A POSITIVE OUTLOOK - NHS Wales

1 A POSITIVEOUTLOOKA good practice toolkit to improve discharge from inpatient mental health careApril 2007 ContentsAcknowledgements1 Foreword2 Executive summary31 Introduction52 Whole Systems and Care Planning73 Admissions management between community based teams and inpatient care154 Consistency in risk assessment and discharge planning215 Focusing ward arrangements25 Appendix A:Summary of POSITIVE practice examples31 References32 Glossary34 AcknowledgementsWe are grateful to all the services who have contributed the POSITIVE practice examples cited in thisdocument and to all the staff and service users involved. Our thanks also go to all who havecommented on the toolkit drafts and assisted its production.

2 Particular thanks are due to Paul Rooneyand Yvonne Stoddart (CSIP NIMHE Acute Care Programme), and Nye Harris (CSIP Change AgentTeam) who drafted and project managed the production of the welcome this important addition to our efforts of improving delivery of inpatient mental healthservices. A POSITIVE OUTLOOK good practice toolkit contains clear messages about the needs andbenefits of focusing on reducing present levels of delayed discharges from hospital and providesclear evidence from the range of POSITIVE and innovative practice developing in local services thatsuch a reduction is aim is to ensure that best practice in facilitating safe and effective discharge becomes commonpractice.

3 If we succeed in this, it will be a major contribution to reducing pressure on inpatient wards,by enabling more therapeutic and effective treatment and facilitating the recovery and wellbeing ofservice users and wealth of POSITIVE practice examples featured in this toolkit are a testimony to the dedication andservice development expertise that characterise so many local services and those who use and work inthem. Our thanks and congratulations go to all toolkit is not just for acute mental health staff and management but is equally relevant to the widermental health and social care services commissioner and provider agencies.

4 All have a part to play. Akey theme running through so many of the POSITIVE practice examples is that developing clearly definedjoint working arrangements within and across local services is central to overcoming current barriersand using resources to their full potential across the care pathway. In successfully tackling delayeddischarge issues, the sum is very much greater than the parts! A POSITIVE OUTLOOK is a very accessible good discharge toolkit that can assist and encourage localservices to analyse their delayed discharge issues and develop their own solutions informed by whatworks elsewhere. We commend it to you.

5 Professor Louis ApplebyProfessor Ian PhilpNational Clinical Director for Mental Health National Clinical Director for Older People2 Bed occupancy rates of 100% or more,pressures to find a bed, overcrowded wardsand the associated negative consequences foreffective therapeutic engagement, service quality,safety and service user recovery are all toofamiliar for many of our inpatient mental healthservices. Despite these pressures and associateddemands to increase inpatient capacity, wehave 9% of our mental health admission bedsunavailable due to delayed discharges disrupt the therapeuticpotential of the ward, create dependence inservice users and waste scarce resources.

6 Theevidence also shows that it is in areas of greatestpressure on beds that there are the greatestnumber of delays. There is even more scope forimprovement: the 9% of beds that areunavailable due to delayed discharges do notinclude those inpatients who are ready for earlydischarge from hospital to community acutetreatment are many reasons why delayed dischargesoccur which require locally sensitive analysis andaction planning. However a high level of delayeddischarges often indicates a lack of clarityregarding the delivery of a locally integratedwhole system, inadequate monitoring systems,poor discharge practice and a lack of servicewide management from being an intractable problem, this toolkitdescribes a wealth of practical examples whichdemonstrate that effective discharge practicereduces delayed discharges and promotesindividual recovery.

7 We need to spread the works: A summary of key pointsWhole Systems and Care Planning A commitment to whole system working isrequired to develop a shared understanding ofthe issues. This works best when all local keystakeholders involved agree a collaborativeaction plan to reduce delayed discharges. The hospital (acute inpatient services) andcommunity components (Crisis ResolutionHome Treatment) of the acute care pathwayare best delivered when they are effectivelyintegrated, defined and agreed. For adult acute mental health services, AcuteCare Forums (ACFs), working closely with their local NSF Local Implementation Teams(LITs), are the appropriate vehicle to discuss,devise and deliver local whole systemintegrated care proposals.

8 Streamlining processes and changing practiceare as important as investment in capacity. Workforce skills are needed regarding serviceand process redesign, collaborative principles,lean thinking and practice development. Admissions Management Agreed inter-agency integrated care protocols,which incorporate the purpose of admissionand the role of the acute ward will improveservice co-ordination. The CRHT service should gatekeep all acuteadmissions and provide access to a 24/7service. This service should also have a clearrole in facilitating early discharges. Effective single system 24 hour admissionsmanagement and joint care arrangements needstrengthening, particularly between CRHT andacute inpatient summary3 The reasons for admission should be clearlydocumented and an expected date ofdischarge should be set at these issues should be proactivelymanaged against the care plan.

9 Service user and carer input is central to all aspects of discharge planningarrangements. There is a need to maximise the potential of direct payments, advancedirectives and advocacy. Timely, safe and appropriate discharge is theresult of good care planning from the decisionto admit to providing post discharge support Single management and staff teamarrangements will help deliver integrated care solutions. The development of less restrictive alternativesto inpatient admission such as crisis or respitehouses and acute focused day services willhelp to reduce unnecessary inappropriateadmissions and promote early assessment and discharge Planning It is important that the same evidence basedcontinuous risk assessment processes areconsistently applied across the care pathway.

10 It is important to ensure that the practical andsocial reasons influencing the admission havebeen addressed. Specific attention should be given to ensuring staff competence in the care anddischarge planning for service users with dual diagnosis problems. Specific discharge co-ordinator posts can helporganise and expedite discharge arrangementsacross the service system. Medicines management should be a corecomponent of discharge planning. discharge information should be sent to the GP prior to the service user s discharge from hospital. Service users with dual diagnosis problems, thehomeless and those with a history of violence orself-harm are especially vulnerable and needrapid follow-up arrangements to be put in Ward Arrangements Clear clinical leadership arrangements shouldbe in place.