www.england.nhs.uk

Learning Disabilities: Share and Learn Webinar

24 November 2016

Topic One:

Enhanced Care Service (ECS)Caroline Kirby, Angie Simmons, Ted Page and Rachel Barrett,Worcestershire TCP

Topic Two:

Strategic resettlement, personalisation at scale and pace Pól Toner, Head of Improvement, NHS England

#improvingLD @NHSEnglandSI

Worcestershire TCP Collaborative working and patient

experience

Presented by Caroline Kirby – Interim Lead Complex Needs CommissionerAngie Simmons – Team Leader, Enhanced care Service (ECS)

Ted Page – Behavioural Nurse Specialist ECSRachel Barrett – Expert by Experience, Speakeasy Now

Caroline – Interim Lead Complex Needs Commissioner and Programme Lead for TCP

Angie – Team Leader, Enhanced Care Service (ECS)

Ted – Behavioural Nurse Specialist, ECS

Rachel – Expert by Experience, Speakeasy Now – Lead Expert by Experience for local TCP

Introductions:

Painting the picture of LD Services within Worcestershire

• Commissioning – LD Health and Social Care is integrated and led by the County Council

• Community Learning Disability Teams – 4 Locality Teams across the County, each team has LD Nurses, Behavioural Nurse Specialists, Social Workers, SALT, OT, Psychologists, Psychiatrists and Physiotherapists

• ECS are a small Team of LD Nurses and Support Workers• Speakeasy Now are a team of people with learning disabilities who are experts

by experience. They have become integral to developing and transforming services in Worcestershire by attending CCG Care & Treatment Reviews and co-presenting TCP Highlight Reports to our Executive Board

Community Provision

• Worcestershire closed all the LD hospitals in 2009, developing Community Teams to manage individuals in their own homes

• We have a range of domiciliary, supported living and residential provision across the county

• We are currently developing the market to ensure that we have a wider range of providers to meet the needs, manage and understand the presenting risks, working towards sustainable provision for individuals stepping down from locked and secure hospitals

Enhanced Care Service (ECS)

• The ECS was developed in 2014• Working with people with a primary diagnosis of LD, autism and/or a co-

morbidity of MH conditions• The ECS are a small team of experienced LD Nurses and Support Workers• The ECS work across the county to prevent hospital admission and support

Worcestershire patients stepping-down from locked and secure units and returning to Worcestershire

• The ECS work alongside the Community Learning Disability Teams, where many of the referrals are received

ECS involvement in Care & Treatment Reviews (CTR)

• The ECS attend Care & Treatment Reviews for all Worcestershire patients in locked and secure hospitals

• This has enabled them to gain an understanding of patients and become involved with developing relapse plans and Positive Behavioural Support Plans at the earliest opportunity

• The ECS lead on delivering Positive Behavioural Support to Community Teams, providers and carers; supporting successful discharge within our communities

• The ECS have become an integral part of the transition for patients

Case Studies

We wanted to share three case studies to demonstrate the pro-active work of the ECS. The Case Studies represent:

• Patient 1 - has been successfully discharged from locked rehab following many years of secure and locked services. The ECS have supported the patient during the transition period

• Patient 2 - lives with an elderly carer in the family home. The ECS have supported the patient in the community during medication review and changes

• Patient 3 – prevent a hospital admission, whilst supporting the provider to manage a transition to a temporary service and the return

Case Study 1Pen Picture:• 28 year old male• He has a mild learning disability• He has a diagnosis of Autism • He is very ritualistic and suffers with anxiety• There are complex family dynamics• There is a long history of placement breakdowns• He has spent a number of years in locked accommodation

Brief History:• Admitted to hospital following a placement breakdown linked to his obsessive behaviours

which could no longer be managed in community• Structured environment and MDT approach met his needs• Discharged into community which broke down in 11 days so readmitted• Enhanced Care Service involved to support community and hospital to discharge

Support Given:• Regular visits to develop relationship• Attended CTR • Collaborative working with MDT to support in identifying care provider to meet his needs• Recommendations around building modifications• Staff training with identified provider• Work closely with family• Regular visits once discharged (16 weeks)

Outcomes:• Links remain open with provider• Has now lived in community for 18 months• Incidents continue to decrease• He has recently been on holiday for a week with staff• Has progressed within setting into flat with access to own kitchen

Case Study 2Pen Picture:• A 47 year old gentleman• Learning Disabilities/Bi-Polar/Stress Anxiety Disorder/Kidney Failure• Lived at home with elder carer receiving 1:1 from domiciliary support for day provision• The gentleman had been receiving Lithium therapy for many years but needed to change

medication due to his deterioration in health. As such psychiatry had planned a phased medication review to omit lithium before introducing new therapy regime

Support given:• ECS maintained close liaison with psychiatry to monitor each stage within the medication

review and report back any side effects or concerns• A Positive Behaviour plan and support plans was devised and reviewed during the stages

of the phase reduction. Also monitoring forms were distributed• Hands on support was given in the interim whilst additional domiciliary support was

sought, with an agency who could provide 2:1 and out of hours support and weekends during this period

Support given:• Reintroduced respite with hands on support • Referrals was also made to the wider MDT to support other health needs. • Training was given to staff to ensure a consistent approach was maintained amongst new

and current staff.• Daily contact with family for advice and monitoring.

