NICE Resources for local partnerships

 Resources for local partnerships

• NICE has produced a set of resources for local partnerships designed to help systems work together to provide consistent, high-quality care, based on the best evidence. Each topic includes resources from PHE, NICE, Right Care, NHS England and others.
• Current resources are: CVD prevention (kidney management, risk assessment, NHS Health checks, hypertension, atrial fibrillation, diabetes); Frailty, Transfer of care, Making Every Contact Count, Medicines Optimisation and Urgent & emergency care.
• The Urgent and emergency care care resource includes detailed tables linking to appropriate guidelines, NICE Pathways, quality standards and quick guides relevant to each strand of work.

What works in delivering effective hospital discharge services?

What works in delivering effective hospital discharge services?
CordisBright 13 November 2018

• A review of evidence from pilots and research articles and good practice guidance on hospital discharge and transfers of care.

Emergency readmissions: What's changed one year on?

Emergency readmissions: What's changed one year on?
HealthWatch 14 November 2018

• New research indicates that emergency readmissions to hospital grew by 9% over the last year. The increase for emergency readmissions where someone has returned to hospital within just one day of discharge has increased by 15% year on year. 
• New data shows no correlation between DToC reductions and rising emergency readmissions.

DTOC Improvement tool

Delayed transfer of care (DTOC) improvement tool
NHS Improvement 12 April 2018

• This tool has been developed to enable trusts, CCGs and local authorities to understand where delayed transfers of care are in their area or system. It brings together data already submitted by NHS organisations and local authorities into an easy to use dashboard which as well as showing where their biggest delays are, also allows them to track the progress of any actions.

Improving Hospital at Home for frail older people in Exeter

Improving Hospital at Home for frail older people: insights from a quality improvement project to
achieve change across regional health and social care sectors
BMC Health Services Research 2017v 17:387 https://doi.org/10.1186/s12913-017-2334-9 

• This paper describes use of rapid cycles of PDSA tests to support the development of a community based Hospital at Home service for older people in the Exeter sub-locality to enable appropriate admission avoidance and early supported discharge. 
• The new service included a single point of access for referrals, joint geriatrician and community rehabilitation practitioners review for both admission avoidance and early supported discharge, extended weekday and weekend working hours, and an acute hospital ‘step-down’ ward for patients who were no longer acutely unwell.
• While discharge destination, length of hospital stay and number of referrals to the community team remained stable this was achieved against a backdrop of intense financial pressures, significant community bed closures, and difficult relations between hospital and community services. 

DTOC - examples of emerging and developing practice

High impact change model examples of emerging and developing practice
LGA 7 January 2018

• The high impact change model for managing transfers of care identifies eight system changes that will have the greatest impact on reducing delayed discharge. This report references a range of initiatives where there is already evidence of impact, points to examples of emerging practice that are starting to make a difference and includes links to published guidance, and further information.

Framework for maximising the use of care homes and use of therapy-led units for patients medically fit for discharge

Framework for maximising the use of care homes and use of therapy-led units for patients medically fit for discharge
NHS England 18 December 2017

• This best practice framework aims to address two models and the implementation approach that needs to be taken by STPs and their Provider Organisations to address winter pressures.
• These models aim to describe ways of working to maximise the appropriate use of care homes and describe an operating model for optimising care of cohorted patients in Therapy-Led Units, who are Medically Fit For Discharge.

