Meridian’s client is one of the leading NHS Foundation Trusts in West Yorkshire. Working in three localities, it provides mental health, community mental health and learning disabilities services.
Meridian have been invited to carry out an analysis of the Adult Acute Inpatient Wards, the Intensive Home Treatment Teams and Community Mental Health Teams. The main concerns of the Trust were:
- High spend on Out Of Area treatments for local patients (ca. 62 bed nights per week at a cost of £1.6 million a year)
- High Average Length Of Stay on the Inpatient Wards (53.1 days)
- Significant Agency spend in the Community-based services (ca. £1.5 million)
During a two week’s analysis phase, Meridian were able to identify several issues in the different areas:
A) Adult Acute Inpatient Wards
- No discharge dates for patients
- No appropriate planning for discharge
- No review of planned discharges and no proactive action in order to remove barriers preventing a discharge
B) Community Mental Health Teams
- Contacts per day between 2.0-2.9 (depending on methodology)
- No understanding of the caseload in terms of the work required
- No visibility of care coordinators’ capacity needed when allocating new referrals
C) Intensive Home Treatment Teams
- No clear definition of the service
- Contacts per day between 1.9 and 2.2
- Majority of visits done as joint visits
- Long-term Agency staff usage
The 18 weeks’ project schedule was built around maximising the opportunities connected with the above mentioned issues. Meridian worked ‘on the ground’ with all of the teams in scope, conducting workshops for the managers, explaining concepts, installing management controls and encouraging positive behaviour change. The key specific actions for each area were following:
A) Adult Acute Inpatient Wards
- Providing each patient with a discharge date from the point of admission to the ward and immediate planning for the discharge
- Installation of a bespoke (yet straightforward) ‘Discharge Countdown Tool’, which focused the actions of the staff on the ward towards removing the most frequent obstacles preventing patients from being discharged (used on a daily basis, in handovers)
- Setting up of a Weekly Bed Management Meeting with Top Decision Makers (up to the Deputy Director level) to review current discharge dates, obstacles preventing discharges, delayed discharges and any variances to the wards’ performance
B) Community Mental Health Teams
- Setting of new target of 50% face-to-face time per day spent in patient / patient’s family contact for care coordinators
- Translation of the caseload into ‘work required’ expressed in time, which provided a detailed, deep overview over the actual capacity of care coordinators
- Installation of a Work Allocation Tool that ensures that the care coordinators are planning their work towards the 50% target and highlights excess capacity (which aids with Agency cost reduction)
C) Intensive Home Treatment Team
- Redefinition of the service – clear description of its role and way of working
- New % face-to-face target of 50% (similar to CMHTs)
- Removal of Agency workers
- Reduction in joint visits (joint visit as a last resort and not as default)
- Installation of a Work Allocation Tool (similar to CMHTs) to show whether there’s enough work for IHTT workers to achieve the 50% target
Week 5 of the project was the last week the Trust had any Out Of Area Patients. By the end of the project, the Trust hit more than 100 days of no OOA patients, which resulted in savings of more than £500,000 by the end of the project (the programme paid for itself 2.5 times before it finished). Other significant results were following:
- The lowest recorded bed occupancy (with leave) in the last 5 financial years (average in the last four weeks of the project: 90.7%; previously lowest figure was 99.6%)
- Average Length of Stay of patients admitted after the beginning of the project – 26.1 days (base ALOS: 53.1 days)
- Creation of 4 ‘flexi-beds’ which is in line with the Trust’s strategic goals and freed up nursing time
- Visible behavioural change on the Adult Acute Inpatient Wards and the installation of a dischargedriven culture
- Installation of a Weekly Bed Management Meeting which enabled more intensive contact with the Local Authority in order to transfer ‘long-stayers’ to more appropriate settings
- Installation of a Weekly Management Report with the key indicators enabling specific actions towards achieving the Trust’s goals
- Unification of the systems across all Inpatient Wards
- New, clear definition of the Intensive Home Treatment Service
- Reduction the ‘admin burden’ within IHTT
- Reduction of joint visits (defaulting to lone working)
- 46% increase in productivity (F2F or telephone contacts) in Community Mental Health Teams
- Removal of all of the Agency staff in the Intensive Home Treatment Teams
- Reduction of Agency spend in CMHTs and reallocation of the workload