Pathway Support Team, OPMH Inpatient Services South of Tyne – CNTW NHS Foundation Trust – Winners #MHAWards19

By adopting a devolved leadership approach, we have achieved and embedded a “culture change” in which ward clinicians have been supported and empowered to troubleshoot the individual issues delaying patients’ progress through care pathways. To date the programme has achieved the following benefits: 1. The Quality of the patient experience: Increased patient/carer input; broader holistic person-centeredness; shorter times away from home; locality hospital stay closer to home; improved access for visiting families; improved engagement from community professionals to support earlier discharge planning; enhanced choice through development of nurse consultant role as “responsible clinician”, adopting a wider psycho-social approach. 2. Performance: Improvement reflected in reporting on national/local standards including CQC inspection (Outstanding), NHS Improvement, locality commissioning, Accreditation for Inpatient Mental Health Services (AIMS).

Hours the service operates   24 Hours per day, 365 days per year

Winners #MHAwards19

Co-Production

  • From start: Yes
  • During process: Yes
  • In evaluation: Yes

Evaluation

  • Peer: Yes
  • Academic: Yes
  • PP Collaborative: Yes

Find out more

Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.

Pathway Support Project: Due to extended lengths of stay and delays to discharges, demand exceeded locality supply for Sunderland/South Tyneside inpatient mental health beds for older people. Increasing numbers were admitted out of locality, patients were increasingly distanced apart from loved ones causing distress, and locality community professionals were less accessible to engage. In January 2018 we created two dedicated staff posts to troubleshoot hotspot areas, improving the patient experience through better ‘flow’ of care. Focus on earlier discharge planning has driven ‘culture change’, improving integrated working between health and social care, resulting in 30% and 50% reductions in lengths of stay and bed occupancy respectively. Circumstances of the project’s inception: On 01/12/2017, 58 older people from Sunderland/South Tyneside were admitted into only 42 older people’s mental health (OPMH) beds; consequently 16 of them had to be admitted to beds elsewhere in the region. Average lengths of stay were prolonged and little resource was free to effect meaningful change. For some patients, families and carers the experience was of isolation both from loved ones and community healthcare professionals, causing significant delays in future care planning/discharge.

We encountered stories of distressed patients missing loved ones and heinous journeys endured by elderly spouses and siblings to visit patients. With ongoing admissions continuing at +100% capacity, the opportunity to repatriate patients to their home locality was minimal; placements in Newcastle and Northumberland, up to 35 miles from home, resulted in community professionals not being able to visit patients or attend Multidisciplinary Team meetings in a timely fashion, lengthening discharge planning. NTW was approached by Sunderland CCG to support contingency planning for “winter pressures” in locality acute services. We identified that an OPMH occupancy reduction could indirectly reduce bed pressures at locality acute hospitals through more timely transfers to OPMH beds. This provided an initial funding source to trial an idea to resolve this problem. Project aims and targets We identified an injection of focused resource to unblock hotspots in patient “journeys”, moving patients a step back in the pathway. Earlier discharges would lead to reduced bed occupancy, in turn releasing resource to prevent admission.

The largest cause of prolonged admissions in OPMH Inpatient Services was patients waiting for community care packages. A lack of knowledge of social care criteria meant delays were difficult for clinicians to challenge; variation in locality social worker performance evidenced scope for improvement by nurses being better informed, supported and empowered to be less passive. The project plan appointed a senior nurse and social worker to support OPMH clinicians and locality social workers to work more collaboratively, promptly and person-centrally. By working more cohesively, lengths of stay (LOS) could be significantly reduced, improving patient experiences. Our key targets included: a) Reducing bed occupancy to 86% b) Eradicating all admissions out of locality/specialism c) Reducing average LOS

 

What makes your service stand out from others? Please provide an example of this.

