- ……………………..so who is eligible to be admitted…………..? Remember Sandwell and West B’ham Hospitals (x3) encompasses Sandwell and West B’ham – I’m outlining Sandwell’s OBI – B’ham has different system – we all need to work to the same KPIs 7/7 – strictly time limited – motivated pts. Bearing in mind the info earlier on the type of area Sandwell is – ‘safe environment’ has been a challenge on occasion
- What does the team actually do? Normally therapy input is swifter than the 3 day standard (OT/PT – x2 locums for the pilot which was originally Nov- April) – Nurse support is improving but has been subject to staffing problems in IBEDs who co-ordinate all pts to rehab beds Prior to project starting, an audit was done across all IMC beds – night support was seen as key BUT this has not been the deal breaker for safe admission – very few have needed this support (There has been a role for it for urgent step-up cases where IMC bed is not availble ‘til the following day and has prevented admission) Role of therapy is to provide intensive support which can start at several calls a week (more than the routine community service can provide) but on a sliding/ reducing scale
- MADGE CORBETT – patient journey on OBI Date admitted onto OBI: 27.12.2014 Date discharged from OBI: 28.01.2015 Number of face to face contacts: 19 Age: 84 years old Referral from: ESD – stroke team, OT Reason for referral: left cerebellar infarct 09.12.2014, admitted to Russells Hall Hospital. Discharged home 20.12.2014 referred to ESD. On assessment patient needed assistance of 1 for bed transfers, mobile 5m with RF, assistance of 1 to strip wash. No POC set up on discharge, ESD could not get access to Fast Response, therefore, referred to OBI for STAR POC and ongoing therapy. Previous level of function: fully independent with mobility, transfers and ADL’s Rehab journey: ability at the start of OBI: Transfers: - chair transfers: independent bed transfers: supervision with bed lever as patient tends to sit in the middle of the bed and slips off the bed toilet transfers: not currently using due to decreased space in the toilet to accommodate the RF, therefore, using the commode independently Personal care – washing: assistance of 1 from carers with strip wash using a bowl dressing: assistance of 1 from carers, especially with lower half Domestic activities – meal and drink preparation: assistance from carers and family as patient too fatigue to complete tasks medication: supervision from carers housework and laundry: family assist shopping: son Mobility: - able to manage 2 metres with RF with close supervision of 1 due to fatigue staying upstairs and not using stairlift, has to negotiate x1 step at top of staircase Physio input: strengthening exercise for UL and LL – HEP, theraband, putty High back chair provided for bedroom to encourage to sit out of bed Mobility practice OT input: Mobility practise due to function Personal care practise Meal and drink preparation practise – graded due to fatigue Transfer practise Step practise at top of stairlift Order newell post rail to assist with this Fatigue management Fix kitchen step STAR input: X2 daily POC initially, increased to x3 daily by physio Progress: 30.12.2014 – coming downstairs to sit in living room 04.01.2015 – mobilising from living room to kitchen with 2 rest stops 06.01.2015 – high backed chair to be collected as now sitting downstairs - mobilised living room to kitchen with 1 rest stop - made hot drink with all items made ready by OT - cancelled lunchtime call 08.01.2015 – exercises and mobility practice - ordered 2 narrow RF due to limited space in the property 09.01.2015 – practised with quadrupod, to use in therapy only 10.01.2015 - exercises and further practise with the quadrupod 12.01.2015 - further practise with quadrupod 13.01.2015 - further practise with quadrupod 17.01.2015 - walked from living room to kitchen with no rest stops - kitchen practise: independent making hot drink - MOWs started 19.01.2015 - patient independently dusting living room - independent with strip wash at sink and dressing - kitchen practise: independent with hot drink and washing up - raised toilet seat issued - AM and PM care call cancelled 21.01.2015 - collection of commode as no longer using, independent with toilet transfer - kitchen practise – independent with sandwich and hot drink 22.01.2015 - quadrupod practise 23.01.2015 - balance exercises and quadrupod practise 24.01.2015 - outdoor mobility assessment 25.01.2015 - outdoor mobility practise 26.01.2015 - independent with hot drink and sandwich preparation 27.01.2015 - outdoor mobility practise Discharge summary: Stairlift and step – independent Transfers – independent with all transfers Mobility – independent with quadrupod indoors, supervision outdoors Personal care – independent with strip washing at the sink and dressing Domestic activities – independent with hot drink and sandwich Independent with light housework Onward referrals - Agewell - rails at the front door step - rail on the path - exercise groups
- Own Bed Instead Reason for Admission – November 2014– 24 April 2015 (so couple of weeks ago) Stats are from April’s report to end April 2015 Rehab with fracture - 10 Rehab without fracture - Collapsed vertebrae, low back pain, RA flare-up - 4 Fall - 14 Debilitation due to infection - COPD, gout, Lower Respiratory Tract Infection, sepsis, ulcers, pneumonia, increased SOB, bronchiectasis, cellulitis - 19 Social Admission – really pleased about this as OBI is not for ‘social’ reasons – there are other services for this Other with description - CVA symptoms, lymphoma, collapse - 4
- Length of stay – just under 25 days Approx 20% step up
- Apparently this level of readmission is less than in other IMC beds and a couple of folk actually came back to OBI
- Really good news on the amount of service input needed (ie care package) on leaving OBI – 19 = reduced or needing no support ……………….even ‘3 maintained’ is success after medical crisis
- Community Offer is the scheme ‘Agewell’ is working under for OBI – this is also a pilot scheme whereby Better Fund money has been given to x6 pilot areas, to support voluntary organisations working together to achieve same aims as NHS (eg reduced falls, reduced hospital admissions, increased socialisation)…………………….not everyone needs services at home, eg 1:1 work on balance, befriending. Community offer – not all pts are appropriate for their services – work with Agewell for OBI has included one off eqt eg adapted toilet, carpet, Postural Stability 1:1 at home, befriending, link with CARES/ Crossroads to train carers in skills to care safely for pts It can support ICARES/ OBI to discharge safely as there is follow-up but outside SS and NHS
- Disappointing response to pt questionnaires – started with follow-up phone call but learned this was not effective – need to complete one F:F with pt on final therapy visit – assists pt to know a process has finished too Pt questionnaires – friends and family test – would you recommend this service to your friends and family? - Show copy of questionnaire
- Free-text comments from patients on the questionnaires
- Step up – higher % than my experience in IMC – but works well with the Admission Avoidance ICARES team – direct and priority access to OBI/ beds, especially out of hours
- So how else have we been progressing - Keeping good , accurate paper info has been key Key Performance Indicators have formed part of weekly MDT but are onerous – we have just created questionnaire for S1 to allow inputting of data on admission, during the admission and on discharge – and easy reporting monthly New spreadsheet is being developed as well
- Seamless for pt who want to remain in their own home with services around them to meet their own needs Flexible services to adapt to meet patient’s needs
- So what does the future hold? Pilot continuing until Feb 2016 - although RSW (ie support worker) was requested in original bid, it was not allowed as bids had to be trimmed – an RSW will make the therapy input more efficient and able to cover 7/7 more comfortably as we move to permanent staff from agency Patient leaflet is being improved Commissioning to reduce IMC beds and support ongoing OBI
- Active older age in local population……………………….