Anne Ashby

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May 2004
Intermediate Care Process Mapping and Redesign
Anne Ashby
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Intermediate Care targets definition context Rede
sign why what how who
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Improvement, Expansion Reform the next 3
years Priorities Planning Framework 2003-2006
Health Social Care Priorities
Improving access emergency care reduced waiting,
booking, choice
increase no. supported intensively to live at
home to 30 of total (by March 2006)
Improving services outcomes in - cancer -
coronary heart disease - mental health - older
people - life chances for children
each year - less than 1 growth in emergency
hospital admissions no growth in readmissions
all assessments to begin within 48 hours
completed within 4 weeks all social services to
be provided within 4 weeks all community
equipment within 7 working days.
Improving the overall experience of patients
reducing health inequalities infant
mortality teenage pregnancy
specialised stroke service in general hospitals
by April 2002 integrated falls service by 2005
contributing to cross-govt drive to reduce drug
misuse
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National Capacity Assumptions

• intermediate care target expanded to meet the NHS
  Plan targets of an increase in the number of
  intermediate care beds by 5000 and the number of
  people benefiting from intermediate care by
  220,000 in 2004 compared with 2000.
• By 2006 increase in intermediate care services to
  benefit an extra 70,000 people a year

more support at home - 30,000 more receive care
packages of 5 hrs pw 500,000 more items of
community equipment, 6,900 more extra care
housing places, 6000 more people in care homes -
by 2006
130,000 more carers receiving services - by 2006
delayed transfers of care reduced to a minimal
level by 2006 - as a result of extra capacity and
introduction of reimbursment
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How do we get from this.
to this ?
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Intermediate Carethe 3 aims__________________

• Improving discharge and transfers from hospital
  and promoting rehabilitation
• Reducing avoidable admissions
• Avoiding premature/avoidable dependence on
  long-term care

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Intermediate Care

• Rehabilitation
• Recuperation
• Recovery from surgery
• Re-ablement
• Resettlement at home - tapered care
• Ongoing Assessment

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Interim Care

• Assessment completed
• Optimum function achieved
• Final destination is known
• Maintenance of function and reassessment
• Client awaits
• Care home of choice
• Rehousing
• Complex care packages
• Major adaptations

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Questions?

• What services do you need to have in place so
  that no one is admitted to hospital
  inappropriately ?
• What services do you need to have in place so
  that no older person admitted to hospital from
  their own home is discharged directly to long
  term care in a nursing or residential home ?

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• New Model of Care
• Active health promotion
• Chronic Disease management
• Fast response from community services
• one-off
• crisis
• Use Acute trust for what its good at
• Integrated discharge team
• Integrated Intermediate Interim Care
• Continuing Care
• low, medium, complex care
• extra care housing

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Process Mapping redesign why
?_______________________________

• In order to know how much intermediate care is
  needed the whole community needs to understand
• intermediate care within the whole system
• the aims and objectives
• who to refer
• how to refer
• when to refer
• The whole community
• staff
• patients
• general public

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Aims and ObjectivesP.R._________________________
_____

• All staff have a better understanding of
• scope of intermediate care
• drivers / targets / culture in other agencies
• local access routes
• preferred care pathways
• outcomes of intermediate care
• the whole system
• Improved engagement of fieldwork staff
• opportunity to influence future services
• time out
• networking

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Equipment
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Process Mapping Redesignwhat is it
?_______________________________

• Day One
• Map what happens currently to people when they
  access emergency health and social care
  resulting in
• admission to hospital - through to discharge
• admission avoided
• Identify
• good practice
• blockages, doesnt add value to patient
• bright ideas - park them for day 2

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Process Mapping Redesignwhat is it
?_______________________________

• Day Two
• Map what we would like to happen in the future
• use bright ideas from day one
• eliminate blockages and long waits
• Action Plan to achieve the redesigned pathway

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Process Mapping Redesignhow
?_______________________________

• Steering group
• middle managers
• champions
• all agencies
• SHA Service Improvement Manager
• Modernisation Agency Associate
• Emergency Services Collaborative Lead
• Improving Hospitals Lead
• CAT - Practical Guide
• Budget

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Process Mapping Redesigntips for
success_______________________________

• Hand pick the participants
• Personal invitation
• Seating Plan
• Quality venue - value staff
• Experienced facilitators
• Chief Officers to
• introduce day one
• attend feedback of redesign and action planning -
  day two
• Involve participants in follow up action and
  feedback to all.

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Trios_______________________________

• Groups of 3 (tables of 9 people)
• What does it feel like to be a patient going
  through the process?
• A Carer?
• A member of staff?
• Similar responses from all 3
• frustrated , angry, uncertain
• uninformed, confused
• Good ice breaker

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MappingGolden Rules____________________________
___

• Include everyone
• All contributions are welcome
• No-one is wrong
• Define the process start and finish
• Takes time
• Appreciate the time out
• Chatham house rules
• FUN

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THE PATIENT JOURNEY - fairly high level!!
Patient attends GP with symptoms
GP refers patient
Patient receives OP appointment
Patient attends hospital
Decision to perform rigid sigmoidoscopy
Patient goes homes
Patient attends hospital
Patient receives OP appointment
Cons refers patient to endoscopy
Patient goes home
Patient receives OP appointment
Patient attends hospital
If Ca suspected decision to perform CT
Patient goes home
Cons refers patients to CT
Patient receives OP appointment
Patient receives results
Patient attends hospital
Patient attends hospital
Patient receives appointment
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Thinking Laterally_______________________________

• Exercise in table groups
• Choose an everyday item, eg paper cup, net bag
  for soap tablets
• Brainstorm what else the item could be used for
• Prize for the most innovative (outrageous)
  suggestion
• Good fun
• Encourages to think out of the box

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THE REDESIGNED PATIENT JOURNEY
Patient attends GP with symptoms
GP refers patient
Patient receives OP appointment
Patient attends hospital
Decision to perform rigid sigmoidoscopy
Patient has CT scan (two CT slots block
booked)
Patient receives results
If Ca suspected decision to perform CT
Patient goes next door to nurse endoscopist who
carries out endoscopy procedure
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TnI Results The Ideal Process
Patient presents wih chest pain ?angina
Troponin I sent
Result negative
Patient Discharged
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Systems________
Every system is perfectly designed to produce
the results it does. If you do not like the
results then you must change the system Paul
Batalden, Director of the Institute for
Leadership in Healthcare Dartmouth, USA
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Anne AshbyHealth and Social Care Change Agent
TeamDepartment of Health

• email anne.ashby_at_doh.gsi.gov.uk
• website
• http//www.dh.gov.uk/policyandguidance/organisatio
  npolicy/tertiarycare/changeagentteam/fs/en