By adopting a devolved leadership approach, we have achieved and embedded a “culture change” in which ward clinicians have been supported and empowered to troubleshoot the individual issues delaying patients’ progress through care pathways. To date the programme has achieved the following benefits: 1. The Quality of the patient experience: Increased patient/carer input; broader holistic person-centeredness; shorter times away from home; locality hospital stay closer to home; improved access for visiting families; improved engagement from community professionals to support earlier discharge planning; enhanced choice through development of nurse consultant role as “responsible clinician”, adopting a wider psycho-social approach. 2. Performance: Improvement reflected in reporting on national/local standards including CQC inspection (Outstanding), NHS Improvement, locality commissioning, Accreditation for Inpatient Mental Health Services (AIMS).

This project has also been shortlisted for the 2019 HSJ Patient Safety Awards. 3. Resource Management: The exact financial gain is difficult to quantify as there are many confounding factors, but broad resource management gains include: – Ward staffing costs significantly reduced, including reduced bank/agency use. – Bed occupancy halved (December 2017 = 58 Patients, December 2018 = 29 Patients + 13 empty beds). It is worth nothing that national reporting (NHS Benchmarking Network 2017/18) reports the cost of just one older person’s mental health bed to be £135k pa. – Average lengths of stay reduced from 95 to 69 days, with similar rates of admission and virtually no “failed discharges”. – The increased capacity released by the project has allowed other services within our Trust to avoid going out of locality/area. 4. Surpassing targets for all inpatient stays to be both timely and within home locality: On 31/12/2018, 29 older people from Sunderland/South Tyneside were admitted, all in locality beds.

A 50% reduction in bed occupancy and 30% reduction in average lengths of stay has been achieved 5. The outcomes above have in turn led to savings to support further innovation to the posts, and replication in other Trust services to achieve similar outcomes. The Nurse Consultant role has evolved into that of a Responsible Clinician, with an increased emphasis on psychosocial working enhancing patient care. 6. With similar admission rates and virtually no failed discharges, performance monitoring and National Benchmarking indicates our Older People’s Mental Health wards are now performing significantly better than the national average in terms of lengths of stay and bed occupancy per head of population.

 

How do you ensure an effective, safe, compassionate and sustainable workforce?

Largely not directly applicable to this project as this work is undertaken by our Trust-wide Workforce and Organisational Development teams. It should be noted that these teams have extensive plans and policies in place to support our staff to be effective, safe, compassionate and sustainable, and the two dedicated posts recruited as part of our Pathway Support project exist within this highly supportive wider workforce context.

 

Who is in your team?

Pathway Support Project Team: 1.0wte x Nurse Consultant – Band 8b 1.0wte x Social Worker – Band 6 3 x Older Peoples Wards: (all posts below 1.0wte unless stated otherwise): Cleadon Ward – Functional Illness (mixed, 18 beds): 1 x Consultant Psychiatrist, 2 x Junior Doctors, 1 x B7 Ward Manager, 2 x B6 Clinical Lead Nurses, 14 x B5 Qualified Nurses (inc Activity Coordinator), 14 x B3 Unqualified Nurses, 1 x OT, 1 x Physiotherapist, 0.5 x Pharmacy, 0.5 x Psychology, on demand access to SaLT and Dietician Mowbray Ward – Organic Illness (female, 12 beds): 0.75 x Consultant Psychiatrist, 2 x Junior Doctors, 1 x B7 Ward Manager, 2 x B6 Clinical Lead Nurses, 9 x B5 Qualified Nurses (inc Activity Coordinator), 16 x B3 Unqualified Nurses, 1 x OT, 1 x Physiotherapist, 0.5 x Pharmacy, 0.5 x Psychology, on demand access to SaLT and Dietician Roker Ward – Organic Illness (Male, 12 beds): 0.75 x Consultant Psychiatrist, 2 x Junior Doctors, 1 x B7 Ward Manager, 2 x B6 Clinical Lead Nurses, 9 x B5 Qualified Nurses (inc Activity Coordinator), 16 x B3 Unqualified Nurses, 1 x OT, 1 x Physiotherapist, 0.5 x Pharmacy, 0.5 x Psychology, on demand access to SaLT and Dietician

 

How do you work with the wider system?