Outcome:• New medication regime successfully introduced. • Hospital admission avoided. • Individual was able to remain at home with mother and within a familiar environment.• Incidence of behaviours of concern stabilised

Case Study 3Pen Picture:• 22 year old male• He has a diagnosis of moderate learning disability and autistic spectrum disorder• Communication and sensory needs mean he requires full MDT input• Doesn’t cope well with living with others and has historically required very specialist provision• Has experienced placement breakdown in the past• Complex routines so skilled staff team to work with him• Has epilepsy and associated undiagnosed physical health needs

Brief history:• He was living in a stand alone single occupancy community bungalow which suited his needs• He was suspected as being in pain and was unhappy but unable to communicate needs • Physical assessments were not possible in community setting • Placement was breaking down and aggressive outbursts increasing when ECS became

involved• Hospital placement not seen as option due to complex needs

Support given:• Intensive input given in community • Liaison with potential providers to co-ordinate a move to somewhere that could meet his

needs• He moved to a specialist college overseen by a learning disability hospital where he had input

from required professionals• Worked closely with Worcestershire and provider to keep existing placement available which is

close to family• Training given to existing staff team and building modifications recommended• Co-ordinated transition out of specialist college back to community when assessments had

been complete• Robust relapse planning put in place

Outcome:• Has now been back living in community for 6 months• He does not appear to be experiencing any pain and his mood is very stable• There have not been any incidents since his return• He is close to family and is now visiting them more regularly• He has recently been on holiday with staff to the sea side• He is taking part in new and varied activities on a daily basis

Rachel – Speakeasy Now

Collaborative working to deliver the TCP has become essential and Rachel will share her personal view of her experiences and shared learning of our journey so far

I was asked to be on the Transforming Care Board because I have been involved in Care and Treatment Reviews so I have an understanding of transforming care

Transforming care is about getting people out of locked hospitals and getting people out who are in the NHS beds criminal justice system. It is more difficult for people to come out of the criminal justice system as a Judge needs to agree they would be okay to come out

There have been 2 Pre-Admission CTRs that I have been involved in and we stopped someone getting sent to a locked hospital when they didn’t need to by having me involved as I gave an independent view

I would like to feedback how pleased I have been to see that in each review, the person being reviewed has been central to the review and their needs and wishes have been taken on board

I am pleased that steps have been put in place for people to move back into the community as soon as possible even though there may be delays due to MoJ needing to make the final decision

It’s been good where instead of having everyone in the room together for the review, staff come in individually to give their thoughts on progress of the person and whether they feel they are ready to move on.

This showed whether staff knew the person and whether they feel they are working as a team.

I feel more confident at being able to ask questions especially in a smaller group.

I have been telling other members of Speakeasy Now about how the TCP works so they can see what Worcestershire is doing to support people to come out of locked hospitals and not going in unless it’s needed for a short assessment period.

Thank you for listening

We welcome any questions

www.england.nhs.uk

Learning Disabilities: Share and Learn Webinar

24 November 2016

Strategic resettlement, personalisation at scale and pace

Pól Toner, Head of Improvement, NHS England

#improvingLD @NHSEnglandSI

STRATEGIC RESETTLEMENTTRANSFORMING CARE PROGRAMME“

People with a learning disability and/or autism have the right to the same

opportunities as anyone else to live satisfying and valued lives and to be treated

with dignity and respect. They should expect, as people without a learning disability

or autism expect, to live in their own homes, to develop and maintain positive

relationships and to get the support they need to be healthy, safe and an active part

of society.”

Building the Right Support

STRATEGIC RESETTLEMENT – PURPOSE

• The aim of strategic resettlement is to support discharges and a safe repatriation of patients with the most complex needs

• The main focus is on patients with a long length of stay (over 4.5 years)

• A safe resettlement of patients • Accelerating discharges of patients with a long LoS are one of

the main programme priorities

PATIENTS WITH A LONG LENGTH OF STAY – KEY FIGURES*

• 880 inpatients have a total length of stay exceeding 5 years – this is more than 30% of the total inpatient list

• 250 patients have been in hospital for more than 10 years and 115

patients for more than 20

• Two thirds of patients with LoS over 5 years reside in general and low secure settings

• There have been no significant changes in the proportion of patients with a long LoS since the Assuring Transformation data collection started in March 2015

• This cohort is therefore a key programme priority

* Suppressed Assuring Transformation data as at 31.08.2016

STRATEGIC RESETTLEMENT – APPROACH AND PROGRESS TO DATE

• Resettlement work to date – London and the South Region, North established and Midlands and east work underway

• Dedicated regional functions are being set up to lead the work

• Central team provides support to mobilise and coordinate a safe resettlement of patients across the regions and unpick system issues, i.e. legal technical support, expert clinicians, practical experience and financial modelling

• Additional capacity and expert support may also be provided through a CSU call-off contract – live in December 2016

STRATEGIC RESETTLEMENT – KEY ACTIONS BEING TAKEN

• Clear discharge trajectories are being agreed for patients whose length of stay exceeds 4.5 years

• Strategic resettlement functions provide further support to case management

• Care and Treatment Reviews are being prioritised for patients

with a long length of stay who have not had a review in the last 6 months

• A common framework and tools are being used to support local systems, such as combined Discharge Standards and a 12 point discharge checklist

12 POINT DISCHARGE CHECKLIST

26

Key to Position on Discharge:Stage

Named Respons

ibilityDeadline

Date Stage description - what should be happening? Who/what can help?

