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How collaborative working helped our council reduce DTOCs by 75%


By Valeria Fiore
Reporter
15 February 2019

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Northamptonshire County Council has collaborated with local health partners to reduce the number of delayed transfers of care (DTOCs).

DTOCs happen when a patient who is clinically fit for discharge continues to occupy a bed because follow up care is not available or readily accessible.

By introducing a more integrated way of working, the council registered a 75% reduction in DTOCs related to adult social care: down from 108 in 2016 to 27 in January 2019.

Northamptonshire County Council director of adult social care Anna Earnshaw tells Healthcare Leader how they achieved this result.

The problem

We decided to look into improving our performance because a high rate of DTOCs meant that there were a lot of people stranded in hospital. We know that the longer people are delayed in their transfer, the more likely they are to end up in long-term care.

We were experiencing a growing demand from our hospitals and a high number of DTOCs meant our costs in terms of care and nursing homes were also going up.

We decided to look into introducing some actions to get more people home and allow people to move across care faster.

The solution

Our previous system was based on a multidisciplinary team, who would make decisions about a patient’s journey through care by looking at forms that gave an outline of the patient. They weren’t making decisions in the hospitals.

We’ve changed that to a model where we have an integrated discharge team in the hospital. This means they are able to work with people and see them before making a judgment. It’s about seeing people and understanding their needs.

We also put in place much better processes with our health partners. We agreed with clinical colleagues what constitutes clinical decisions and what is a social care decision.

The benefits

With our clinical colleagues, we have worked on a tool that is now live and tells us what type of person we are dealing with, therefore helping us making decisions about their care pathway.

What we were doing before was [working in isolation], waiting for each organisation to make their decisions. For example, even if we knew that someone might need to go into a care home, we wouldn’t start looking into care homes until our clinical colleagues said we should.

Now we work parallel and collectively make a judgement regarding what type of forward care is needed for a patient. Whereas before, with the hospital deciding that exclusively, we were getting overprescribing of onward care.

The council spends around £198m on care provision across a range of customers with different needs. The care budget for older people is £69m annually and we are currently overspending by £10.7m overall on care and support for the over 65s.

About £7m of our £10.7m overspending comes from demand from our hospitals.

In 2017/18 the care budget for older people was under greater pressure as we were seeing very high demand and more people were staying longer in hospital and ending up in long term and more expensive care.

The full year cost for people being placed into long term nursing and residential care after leaving hospital was £4m. This winter we have significantly invested in our crisis support teams, which help people recover at home with short term help.

On average, a short term support package for reablement costs £700 and a complex reablement and rehabilitation plan cost the council around £2,500 per patient. This is compared to an annual cost of £34,000 for residential or nursing care.

Initially we assumed we would see a similar level of demand as last year for 2018/19. However, based on what is happening we adjust the budget to actual spend and revise the forecast. The actual spend has been dropping month on month compared to the original forecast to the year end – which was based on last year’s trend.

This year, we have undertaken more short term and reablement activity, which has allowed us to reduce long term care placements. So far, this has resulted in £2m less in care costs than last [financial] year.

In January 2019 the number of DTOCs for adult social care was 27, compared to 51 in 2017 and 108 in 2016.

The challenges

The biggest challenge is cultural change. We had a lot of conversations with partners about risks. Everyone wants to make sure risk is minimised.

Social care colleagues make a judgement of people’s needs. They take into account a patient’s wish and consider if they have the capacity to make a decision. For example, if a person says they’d rather go home and get support at home, we’ll support them to do that.

In the past, I think clinical colleagues were more concerned about letting people make that judgement, as they wanted to make sure they had access to the absolute right amount of care so risk was minimised.

I think we have now got to a much more comfortable place culturally, which is about trusting each other. We don’t just think ‘it’s just your patient’; rather we think ‘it’s one person we all have to work with’.

We have massively improved the way we are working and finding solutions together: that’s our biggest achievement.

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