We codesigned and delivered a transformation programme for the improvement of care for people with learning disabilities and/or autism.

Background

NHS England and NHS Improvement set out key priorities for commissioners within the Learning Disability and Autism (LD&A) Programme and the NHS Long Term Plan. These include improving community-based preventative support, transitions into adulthood, and our understanding of best practice models. They also wish to address issues with workforce, funding flows, and the lack of appropriate housing to prevent admission to hospitals, and to facilitate discharges from hospitals. NHS Midlands and Lancashire and Shropshire, Telford and Wrekin health system co-created an approach to develop and deliver a robust Transforming Care Programme (TCP) to meets these priorities.

Action

Our TCP Service provides a case management function for NHS funded individuals outside of continuing healthcare (CHC). The service aims to reduce expensive hospital admissions, and improve care outcomes and experiences for individuals with LD&A and complex needs. We provided an ongoing clinical case management service to offer robust support mechanisms for patients.

Deliverables:

• Supporting TCP policy development and stakeholder management to enable robust referral management
• Overseeing, governing, and attending Care, (Education) and Treatment Reviews
• Developing and maintaining a dynamic support register to update an individual’s risk of admission to inpatient or residential units in real time
• Brokering and sourcing care packages to meet individuals’ needs
• Providing clinical case management which includes engaging the individual, assessing, planning, linking with resources, consulting with families and collaborating with clinical and social care partners
• Providing a quality assurance process for referral management
• Attending inpatient discharge review meetings and discharge planning
• Implementing a robust care review process with local authorities where required.

Impact

• Improved person-centred care and individualised packages of support for people with learning disabilities and/or autism
• Brokering care in the most appropriate environment with effective use of resources
• Effective use of expertise, promoting multi-disciplinary team working
• Individuals are active participants in their care process
• Ensuring the role of carers are active participants in the reviewing process
• The responsibilities of partner agencies, ensuring they are active participants in the reviewing process
• Family members or carers feel well supported
• Individual satisfaction (involvement, decision-making, information, respect and dignity)
• Carer satisfaction
• The individual is treated with dignity and respect