Discharge Facilitator Project

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					   Discharge Facilitator
   Project
January 2004 - Current
 Sheffield Care Trust
Discharge Facilitator Project
   Circumstances before Project
   Issues leading to Proposal
   Project Aims & Development
   Bedding Down, beyond the Project phase
   Project Outcomes
   Other Service developments / approaches
   Where are we now
Circumstances before Project
   Sheffield Adult population = 337,000 (total – 516,000)
   91 Acute Admission Beds
   15 Specialist Beds within Acute Inpatient Service
   56 Rehabilitation / Continuing Care

   Assertive Outreach Team (1996), but need for more
   ‘Out of Hours Team’ (1997), not CRHT at that time
Circumstances before Project (Cont’d)
   High Bed Occupancy                   - 120 % (02/03)
                                         - 119 % (03/04)
 Length of Stays
     Trimmed   (Patients)   Untrimmed   (Patients)

     26 Days      733        43 Days       259       2002/ 03

     26 Days      758        44 Days       209       2003/ 04

   Good Care Pathway in place (2001)
   Explored Capping of Admissions / Zoning
Issues leading to Proposal
   Complex Information interface – time consuming
          Benefits                   Housing
           Dept                       Dept




                       PATIENT
                         Ward
Housing              ‘Named Nurse’             Family /
 Option                                        Carers




          Housing
           Option                    CMHTeam
Issues leading to Proposal
   Complex Information interface – time consuming

   A range of hold ups in time and process

   Concerns regarding discharging to homeless

   Vulnerability of those discharged to new
    accommodation

   Every one doing a bit – no one doing it well

   “What we really need is …… “
Project Aims & Development
 2 Dedicated staff

 Temporary Funding from Social Services
   Reducing Emergency Re-admissions
   Reduce rates of Out of Town Admissions


 Pilot Phase January 04 to April 04
Project Aims & Development (Cont’d)
   Main focus of their role
    1.   Benefits review/ Home circumstances assessment
    2.   Reducing risk of becoming homeless
    3.   Improving patient choice and decision making
    4.   Reducing the time patients can experience to obtain
         accommodation
    5.   Reduce the stress and anxiety that patients can
         experience
    6.   Ensuring the patient is able to move into their new
         home positively and confidently
    7.   Co-ordinate and action a range of measures
Project Aims & Development (Cont’d)
   Close links with Voluntary Sector during start up

   Targeted experienced Support Workers

   Unexpected Successes
     • Being with Patients on day of move
     • Furniture networks !
     • Banana Bob !!!


   Early Learning
     • Not taking over Care
     • They are Support Workers !
Bedding Down, Beyond the Project Phase
   Strong networks/ relations with Housing providers

   Strong joint working with Housing/ Homeless Section

   Holding the Line / Boundaries
     • Care Co-ordinators
     • Ward Staff
     • Discharge Facilitators getting carried away


   Early Feedback resoundingly successful

   Extended Pilot – May 04 to October 04

   Permanent Funding – November 04 (£40,000)
Project Outcomes
Service User Benefits
    A large number of service users have used this service
       20% of Patients accessed their support ( 2004 / 05 )

    Reflecting the range of accommodation / benefits issues that arise

    From this group 60 individuals have benefited from assistance in
     obtaining new accommodation.

    Feedback and Letters of appreciation from patients and family members
     indicate key benefits to be the:

        Proactive work the Discharge Facilitators are able to do on the
         patients behalf,
        The focus on the patients wishes and choices,
        The commitments to be flexible and responsive to the individuals
         circumstances
        Practical support of being with / accompanying the patient move
         and settle in
Project Outcomes (Cont’d)
Team Benefits
   From the availability of dedicated roles to provided concentrated
    effort to processing applications and supporting patients with visits
    and choices.

   This has ensured that the individual patients needs are being
    progressed proactively

   Removed a range of administrative tasks from inpatient nursing
    duties enabling more time for direct patient care.

   Significantly improved communication and interface issues across
    mental health services and professionals.