The largest cause of prolonged admissions in Older People’s Mental Health Inpatient Services was patients waiting for community care packages. A lack of knowledge of social care criteria meant delays were difficult for clinicians to challenge; variation in locality social worker performance evidenced scope for improvement by nurses being better informed, supported and empowered to be less passive. The project plan appointed a senior nurse and social worker to support OPMH clinicians and locality social workers to work more collaboratively, promptly and person-centrally. By working more cohesively, lengths of stay (LOS) could be significantly reduced, improving patient experiences.

Do you use co-production approaches?

We engaged with both patients and their families at an early stage and explore their thoughts on what discharge would look like. This in turn helped our teams establish clear shared goals, tailoring care better to meet individual needs and preferences. In particular, by being able to build relationships with patients’ wider families, the ability to have “difficult” conversations was made easier and to be sought rather than avoided on both sides. Through better access, relatives were also better enabled to support patients through any distress felt during their inpatient stay, in particular with leave periods off the ward being more effectively utilised. By significantly improving the chances of patients being admitted into their home locality provision, this project has improved the ability of patients’ friends, relatives and carers – who themselves are often frail and elderly – to visit patients and engage in face-to-face conversations. The project has also helped patients and families engage better with ward and community professionals.

Do you share your work with others? If so, please tell us how.

Within NTW, the Pathway Support work has been shared across our Newcastle and Northumberland localities, helping to drive forward change. By reputation and as directed to by other bodies such as CQC, AIMS and Stirling University, the Older People’s Inpatient Mental Health wards for Sunderland and South Tyneside regularly receive visiting parties from other NHS providers from across the UK. This Pathway Support project has also been shortlisted as a finalist for the Health Service Journal Patient Safety Awards 2019.

 

What outcome measures are collected, how do you use them and how do they demonstrate improvement?

Progressively during 2018 we achieved reduced lengths of average inpatient stay, with patients spending less time away from home/loved ones and no longer being placed out of their home locality or the specialism they required. The increased focus on discharge planning from the point of admission, with dedicated staff to support progression/momentum with all stakeholders, made the service we provided more effective and responsive without compromising on safety or standards of care. Through question and challenge we have evolved more of a positive ‘can-do’ culture, making it the shared belief of our staff to all strive for positive change. We achieved positive outcomes against each of our core targets, with specific figures for outcomes as follows: a) “Reduce average bed occupancy to 86%” (36/42 beds) Last 6 months 2017: 121% = 51 patients (1 Dec 2017 p=58) First 6 months 2018: 98% = 41 Last 6 months 2018: 80% = 34 (31 Dec 2018 p=29) b) “Eradicate all admissions out of locality/specialism” Last 6 months of 2017: average of 9 patients (1 Dec 2017 p=16) First 6 months 2018: 2 Last 6 months 2018: 0 (31 Dec 2018 p=0) c) “Reduce average length of stay (LOS)” Last 6 months 2017: 95 days (Dec 2017 d=97) First 6 months 2018: 86 Last 6 months 2018: 75 (Dec 2018 d=69)

 

Has your service been evaluated (by peer or academic review)?

Northumberland, Tyne and Wear NHS Foundation Trust is currently rated as “Outstanding” by CQC following its latest inspection in April 2018 (report published July 2018). Within this inspection the Older People’s Mental Health Inpatient Services across North and South of Tyne localities were rated as “Good”. The South of Tyne Older Peoples Mental Health Inpatient Services are all “AIMS” accredited with College Centre for Quality Improvement at the Royal College of Psychiatrists. The NTW admission wards for Sunderland and South Tyneside for those living with dementia were the first NHS service nationally to achieve/receive the Gold Standard Award from Stirling University in terms of their dementia-friendly design (Stirling University being a recognised world leader in “Dementia friendly” design)

 

How will you ensure that your service continues to deliver good mental health care?

Moving from a successful pilot, the two Pathway Support posts have since been recruited to on a permanent basis as part of an “invest to save” strategic plan. Supported by commissioners from its inception, our approach is eminently transferable across the wider Older People’s Mental Health pathway, and indeed as a culture change could be replicable across wider NHS departments. Discussions are underway within our Trust as to how this approach could be used in the community to help avoid admissions, utilising the capacity and resource the initial project has released.

