Bed-based intermediate care: Somerset Care and Yeovil District Hospital

The overall aims of this collaboration were to:

• improve patient flow at Yeovil District Hospital
• reduce unnecessary length of hospital stay
• enable reablement in an appropriate environment
• maximise patient clinical outcomes
• reduce ongoing costs of care

In 2015, Somerset County Council’s significant deficit meant that doing more of the same was not an option. Its task was to save money for the health and care system and improve the health and wellbeing of people with highest levels of need.

Initially we approached Somerset CCG and Somerset County Council commissioners for funding for a pilot project, to evidence that we could achieve the aims listed above by working in a different way across the health and care system. Both declined. So YDH decided to fund the pilot itself using some of its “winter pressures” money.

Somerset Care is a not-for-profit provider of social care for older and disabled people, and initially, funding for the block purchasing of 18 beds at Cookson Court came from YDH ‘winter pressures’ money. Initially they paid only £750 per bed per week, in contrast to the cost of acute care estimated by the Department of Health to be £400 per day, or £2800 per week; now the fee rate is £825 per bed per week. The average cost of care in this brand new purpose built nursing home is currently £963 per resident per week.

The facility is staffed by Somerset Care’s nurses, advanced healthcare practitioners (Nurse Associates) and care staff. However, between 8am and 8pm every day, members of YDH's rehabilitation team (e.g. physiotherapists and occupational therapists) work on site in collaboration with Somerset Care staff. The NICE guidance encourages the partnership approach to delivering intermediate care in this way through recommendations under section 1.2.9 of the guideline which recommends a range of skills and competencies are available for people who need them.

Collaboration and integration of services does not require a change in organisational form or complex rearrangement of budgets, it depends on relationships between people at different levels in the collaborating organisations.

Admissions and discharges to the service are managed by the physiotherapists on the team.

A proactive approach to case finding is taken with the team conducting daily searches for patients at Yeovil District Hospital. Patients are eligible if they are:

(1) Assessed and documented as medically fit for discharge to their usual place of residence, with a completed discharge summary, a Treatment Escalation Plan in place, and medications ready.

(2) Have an evidenced potential for reablement, are signed up to a programme of intensive reablement for 10 days, with a demonstrable ability to actively engage with rehabilitation (physically and mentally), have had their holistic therapy requirements identified, and have a completed care plan if specialist involvement is required.

Elements of this approach align with recommendations for assessment of need for intermediate care in section 1.3 of the NICE guidance.

Patients are ineligible if they have had a stroke; have had chest pain within the last 24 hours; are receiving intravenous therapy; are medically unstable; are ≤ 72 hours post myocardial infarction; or have no fixed place of residence.

Physiotherapists and occupational therapists assess patients in hospital to determine outcome goals. Goal planning is a key recommendation in section 1.1 of the NICE guidance. For the purpose of the pilot, they also assessed levels of care and support that would have been needed if the patient been discharged straight home from hospital.

When suitable patients are identified, they are transferred to Cookson’s Court, with their consent, for a 10 day period of intensive reablement. At the end of the period of reablement, they are assessed again and discharged home, with or without home care and support, as required.

Care needs before and after admission to Cookson’s Court are then compared.

When patients arrive at Cookson’s Court, they have a care plan for their reablement and clear individual goals to achieve, which they are involved in setting. Both YDH and Somerset Care staff are trained to promote independence, encouraging people to perform activities of daily living themselves. Doing everything for people has a tendency to “dis-able” them, so instead we demonstrate how to perform tasks safely and then support people to do them independently. Where possible, and with help from families, we adjust furniture height and position to most closely resemble a person’s own home.

When a person is ready to go home, we ensure they have appropriate care and support in place if necessary.

A key barrier to continuing this collaboration and starting more collaborations like it is the way funding is currently organised across the health and care system. Hospitals for example are paid for activity, so there is a financial disincentive to move people out of hospital. Cost-benefit analysis needs to be performed on a system-wide basis, with a recognition that investment in one area may benefit another, but the people receiving care and the system as a whole benefit. Local politics can also impede the most cost-effective services being developed and delivered for the communities we serve. For example, use of community hospitals, costing £2000 per person per week, for rehabilitation, when more appropriate care home environments exist for less than half the cost.

