Transforming Care Programme
Transforming Care is all about improving health and care services, so that more people with a learning disability and autistic people can live in the community, with the right support. This means that fewer people will need to go into hospital for their care.
Our Transforming Care Partnership includes Local Authorities, Place Based Partnerships (formerly known as Clinical Commissioning Groups), and NHS providers across the Humber, York and North Yorkshire areas, including Hull, East Riding, North Lincolnshire, Northeast Lincolnshire, York and North Yorkshire
The Admission Avoidance HUB – Our Aim
To offer co-ordination and facilitation to allow partner organisations to work together to prevent un-necessary hospital admissions, prevent delayed discharges and to support individuals to live safely and happily in their communities with the right care to meet their needs. We will achieve this by -
- being a single point of contact for all Children and Young People's and Adult Dynamic Support Registers across the Humber, York and North Yorkshire – allowing us oversight of all individuals at risk of admission (allowing strategic planning)
- supporting co-ordination of partner organisations and to support case managers unblock barriers to support
- initiating an escalation process if it has been identified that current care is not meeting an individual's needs
- providing assurance (Learning reviews, audits, governance)
- facilitateing all Cand Treatment Reviews/Care Education and Treatment Reviews/Local Area Emergency Protocols across the six areas to ensure consistency and awareness.
The Dynamic Support Register (DSR)– Humber, York and North Yorkshire Transforming Care Partnership
Dynamic Support Registers (DSRs) are the mechanism for local systems to -
- use risk stratification to identify people at risk of admission to a mental health hospital
- work together to review the needs of each person registered on the DSR
- mobilise the right support (eg a C(E)TR, referral to a keyworker service for children and young people, extra support at home) to help prevent the person being admitted to a mental health hospital.
The DSR enables systems to identify adults, children, and young people with increasing and/or complex health and care needs who may require extra support, care and treatment in the community as a safe and effective alternative to admission to a mental health hospital. Additionally, they play a role in ensuring that people’s needs are included in commissioning plans, financial plans, service delivery and development.
Every ICS/ICB has a named lead person with responsibility for the maintenance of the DSR. The lead for the Children and young people's DSRs across the Humber, York and North Yorkshire Transforming Care Partnership is Joanne Pannhausen, Clinical Lead – Transforming Care Programme (Children and young people) and the lead for the adult DSR is Julie Butterworth, Clinical Lead – Transforming Care Programme (Adults).
Community Care Education and Treatment Reviews (CETRs)
The aim of a CETR is to support young people with learning disabilities and or autism who present with behaviour that challenges or who have mental health conditions and are at risk of admission to a specialist learning disability or mental health hospital.
A CTR/CETR will test and challenge the care people receive in hospital by asking key questions and making recommendations that lead to improvements in safety, care and treatment. CTRs/CETRs aim to reduce the amount of time people spend in hospital by identifying any barriers which can keep people in hospital longer than necessary. They do this by helping to improve current and future care planning, including plans for leaving hospital. CTRs/CETRs bring together those responsible for commissioning and providing services for individuals alongside independent clinical opinion and lived experience.
CETR’s are arranged and reviewed by the Admission Avoidance HUB on behalf of the Integrated Care Board or NHS England using a multi-agency, person centred approach to identifying appropriate support in the community for young people at risk of admission.
The CETR will develop recommendations through addressing four main areas – these will seek to answer the following questions -
- is the person safe?
- are they getting good care now?
- what are their care plans for the future?
- can care and treatment be provided in the community?
Local Area Emergency Protocols (LAEPS)
The aim of the local area emergency protocol (LAEP) is to provide the commissioner with a set of prompts and questions both to prevent people with a learning disability or autistic people from being admitted unnecessarily to a mental health hospital; and where there is a clearly supported clinical indication for admission to ensure that the intended outcomes and timescales are clear. It is also intended to help identify barriers to supporting a person to remain in the community and to make clear and constructive recommendations as to how these barriers could be overcome by working together and using resources creatively.
It is important to note that the LAEP does not replace the community C(E)TR and should only be used by exception. Where a community C(E)TR has not taken place, the pathway for a post-admission C(E)TR must be followed.
A review cannot take place, or a name added to a DSR without the person’s informed consent (see Shared decision making to comply with national legislation and policy). Consent must be formally documented.
Further information on DSR's and CETR's can be found through NHS England.
Down's Syndrome Care Pathway
NHS Hull Health and Care partnership, in partnership with Downright Special and health and social care services in Hull, has continued to update and develop a pathway for people living with Down’s Syndrome and their families or carers.
NHS
The NHS website provides helpful information on getting right care and support for your needs. This site covers -
- local health services
- 111 service
- A to Z of health conditions
- advice on mental health and wellbeing
- list of pharmacies
- list of community dentists