This workstream is all about improvements that link into the North Mersey System plans that positively effect:
- Attendance avoidance into emergency departments by working with partners to ensure robust alternatives are in place and easy to access (Stay at Home)
- Admission avoidance from emergency departments with a focus on alternative options like home with urgent community response, same day access to specialty clinics including frailty, rapid diagnosis and decision making (Keep me at home)
- Patient flow through the hospital once patients have been admitted and aim to reduce the length of time they are in hospital and the probability of unnecessary harm (Get me home)
- Appropriate and timely discharge to a patient’s normal residence as much as possible and limit the requirements for long term care (Stay at home).
- It has been agreed with strategic system leaders that Mersey Care will focus on development of the systemwide Transfer of Care Hubs across the Mersey Care footprint, improving data and pathways with local authorities
- Transfer of Care Hub is mobilising its operational framework and working on the aim for patients to leave hospital quicker and more patients on pathway 1 (home with care) rather than pathway 3 (long term care)
- There is now also a focus on Mersey and West Lancs with the streamlining of Whiston Transfer of Care Hub processes
- Admission Avoidance projects continue to progress at pace. UCR: NWAS Pilot has been undertaken and continues to be reviewed and improved. PC24 Pilot saw the highest number of PC24 referrals received to date in September 2024. Referral trajectory rate improving month on month.
- Walk-in centre and urgent treatment centre model being further developed to ensure a consistent offer and maximisation of their impact for primary care and emergency departments. Point of Care testing now live across four UTC sites (Old Swan, Garston, Litherland and Kirkby). Further enhancements of UTC/WIC diagnostic pathways are on-going.
- The processes in and out of Single Point of Contact making sure the following principles are core (simple, responsive, clear and accountable) are being reviewed.
Four “Test of Change” priorities as an output of an avoiding attendance and admission workshop in June:
- Frailty – diversion and changes to the model
- Processes in and out of Single Point of Contact making sure the following principles are core (simple, responsive, clear and accountable)
- Zero referrals rejected through Single Point of Contact as a perfect care goal.
- Agreement of a risk positive framework. Transfer of Care Hub mobilising its operational framework and working on the aim of more patients leaving hospital quicker and more on pathway 1 (home with care) rather than pathway 3 (long term care)
- Walk-in Centre and Urgent Treatment Centre model being further developed to ensure a consistent offer and maximise their impact for primary care and emergency departments.
Key themes to take forward and undertake “Test of Change” from the avoiding admission workshop in early September:
- MDT – Holistic/comprehensive assessment at the front end – frailty and other
- Process and timescales into urgent care response – pathways from emergency departments and wider same day urgent care to be understood and made simple
- Unplanned pathway into planned pathways i.e. development of hot clinics et.
- New communication style and approach – new tone and focus to make comms more relevant. Better visibility and our intent to manage risk conversations better.
- Direct conveyancing – including diagnostic opportunities.