   An identified person to contact during the 'working week' has been a
    key feature in the feedback CMHT Staff
Project Outcomes (Cont’d)
Housing Department Benefits
   Highlighted a key benefit of being able to establish and
    develop working relationships with the Discharge
    facilitators in progressing individual cases

   With improvements in access and day to day
    communication

Service Benefits
   The numbers of new patients who have experienced a
    delay in their discharge being finalised has reduced over
    the period
Project Outcomes (Cont’d)
  Of 182 Patients at risk re accommodation
   67% did not experience a delay in their
   discharge ( 2004 / 05 )
  Periodsof delay reduced by 50%, from an
   average of 11 weeks to 5 weeks
  Re-Admission     rates for the 182 were
    •   2% at 1 Month &
    •   8% at 3 Months
Other Service Developments /
Approaches
   Information – Monitoring and Reviewing
                                                                      DELAYED DISCHARGES OVERVIEW
                  Year 2004                        Year 2005
Burbage                             Position at Two Weeks
          O            N            D       J      F       M                    A         M         J         J         A         S            O         N         D
Patient       7    8       9   10    11   12   13   14   15      16   17   18   19   20   21   22   23   24   25   26   27   28   29 30        31   32   33   34                      =      Standard Tenancy
AS                                                                                                  D    I    S    C    H    A    R  G         E    D    X    X    X    X
MG                                                                                        D    I    S    C    H    A    R    G    E  D         X    X    X    X    X    X             =      Supported Accommodation
PW                                                  D        I   S    C    H    A    R    G    E    D    X    X    X    X    X    X  X         X    X    X    X    X    X
JB        X       X    X       X                                 D    I    S    C    H    A    R    G    E    D    X    X    X    X  X         X    X    X    X    X    X             =      Residential/Nursing Care
FK        X       X    X       X     X    X              D       I    S    C    H    A    R    G    E    D    X    X    X    X    X  X         X    X    X    X    X    X
TC        X       X    X       X     X    X              D       I    S    C    H    A    R    G    E    D    X    X    X    X    X  X         X    X    X    X    X    X             =      Rehab & Cont. Care
SS        X       X    X       X     X    X                                     D    I    S    C    H    A    R    G    E    D    X  X         X    X    X    X    X    X
SB        X       X    X       X     X    X    X    X    X       X    X    X              D    I    S    C    H    A    R    G    E  D         X    X    X    X    X    X             =      Specialist Health Placement
DT        X       X    X       X     X    X    X    X    X       X    X                                                           D   I        S    C    H    A    R    G
AC        X       X    X       X     X    X    X    X    X       X    X    X                   D    I    S    C    H    A    R    G   E        D    X    X    X    X    X             =      Practical Support
JG        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X    X                             X  X         X    X    X    X    X    X
JS        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X    X    X                   D    I   S        C    H    A    R    G    E             =      MDT decision making/
SB        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X    X    X                                          D    I    S    C    H                    Ward CMHT interface
KP        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X    X    X    X                                          D    I    S    C
LD        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X    X    X    X                                     D    I    S    C    H
CR        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X    X    X    X              D        I   S    C    H    A    R    G    E    NOTE
GG        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X    X    X    X    X         D        I   S    C    H    A    R    G    E
LM        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X    X    X    X    X                                          D    I    S    Clients showing as Rehab & Continuing Care
DS        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X    X    X    X    X    X    X                 D    I    S    C    H    A    reflect the view of the Acute Inpatient Team
                                                                                                                                                                             that this is what the individual needs.
Maple                               Position at Two Weeks                                                                                                                    The outcome may be different following
          O            N            D          J         F            M         A         M         J         J         A         S            O         N         D         Assessment from the Rehab Service.
Patient       7    8       9   10    11   12   13   14   15      16   17   18   19   20   21   22   23   24   25   26   27   28   29      30   31   32   33   34   35   36
JK                     D       I     S    C    H    A    R       G    E    D    X    X    X    X    X    X    X    X    X    X    X       X    X    X    X    X    X    X    Practical Support reflects where an individual is
RG                                                                         D    I    S    C    H    A    R    G    E    D    X    X       X    X    X    X    X    X    X    ready to be discharged, has accommodation
GG                                                                                             D    I    S    C    H    A    R    G       E    D    X    X    X    X    X    but is experiencing delays around issues
JW        X       X                                                             L    E    A    V    E    X    X    X    X    X    X       X    X    X    X    X    X    X    such as Grant application, Furnishings for house etc
JP        X                    D     I    S    C    H    A       R    G    E    D    X    X    X    X    X    X    X    X    X    X       X    X    X    X    X    X    X
MC                                                                              D    D    D    D    D    D
JM                                                                                                  D    I    S    C    H    A    R       G    E    D    X    X    X    X
TM                                                                                                            C    H    A    N    G       E    X    X    X    X    X    X
SB                             D     I    S    C    H    A       R    G    E    D    X    X    X    X    X    X    X    X    X    X       X    X    X    X    X    X    X
RM                                   D    I    S    C    H       A    R    G    E    D    X    X    X    X    X    X    X    X    X       X    X    X    X    X    X    X
JL        x       x                                                                                           D    I    S    C    H       A    R    G    E    D    X    X
PL        x       x    x                                         N    O         L    O    N    G    E    R    X    X    X    X    X       X    X    X    X    X    X    X
PB        X       X    X       X     X              D        I   S    C    H    A    R    G    E    D    X    X    X    X    X    X       X    X    X    X    X    X    X
PN        X       X    X       X     X    X    X                 D    I    S    C    H    A    R    G    E    D    X    X    X    X       X    X    X    X    X    X    X
HH        X       X    X       X     X    X                           D    I    S    C    H    A    R    G    E    D    X    X    X       X    X    X    X    X    X    X
TS        X       X    X       X     X    X                                               D    I    S    C    H    A    R    G    E       D    X    X    X    X    X    X
NS        X       X    X       X     X    X    X    X    X       X    X    X    X                   D    I    S    C    H    A    R       G    E    D    X    X    X    X
DJ        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X    X                                               D    I    S    C    H
AK        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X                             D    I       S    C    H    A    R    G    E
RD        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X                        D    I    S       C    H    A    R    G    E    D
RT        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X    X    X    X    X              D       I    S    C    H    A    R    G
SB        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X    X    X    X    X              D       I    S    C    H    A    R    G
GB        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X    X    X    X    X         D    I       S    C    H    A    R    G    E
GC        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X    X    X    X    X                                          D    I    S
CA        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X    X    X    X    X         D    I       S    C    H    A    R    G    E
DJ        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X    X    X    X    X    X    X    X       X    X                   D    I
JK        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X    X    X    X    X    X    X    X       X    X    X    X
JE        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X    X    X    X    X    X    X    X       X    X    X    X
GM        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X    X    X    X    X    X    X    X       X    X              D    I    S
DS        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X    X    X    X    X    X    X    X       X    X    X    X    X
PA        X       X    X       X     X    X    X    X    X       X    X    X    X    X    X    X    X    X    X    X    X    X    X       X    X    X    X    X
Other Service Developments /
Approaches
   Information – Monitoring and Reviewing