1) Patient in active treatment, commence discharge planning

 

Timescales to be agreed

Person-centred plan to be developed if not in place (or updated):• Support plan for future to be developed- what support does the individual need to keep them and others safe and enable them to live a good life in the community• Home identification form to be completed and discussions on what type of housing arrangements (e.g. tenancy/shared ownership etc)• Person-centred specification developed based on above

Community care coordinator/Social workerFamily and personPCP facilitatorCommunity providers and team need to be involved

2) Patient identified ready for discharge - Specification Outline Required

   

• CTR completed• Discharge date or target discharge date confirmed

CTR panel and leads for actions

3) Capacity Assessment Required     • Tendering of the specification /identification of the right care

and support• Panel/decision on care and support providers (involving the person and family/those who know the person best)• Plan for community team support agreed (e.g. community nurse, psychology, GP) and for handover between hospital and community (e.g. identifying responsible clinician in community) and EHCP if CYP

Commissioner/Social workerCommunity care coordinator/Community team/Local AuthorityLocal authority

4) Risk Assessment Required    

5) Specification Complete    

6) Procurement Process Required    

Funding assessments completed including continuing health care and social care funding.• Include options for personal budgets

Commissioners/Social worker

7) Placement & Provider Identified    

• Identification of housing (involving the person & family/people who know best)• Visits from person, family and professionals to assess and advise on any adaptations• Housing agreements signed (e.g. tenancy)• Adaptations/changes to house take place• Recruitment and training of care staff (involving the individual and family/those who know the person best)

Community care coordinator/Support provider /Housing officerCommunity or inpatient team member (E.g. OT)

12 POINT DISCHARGE CHECKLIST - CONTINUED

27

Key to Position on Discharge:

StageNamed

Responsibility

Deadline Date Stage description - what should be happening? Who/what can help?

8) Funding Request Required     As applicable Case manager

9) Legal Requirement Application in Progress: (DOLS,COP,MHT,MHA,BI etc)

   

Legal frameworks applied (throughout admission period and in preparation for discharge) including MCA; DOLs; MHA – relevant preparations for discharge - ensuring human rights are upheld

Responsible clinician (RC)/Approved mental health professional/Social worker/AdvocateCase manager

10) Awaiting outcome of Legal Process    

Pursuing and awaiting the outcome Responsible clinician (RC)/Approved mental health professional/Social worker/Advocate

11) Transition planned and underway    

• Leaving Hospital transition plan agreed and underway, including leave arrangements and funding for new staff to shadow, individual to visit new home. • A discharge meeting (usually a CPA) is held- ensure contingency and follow up plans in place including how extra help can be sought(CTR may be helpful to ensure discharge package is robust)• Consent for recording individual on at risk of admission register on discharge

Hospital discharge facilitator/Community care coordinatorAgreed lead clinician for ongoing support

12) Patient discharged    

• Follow up review meetings planned – dates agreed-first meeting within four weeks• Follow up contact (CPA follow up) should take place within 1 week of discharge

Agreed lead clinician for ongoing support

NATIONAL, REGIONAL AND TCPs

• National strategic direction and support

• Regional:

Teams being established with clear remit and deliverables

Supporting DCO and TCP functions

Ensuring TCP and local capacity and working that through

Ensuring all the basics are in place

Ensuring every person is mapped onto 12 point discharge checklist and prioritising 4.5 year plus cohort

ESSENTIALLY

• Know all your patients

• In particular focus on 4.5 year plus cohort

• How many are coming home:

When?

What are their needs?HousingCareSpecialist health General health and social care support

DISCUSSION

• Care needs mapping

Who, what and when?• Housing

What, where and when?

• What is strategic and how can you plan for that?

Scale and pace

• And what is person centred?

Needs, hopes and aspirations

www.england.nhs.uk/learningdisabilities

Questions?

www.england.nhs.uk

Date Topic Guest speaker

26 Jan 2017 Workforce

Employing expert by experience in commissioning

Lisa Proctor, Health Education England

Sharon Jeffreys, South West Lincolnshire CCG

23 Feb 2017 Housing

Launch of CTR Policy

Amy Swan, NHS England

Anne Webster, NHS England

30 Mar 2017 To be confirmed To be confirmed

Learning Disabilities: Share & Learn Webinar Programme

#improvingLD @NHSEnglandSI