The Humber Transforming Care Programme

What is the Transforming Care Programme?

Transforming Care is all about improving health and care services, so that more people with a learning disability and/or 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 area, including Hull, East Riding, North Lincolnshire and North East Lincolnshire.

Our Goals;

Reducing Reliance on inpatient care
Inclusive Communication CoProduction and Engagement
Training, housing and workforce
Improving Wellbeing
Transformation for safe and preventative services.

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:

Single point of contact for all CYP and Adult DSRs across the Humber four – allowing us oversight of all individuals at risk of admission (allowing strategic planning)
To support co-ordination of partner organisations and to support case managers unblock barriers to support
To Initiate an escalation process if it has been identified that current care is not meeting an individuals needs
To provide assurance (Learning reviews, audits, governance)
To facilitate all CTR/CETRs/LAEPs across the four areas to ensure consistency and awareness.

The Dynamic Support Register (DSR)– Humber 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.

The DSR should be organised in such a way that adults, children and young people can be identified when their health and care needs are increasing or complex, and may require a multi-agency response, monitoring and prioritisation for extra support. The proactive management of the DSR should enable the identification of people early enough to enable interventions that may prevent the need for a C(E)TR, but if required, trigger a community C(E)TR at the appropriate time.

Every ICS/ICB has a named lead person with responsibility for the maintenance of the DSR. For children this is usually a commissioner for children and young people DSRs and for adults a commissioner for wellbeing. The lead for the Children and young peoples DSRs across the Humber Transforming Care Partnership is Joanne Pannhausen, Clinical Lead – Transforming Care Programme (Children and young people) and the lead for the adult DSR is Rachael Watson, Clinical Lead – Transforming Care Programme (Adults)

Community Care Education and Treatment Reviews (CETRs)

The Care (Education) and Treatment Reviews (CETR’S) have been commissioned as part of the NHS England response to Transforming Care and the Concordat.

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: