What is the challenge your project is going to address and how does it connect to the theme of 'How can we improve across system boundaries?​

As identified in the ICB led locality bed audit, MaDE (multi audit discharge event) events supported by ECIST (Emergency Care Improvement Support Team) and local mapping capacity is not always aligned to need across Intermediate care and partner services in Swindon impacting on the rehab, reablement and long-term care provision for patients. The implementation of new community provisions such at Home First and Urgent Community Response have changed the way many patients are managed and bed-based units are caring for more patients who have complex medical and nursing care needs alongside higher frailty levels. Locally there is also an increasing number of international patients, patients who are homeless and patients with complex safeguarding needs.

What does your project aim to achieve?

Facilitate system stakeholder discussion and co-creation of a shared multiyear transformation plan to meet the changing health needs of the locality population and make best use of available resources.  Optimising bed-based and home-based rehabilitation, reablement and recovery services to deliver appropriate place-based care that improves outcomes:

Patients receives intensive support from a multi professional team personalised to their needs
Patients have agreed personalised goals and a transition plan for when their support ends
Helps patients return home more quickly after a hospital stay
Reduces the need for acute bed-based care
Improves re-admission numbers
Improves admissions numbers to residential care including nursing support
Supports patients with independence, choice and control over daily life
Helps patients to stay at home

How will the project be delivered?

We will use the Trusts Improving Together methodology and the work will be embedded within our continuous quality improvement management system which will include:

System stakeholder engagement sessions
Utilise A3 methodology to define the problem statement, root cause and countermeasures to produce a multiyear transformation plan based on findings.
Project workbook including timeline, risk register, benefits tracker and action log
Utilise local population health data to identify health inequalities and focus work on equity of care and supporting underserved communities
Aim for co-production with patients and public through patient forums and friends and family feedback
Help mobilise multi disciplinary team)and multi-agency support for the operational and clinical implementation of any new patient pathways and criteria for bed bases.
Monitor, evaluate and feedback on early implementation changes made to assess and refine plans as required.
Support Intermediate Care planning and long-term goals development aligned to the Integrated community care contract:

How is your project going to share learning?

A finalised system plan and project planning report will be generated and shared with stakeholders to define the shared transformation plan, define anticipated benefits, what went well what did not go so well and lessons learnt from the planning phase and early implementation work.