The document introduces the Later Life Project toolkit, which was developed to help improve care for the elderly population in the UK. It consists of six phases and has produced three main outputs, including an online toolkit built on an eight-stage care pathway workforce planning approach. The toolkit aims to improve standard care pathways by considering workforce skills, competencies, and requirements. It has been tested in Cambridgeshire and is being implemented in South London and Lincolnshire. The toolkit helps map and analyze workforce, identify bottlenecks, conduct gap analyses, and model scenarios to improve patient flow, reduce duplication, and achieve cost savings.

1. THE CFWI CARE PATHWAYS TOOLKIT:
An introduction to the tool and its benefits
IHWC conference – May 2013
Meena Mahil
The CfWI produces quality intelligence to inform better workforce
planning that improves people’s lives

2. The complex needs of the ageing
population are amongst the greatest
challenges facing the health and social
care system.
The Later Life Project focuses on
identifying and analysing the workforce
implications of this scenario. We have
developed a toolkit to assist workforce
and service planners in planning across
an integrated care pathway.
What is the Later Life Project?
The population of the UK is ageing. In thirty years time, a
quarter of the population is projected to be aged 65 and over.
2

3. The later life project was developed to help improve the care
received by the elderly. It consists of six phases.
What is the Later Life Project?
Interim report
identified the
scale of
potential
benefits and
the broad
implementatio
n themes
Report
documenting
potential
benefits in
more detail,
and provided
narrative
around the
workforce
Intelligence
report
Draft online
care pathway
toolkit
Guidance for
NHS planners
Interim care
pathway
toolkit
Toolkit testing
and refining
Develop case
study
User
acceptance
testing and
benefits
evaluation
Public launch
of care
pathway
toolkit
Ongoing
benefits
evaluation
PHASE 1 PHASE 2 PHASE 3 PHASE 4 PHASE 5 PHASE 6
SEP 2010 –
DEC 2010
JAN 2011 FEB 2011 –
JUN 2011
JUL 2011 -
NOV 2011
DEC 2011 –
MAR 2012
APR 2012 -
ONWARDS
CAMBRIDGESHIRE
LINCOLNSHIRE
SOUTH LONDON
3

4. The project has produced three main outputs:
What is the Later Life Project?
Jun 2011
Report exploring the
workforce that supports
care for older people.
Focus on integrated
models of care.
Nov 2011
Report detailing the
testing of CfWI toolkit in
the Cambridgeshire health
and social care system.
Nov 2011
Online toolkit built on eight
stage care pathway
workforce planning
approach. Final version to
be released Mar 2012.
4

5. The care pathways toolkit is an online resource designed to
support workforce planning across organisational boundaries.
The toolkit consists of eight stages
composing of19 individual steps.
Each stage contains a series of
tools and templates designed to
identify the care pathway, the
workforce skills required, and how
these might be deployed differently
to remove blockages impeding
better care.
What is the care pathways toolkit?
5

6. The tools and templates within the toolkit are simple to use.
What is the care pathways toolkit?
We have also produced an illustrative
guide to the toolkit, which sets out what
each stage tries to achieve and what tools
and templates are required to be
completed.
It is recommended that the eight stages
are carried out in order. However, the
stages have been designed so that it is
possible to complete them independently
of each other, as might suit the specific
needs of a site.
6

7. The toolkit was originally developed to improve older people‟s
services. However, it can be applied to any pathway.
What is the care pathways toolkit
An integrated discharge care pathway
was chosen because it relies heavily on
integration between health, social care
and the third sector. Complex discharges
are also often seen in later life care.
We developed and tested the toolkit in
Cambridgeshire, and it is currently being
implemented in South London and
Lincolnshire.
7

8. The toolkit aims to improve the standard care pathways
approach by taking into consideration the skills, competencies
and requirements of the workforce.
How can the toolkit help?
It helps organisations to:
 map and analyse workforce along
a care pathway
 identify workforce blockages
 conduct gap analyses
 model different pathway
scenarios.
8

9. How can the toolkit help?
In Cambridgeshire, we identified that the assessment process
was a significant reason for delays. Following the toolkit, it was
found that some assessments could be done in the community.
This would improve patient flow in the acute setting, and
remove duplication.
9
From this, the toolkit has evidenced potential savings,
purely from workforce cost. Other savings are also likely to
be made, from reduced administration and reduced length of
stay.

10. How can the toolkit help?
10
“The toolkit is useful as whole system,
reviewing the pathways and interfaces
between them. This has given us a
wealth of information from all partners’
perspectives.”
Catherine Mitchell, Director of Integrated
Commissioning, NHS Cambridgeshire
“We are confident the CfWI’s toolkit will help us to develop
our new integrated community teams and reduce
duplication in activity across organisations.”
Sarah Button, Service Improvement Manager, NHS
Lincolnshire

11. Examples from
Cambridgeshire
11

12. Priorities
12
Priorities Weightin
g
Reduce number of delayed discharges 1-5
Increase patient/service user satisfaction of the discharge
process
1-5
Make cost savings by making better use of resources 1-5
Increase cross organisational working 1-5
Reduce the average length of stay, especially for complex,
longer stays
1-5
Increase staff satisfaction 1-5
The weightings have been chosen by CFWI based on
knowledge of the discharge planning team obtained
from reading background information, speaking to
staff and understanding the different priorities

13. Main workforce bottlenecks
13
 To-take-out medication
This is a bottleneck due to problems with the process for requesting medication and last
minute changes to prescriptions
 Transport
This is a perceived bottleneck due to last minute referrals from wards and limited availability at
the weekend
 Completing assessments in a timely fashion
This is the main reason for delayed discharges and comes from difficulties in coordinating
MDT input into assessments
 Communicating with out-of-counties and external organisations
This bottleneck exists due to different processes in different counties, and a lack of
compatibility between the technology systems used
 Patients / families not wanting to leave acute setting
This is an ongoing problem due to patients / families thinking they have the „right‟ to remain in
a hospital bed
 Availability of community resources
This is a perceived bottleneck, although it has yet to be established whether resources
are limited or whether they are being used in a sub-optimal way

14. Priorities vs bottlenecks
14

15. Example - Assessments
15
Current issues
 xx of people interviewed from DPT said
assessment forms still take a long time to
complete and are bureucratic.
 XX% of DTOCs in Feb 2011 were due to
people „awaiting assessments‟.
 All assessments are completed in the acute
setting, which increases the number of
unproductive bed days.
 Legislation - an NHS body “must carry out
such an assessment as it considers
appropriate or as the individuals needs for
continuing care…” (The Delayed
Discharges (Continuing Care) Directions
2004).
Options for consideration
 Legislation - “If the Checklist is used at the
point of discharge…a decision should be
made, and recorded, to undertake a full
consideration of eligibility once all treatment
and rehabilitation has been completed. This
full consideration should be completed
in the most appropriate setting….” (The
National Framework for Continuing
Healthcare and NHS-funded nursing care).
 Some areas carry out CHC assessments
following discharge in the communty e.g.
NHS Rotherham..
 Is a full SAP assessment required when
referring to the re-ablement service -
assessed in the community within 24hrs?