In the last edition of Partnership Update, we focused in more detail on two of the four key areas of work in the iCAN assessment phase. Below, you can find out more about the other two ‘pillars’ of initial iCAN activity: hospital discharge and primary and community care.

Pillar Q&A: Discharge

What is this pillar focused on understanding?
Identifying the number of patients discharged from hospital into residential or nursing care, domiciliary care, home independence and community services, and how we can support colleagues and patients across the system. We know patients too often remain in acute hospital beds after they are medically fit to leave while many are in community hospital beds without needing medical interventions. We want to understand and address the reasons for this.

Why is this pillar important to the programme?
To ensure more people are supported to be safely discharged from hospital at the right time, which in turn can improve the capacity of our hospitals to provide cancer treatment, elective care and emergency care.

How does your pillar hope to support people to choose well, stay well and live well?
As well as supporting the wider iCAN programme, the discharge pillar will look at improving the rate and quality of discharges, reduce lengths of stay where appropriate and support improved operational efficiency and cost-effectiveness throughout our hospitals. The overall aim is to improve patient experience for all patients requiring treatment in an acute hospital setting.

What work is already happening to support the objectives of the pillar?
• Healthcare at Home and Home First initiatives supporting patients to be discharged home
• Improving the quality of medicines information on discharge
• Meeting new national hospital discharge requirements
• Improving patient flow – including through use of real time bed management technology
• Use of discharge criteria to support safe and timely discharge
• Listening into Action – supporting frontline staff to shape service improvements
• Advocating ‘Get Up, Get Dressed, Get Moving’ approach to support improved patient recovery

There is clear enthusiasm, motivation and responsiveness among staff across the system, with colleagues then displaying a real appetite for change, suggesting and making improvements to facilitate excellent patient care at the right time, in the right place and informed by patient wishes.

Pillar Q&A: Primary and community care

What is this pillar focused on understanding?
How can we enable people to choose well, stay well and live well in their own home – with the right support – so that escalation to acute care is the exception not the norm? And when, inevitably, some of our population do experience a crisis, how can we ensure that they are looked after in the right setting by the right team?

Why is this pillar important to the programme?
To create a health and care service in Northamptonshire that is both clinically and financially sustainable, we need to shift our focus to earlier and more effective treatment and support in the community that will reduce people’s need for hospital care. Our work aims to help more people to develop the right health, wellbeing and care plans for their needs, to put in place the right holistic primary and community support to deliver these plans, and to improve the use of urgent community care services and pathways so more people in crisis can receive the care they need at (or near) home.

How does your pillar hope to support people to choose well, stay well and live well?
• High quality holistic care plans (based on frailty assessments) for all older people, regularly reviewed
• Robust and comprehensive primary and community health and care services that are recognised by clinicians and the public as genuine and safe alternatives to acute settings
• Fully integrated team approaches with the right skill mix and capacity
• 24-hour care pathways in the community to safely support people in crisis who would otherwise go to hospital

What work is already happening to support the objectives of the pillar?

Enhanced health in care homes:
• Delivering high quality personalised care within care homes
• Ensuring individuals living (temporarily or permanently) in care homes can access the right care and health services in the place they choose
• Enabling effective use of resources by reducing unnecessary conveyances to hospitals, hospital admissions and bed days, while ensuring the best care for people in care homes

Development of multidisciplinary teams (MDTs)
Building to create fully integrated local teams involving patients and carers and including GPs, care coordinators, pharmacists, community nurses / community care teams, therapists, integrated voluntary sector and social care support, and wider specialist support services – with regular clinics to review care plans.