 

What aspects of your service would you share with people who want to learn from you?

Throughout this project we took care to engage wholeheartedly with locality social services managers, promoting our new social worker role as enhancing and supplementary to build a collaborative approach. Engagement with our ward clinicians ensured the “question and challenge” approach was perceived as constructive and supportive. To ensure a patient-centred approach, the two post holders were empowered to “cross boundaries” and have “difficult” conversations if necessary to champion the needs of service users. Permission to act was not required; timely communication and clear expectations were agreed with all stakeholders and established within 72 hours of admission, so that patients, MDT professionals, community clinicians, social services and patients’ families and carers worked more concurrently with a transparent shared vision. The two post holders encouraged, cajoled, prompted, supported and escalated to problem-solve as per individual needs.

The project also nurtured culture change: for example the nurse consultant role required evidencing as effective to gain the support of some medical colleagues. Some resistance to the “health social worker” by social care social workers occurred, though most now believe it beneficial and supportive; significant tenacity was required by the project post-holders to embed the cultural change required. Buy-in from health and social care professions was essential to achieve the practice change required, with the post holders educating and upskilling all professionals involved to work more dynamically and collaboratively. In evolving the Senior Nurse role further, the idea of the Nurse Consultant’s role as being complimentary to that of the Medical Consultant has been well received by patients and carers, as has the more readily accessible “Pathway Support” Social Worker providing ongoing advice and maintaining momentum in timely (and often emotive) transitions of care back to the community.

 

How many people do you see?

Total number of admissions in 2017: 185 Total number of admissions in 2018: 211 including 36 to support other locality service pressures

 

How do people access the service?

Admission referral from Community, Crisis, and Liaison mental health teams

 

How long do people wait to start receiving care?

There is now no delay from referral to access, and admission is immediately available. This strongly contrasts with the situation previously where due to demand exceeding supply, in up to 40% of cases admission may have been to a unit elsewhere in the region (causing some delay as beds are found & lengthier transport undertaken. As a result of this project’s work, all patients are now admitted immediately to their home locality, into service-specific beds.

How do you ensure you provide timely access?

Through more timely intervention to promote “Patient Flow” by maintaining momentum during the inpatient stay, average lengths of stay and therefore bed occupancy have been reduced such that all patients can now be admitted immediately, to their home locality, into the service specific bed they require. By appointing to the two pathway posts and empowering those in those posts to maintain focus on what needs to be done and what works, decision making and actions have been more timely

 

What is your service doing to identify mental health inequalities that exist in your local area?

Our service works closely with all our service users, their families and carers to identify the needs of our local population. However, while we are keen to understand the needs of our local population in demographic terms (for instance we are aware of the higher-than-average population at retirement age or over within our locality) we believe it is far more important to provide an individualised, customised, patient-centred care package for each and every one of our service users which takes into account their specific individual needs.

 

What inequalities have you identified regarding access to, and receipt and experience of, mental health care?

Our service’s locality has a larger than average population at retirement age or over. Because of the increased complexity of older people’s needs, such as physical health co-morbidities and “frailty”, often requiring care packages to support discharge, lengths of stay for older people are often unavoidably longer than those for working age adults. However, by championing the meeting of older people’s needs more pro-actively, we have been able to reduce lengths of stay in hospital much closer to those of working age patients. The positive outcome of the Pathway Flow project work has contributed to ongoing future service planning, for example helping generate and inform debate at a local and regional level around the need for a bespoke older people’s crisis / home treatment service, more focused on older people issues with specialist expertise, rather than the current, wider, more generic provision.

 

What is your service doing to address and advance equality?