   Acute Care Forum Priority – Bed Pressures

   Bed Management Committee
    • Raised profile, scrutiny, value
    • Formal links with Housing Dept


   Bed Management Policy

   Broader Action re Patient Delays
Where Are We Now?
   Reduced Admissions levels
        2002 - 2003     2003 - 2004     2004 - 2005      2005 -2006
           996             968              892             801
                           -3%            - 10.5 %        - 19.5 %

   Reduced Bed Occupancy
        2002 - 2003     2003 - 2004     2004 - 2005      2005 -2006
         120.5 %          119 %            113 %           108 %
                           -1%             -6%            - 10.4 %

   Reduced Delayed Discharges
    •     67% of those at Risk due to Accommodation did not experience
          a delay
    •     Period of Delay reduced on Average by 50 %
Where Are We Now? (Cont’d)

   Increasing Average Length of Stay !!!!!
    2002 - 2003   2003 - 2004   2004 - 2005   2005 -2006
     26 Days       26 Days       26 Days       30 Days
     43 Days       44 Days       49 Days       52 Days
                                                  Breakdown of Length of Stay - Monthly Average
Number of Patients Discharged




                                25

                                20

                                15

                                10

                                5

                                0
                                     Under 4   4 - 7 days 8 - 14 days    15 - 28    1-3        3-6       6 - 12   over 12
                                      days                                days     months     months    months    months

  02/03 & 03/04 - 2 Year Average                                        Last Year - Average        Current Year - 6 Mth Average


                                195 Discharges in under 7 days = 20% of Admissions
                                Only accounted for 1.9 % Bed Occupancy
Where Are We Now? (Cont’d)
   Increasing Average Length of Stay !!!!!
    2002 - 2003    2003 - 2004    2004 - 2005       2005 -2006
     26 Days        26 Days         26 Days          30 Days
     43 Days        44 Days         49 Days          56 Days




Reduced Out of Town Admissions

    2002 - 2003    2003 - 2004    2004 - 2005       2005 -2006
       N/A             52             26        13 (none from Sept)
Jason.Rowlands@SCT.NHS.UK
 Debra.Breese@SCT.NHS.UK
  Kim.Parker@SCT.NHS.UK

				
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