Headline results from this project have included:

• 402 admissions to Cookson’s Court by April 2017; nearly 600 to date
• 98 per cent of people were discharged home from Cookson’s Court
• 42 per cent of patients required a reduction in their predicted home care packages upon discharge
• Service costs c. £1m p.a. to deliver
• We estimate £1.6 million savings in ongoing care costs to the local authority
• The project has also resulted in reduced elective cancellations, and income protection of an estimated £1.9m in 2017/18.

Clinical outcomes:

Goal Attainment Scaling (GAS) is a method of scoring the extent to which patient’s individual goals are achieved in the course of intervention. In effect, each patient has their own outcome measure, which they help to define, but this is scored in a standardised way to allow statistical analysis. See results here.

Feedback from people who have used the service shows the extent to which they have valued the care and expertise of staff.

• “The world is a better place because of people like you”
• “Wonderful staff, highly efficient, compassionate and very caring”
• “No praise is high enough”
• “A total credit to the service”
• “Dad returned home with renewed confidence”
• “Thank you for the advice and help you have given to us all. We will be able to care for Mum so much better now”
• “Thank you for your professionalism, friendliness and kindness”
• “You deserve a medal for your 100% fantastic service”
• “The care and support given to Mum has been amazing”
• “So grateful for your service”
• “Highly efficient, compassionate and caring therapists”
• “Cannot praise therapy staff highly enough and long may the service continue”
• “The therapy staff were amazing and nothing was too much trouble”
• “The staff were always willing- thank you for everything”
• “I did not think I’d be able to do this for months”
• “I cannot thank the therapists enough for their encouragement and treatment – they are a credit to the NHS”
• “I feel so privileged to have been able to come here, I just wish I could thank you all personally”
• “ There are no words to express my gratitude, thank you with all my heart. I’ve been born again.

• Provider organisations can work together to challenge traditional boundaries and ways of working, even if commissioners are initially unsupportive. Gathering good quality evidence is essential to make a compelling case to commissioners.
• The value of this collaboration is the true partnership and integrated working between the hospital and care home, sharing skills and experience for the benefit of the people we serve. The presence of hospital staff in the care home every day from 8am to 8pm helped to build trust and confidence quickly – as soon as positive relationships were created, the rest was much easier.
• Physiotherapists, OTs and rehab workers rotate shifts between hospital and care home, so they keep information flowing between the two locations.
• Central to the success in achieving a relatively short length of stay is the fact that physios/OTs from the hospital control admissions to and discharges from the reablement service in the care home. One initial objection to this proposed collaboration raised by the local authority was that “once people are in a care home, they remain there”. These data provide clear evidence that this is not the case.
• Reablement requires a culture change, and staff need training and supervision, so they learn to promote independence and encourage people to perform tasks themselves, rather than doing things for them.
• Most people had only positive words to say about their experience in hospital, but really noticed the benefit of moving to a quieter and more homely environment, more suited to their ongoing reablement and recovery. Some people made quite dramatic recoveries in a few days, simply due to the change in environment. An appropriate environment really matters for reablement and facilitates a more rapid return to health and well-being.
• An intensive period of reablement in an appropriate environment like Cookson’s Court is likely to enable a faster recovery than if people go straight home. At home, people do not have access to physios/OTs and rehab workers for 12 hours a day, 7 days per week, and thus it takes longer for confidence and physical strength to be restored. Home care reablement, which is typically funded for up to 6 weeks, is not necessarily a cheaper option than a short term spell of intensive reablement in a care home, and may be less effective and more expensive in the long run. More comparative evidence needs to be obtained on this.
• The administration of a collaboration like this takes more time than we had originally anticipated due to the relatively fast flow of patients/residents through the care home, compared with a typical care home where people typically stay for much longer.
• It is necessary to explain new models of care to CQC and ensure governance arrangements are clear.
• In many areas, Sustainability and Transformation Plan (STP) discussions have excluded social care providers, and health colleagues are unaware of available facilities, workforce and skills. Active engagement with social care providers would encourage innovation and collaboration.