Mental health legislation, the Equality Act 2010, Care Act 2014 and Human Rights Act 1998 all advocate the principle of “least restrictive option” in meeting patients’ needs and promoting person centred care. By reducing lengths of stay and ensuring patients are admitted in their home locality, we have improved the patient experience to be able to leave hospital significantly earlier, and have much better access to family, friends and carers as well as locality community providers, to make their inpatient stay less distressing, better informed and more timely and effective.

 

How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?

We use a comprehensive and holistic initial assessment over 72 hours to identify individual needs and inform subsequent care and treatment. Part of the quality improvement has been in more pro-actively engaging in commencing discharge planning within 72 hours of admission, engaging community and social care professionals at this earlier stage, such that physical, psychological and social needs are addressed concurrently and inform each other rather than in a more linear fashion.

 

How do you meet the needs of people using the service and how could you improve on this?

As described in the sections above, the need to maximise the quality of the patient experience by getting the best performance from the available resources is what generates the best overall value for all in delivering a service. Times of transition are often the most challenging aspect of this; the pathway flow approach has looked to develop the wider patient pathway rather than an individual aspect of service. Continuous building of relationships across services to complement each other rather than compete for resource has achieved a collective benefit for patients and providers: Selected feedback from some key stakeholders in this project includes: “This has been an innovative and successful invest to save project of collaborative working between the commissioners and the provider to develop and implement a new pathway. This new way of working has had a positive impact for the patients their families and the organisation, resulted in a reduction in Bed Occupancy, Lengths Of Stay (LOS) and Out Of Pocket (OOP) payments.” Michelle Turnbull, Senior Mental Health Commissioning Manager at Sunderland Clinical Commissioning Group, February 2019 “The pathway work undertaken has enabled closer collaboration between services as well as providing a better experience for people and their families.

Importantly it provides a platform from which to progress and engage with the whole system, through existing locality based GP MDTs, to identity those people most at risk of, and to prevent their unnecessary admission to psychiatric hospital.” Phil Hounsell, Service Manager for Locality Teams, Sunderland Social Services, April 2019 “I think the work done as part of the pathways project was invaluable in preventing prolonged, and at times, potentially harmful admissions. It was a pleasure working with the team who were forward thinking, proactive and worked in harmony with the team vision for our patients.” Dr James Hecker, Innovative Specialty Doctor – Psychiatry, Inpatient Dementia Service and Memory Protection Service, April 2019 “We have seen a very positive team who have helped our Mam get better to the point she can now leave the hospital. We never thought she would recover. Thank you.” Patient’s Family, Cleadon Ward, April 2019

 

What support do you offer families and carers? (where family/carers are not the service users)

A key element of the Pathway Flow Project has been to mutually agree expectations with patients’ families and carers at an early stage. Patients living with dementia in particular may lack the capacity to make choices in different aspects of their lives, and rely on loved ones to advocate for them. The NHS Constitution sets out a set of expectations that patients, families and carers can expect on accessing NHS services; when engaging with patients’ families to help inform assessment, care planning and support discharge planning, it has been helpful to also identify any expectations our service has from them at an early stage; for example in arranging for home renovations or identifying a 24 hour care placement in a timely fashion. Building transparent, realistic and collaborative relationships from the outset makes “difficult conversations” that may arise later eminently more manageable, and promotes ongoing partnership working.

 

 

Commissioner and providers

Commissioned by (e.g. name of local authority, CCG, NHS England): Sunderland CCG; South Tyneside CCG

Provided by (e.g. name of NHS trust) or your organisation: Cumbria, Northumberland Tyne and Wear NHS Foundation Trust

 

 

Population details

Brief description of population (e.g. urban, age, socioeconomic status): Situated in the North East of England, the service covers the historically industrial (especially mining and ship building) landscape of the city of Sunderland, including surrounding towns of Washington and Houghton-le-Spring, and South Tyneside towns and villages including South Shields. The locality has a larger than average retirement population with higher than average levels of physical ill health and lower than average incomes, though has developed a successful manufacturing and IT base to replace traditional occupations.

 

Size of population and localities covered:

Sunderland population circa 295k + South Tyneside c.155k = South of Tyne population of c.450k, of which c.85k are aged 65 years or older.

 

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