Flow in providers of community health services: good practice guidance

Flow in providers of community health services: good practice guidance
NHS Improvement November 2017

• Good practice for providers of community health services around reducing Delayed Transfers of Care (DTOC), and NHS Improvement expectations of them over the next six months. NHS Improvement lays out six essential measures and three wider measures of good practice for consideration. 
• Cross-system working 
• 1. Facilitate system-wide data-sharing 
• 2. Actively engage in the operational management of discharge across all local organisations 
• 3. Develop a ‘discharge hub’ referral and co-ordination service as part of an integrated discharge team 
• Addressing challenges in resolving patient choice 
• 4. Effectively implement their patient choice policy 
• 5. Ensure the services they deliver are well understood 
• Boosting operational focus in providers of community health services 
• 6. Collect and share data for Red2Green days, creating a feedback loop between senior operational staff and the clinical workforce 
• Good practice for providers of community health services to consider :
• 1: Enabling staff to work in different settings 
• 2: Assisting patients to identify the best care packages for them
• 3: Taking steps to make nursing and therapy roles more attractive​

Flow of patients between the NHS and social care - local performance metrics

Local area performance metrics
Department of Health, 29 November 2017

• A new dashboard which allows local areas of assess the flow of patients across the boundary between the NHS and social care. 
• It provides a set of six measures indicating how health and social care partners in every Local Authority area in England are performing at the interface between health and social care. Included in the dashboard is a breakdown of delayed days attributable to social care per 100,000 of the population and the equivalent for NHS-attributable delays. 
• The metrics are:
• Emergency Admissions (65+) per 100,000 65+ population 
• 90th percentile of length of stay for emergency admissions (65+) 
• TOTAL Delayed Days per day per 100,000 18+ population 
• Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/ rehabilitation services 
• Proportion of older people (65 and over) who are discharged from hospital who receive reablement/ rehabilitation services 
• Proportion of discharges (following emergency admissions) which occur at the weekend 

Home from hospital: How housing services are relieving pressure on the NHS

Home from hospital: How housing services are relieving pressure on the NHS
National Housing Federation 12 September 2017
Case study report showing 12 examples of schemes where people get the care and support they need outside of hospital wards. These include:

• Temporary homes for people who cannot return to their own home immediately (known as a “step down” service)
• Extra care, and health and wellbeing services
• Home improvements, including safety, sustainability and suitability of homes
• Occupational therapists, telecare solutions and advice on housing options

The rise of delayed transfers of care - a briefing

The rise of delayed transfers of care
NHS Providers August 2017

• Analysis of where the increases in delayed transfers of care are occurring and what is happening on the ground.
• Includes an analysis of DTOC rate by sector, which indicates that community providers are significantly affected.

Plans to improve NHS CHC assessment processes

Plans to improve NHS Continuing Healthcare assessment processes
NHS England 17 August 2017

• This letter to CCG Accountable Officers and CCG Clinical Leaders Plans explains the actions that CCGs are expected to take to improve the NHS Continuing Healthcare assessment processes to support reduction in Delayed Transfers of Care (DTOC).

Ministerial Statement on DTOCs

Delayed Transfers of Care: Written statement - HCWS24
Department of Health Ministerial Statement, Jeremy Hunt, 3 July

• This statement sets out the measures that the Department is putting in place to address delayed discharges from hospital in advance of this winter. 
• These measures include a dashboard that reflects how local areas across England are progressing in their work to improve the interface between health and social care. This can be found here.
• See NHS social care interface dashboard and BCF planning guidelines

Delayed transfers of care in the NHS

Delayed transfers of care in the NHS
House of Commons Briefing Paper 20 June 2017

• A briefing paper looking at policy and statistical trends on delayed transfers of care (DTOC) in the NHS including recent trends, costs, the causes, approaches to reducing DTOC (including Better Care Fund) and regional variations.

Discharging older patients from hospital

Discharging older patients from hospital
National Audit Office 26 May 2016

• This report examines how effectively the health and social care system is managing the discharge of older patients from hospital, in particular: 
• the scale of delays that older patients experience in hospital (Part One);
• the extent to which health and social care providers are adopting good practice in discharging older patients (Part Two): and
• barriers to local health and social care systems working effectively (Part Three).
• Includes local data tables for Delayed discharges, A&E admission LOC and Adult social care spend

Investigations into unsafe discharge from hospital

A report of investigations into unsafe discharge from hospital
Parliamentary and Health Service Ombudsman 11 May 2016

• This report focuses on nine experiences drawn from recent complaints which illustrate the problems with regards to unsafe discharge from hospital. The most serious issues identified are:
• Issue one: Patients being discharged before they are clinically ready to leave hospital
• Issue two: Patients not being assessed or consulted properly before their discharge
• Issue three: Relatives and carers not being told that their loved one has been discharged
• Issue four: Patients being discharged with no home-care plan in place or being kept in hospital due to poor co-ordination across services
• The report highlights three key areas that warrant particular attention:
• Failures to check people's mental capacity and offer legal protections for those who lack capacity
• Carers and relatives not being treated as partners in discharge planning
• Poor co-ordination within and between services

Actions in place around early discharge and DTOC

Actions in place to drive improved early discharge and reduce delayed transfers of care
NHS England Board meeting, NHS Performance paper Appendix B, 17 December 2015

A summary of actions in place to drive improved early discharge and reduce delayed transfers of care: (Appendix B in full)

• Refreshed DTOC guidance: NHS England, DH, ADASS and ECIST colleagues have worked collaboratively to publish refreshed guidance on reporting delays providing clarity on definitions and processes, underpinned by practical resources that areas can use to implement and spread good practice.
• Toolkit for Independent Care Sector: NHS England is developing a Toolkit for Independent Care providers (both care homes and care at home) to support patient discharge from acute trusts to the care sector.
• ECIP support: Each system will have a length of stay (LoS) review – clinical deep dive looking at every patient with a length of stay > 7 days – to identify where blockages are. See http://www.ecip.nhs.uk/  
• Increased nurse training: Health Education England has increased adult nursing education and training 4.2%; and the number of training places for district nurses by 16.5% for 2015/16.
• Community nursing commissioning framework: A Framework for commissioning community nursing has been developed by NHS England to support:
• Moving limited resource from hospital to community-based care;
• Understanding how community nurses can contribute to the effective commissioning of services;
• Effective discussion about the community nursing workforce including an understanding of workforce planning.
• Standards for district nurse education and practice: The new Queen’s Nursing Institute (QNI/QNIS) Voluntary Standards for District Nurse Education and Practice place district nursing at the centre of community healthcare.

SImple guide to the Care Act and DTOC

Simple guide to the Care Act and delayed transfers of care (DTOC)
NHS England, DH, ADASS and ECIST 11 November 2015

• A simple guide to the Care Act and DTOC guidance which includes a series of good practice examples from systems from around the country.
• The guide and accompanying resource pack will be updated as and when other common solutions arise around Delayed Transfers of Care.

Available on Better Care Exchange (registration required)

Burstow Commission: DTOC - causes and how to address them

Right Place, Right Time: Better Transfers of Care: A Call to Action

Commission chaired by Rt Hon Paul Burstow
NHS Providers, 11 November 2015

• The Commission report collates evidence and good practice in transfers of care in all provider settings – across acute, community, mental health and ambulance services - and offers practical approaches to tackle the causes of delayed transfers of care.
• Causes of delayed transfer of care include:
• complex challenges within the patient journey from health settings back into the community or social care.  
• workforce capacity and skills mix
• flow within and between organisations 
• Specific messages for a number of national organisations with a wide range of recommendations are presented. These include a call to the Department of Health for further guidance to speed up the process of Continuing Healthcare assessments, including these assessments in arrangements for assess to discharge.
• The report also includes a wide ranging "Call to Action" for Providers, CCGs,  Local Councils and HWBs. 
• "In the end this report boils down to three calls to action. These calls to action are addressed to every part of the health and care system. First, start with the person (the patient or service user). They are your common cause. Second, ask yourself how do we help this person get back to where they want to be? Third, agree what the data tells you. A shared understanding of the numbers can help with tracking down the root causes."p3

See the monthly statistics on Delayed Transfers of Care here.