Enabling Intermediate Care

Guided by the NICE guidance for intermediate care, our aim was to embed intermediate care core principles in our community hospitals in order to reduce the number of people who are delayed from leaving hospital once medically stable to leave; reduce number of people who are admitted directly to a care home following acute admission and optimise independence to reduce need for long term commissioned care, including care homes.

The new model of care focused on 5 main deliverables:

1). Community equipment in our community hospitals;

2). Development of a new workforce model, including collaborative AHP/Nursing leadership and increased social care presence to support patients and carers;

3). Training and development of the workforce including the development of a shared skills framework to support the development of shared skills across the workforce;

4). Developing a new daily routine including daily board rounds; MDT goal setting;

5). Communication - the use of ‘scrums’ and communication cells. By focusing on the above deliverables we aimed to develop our community hospital services to meet the NICE guidance standards as identified in section 4.

This AHP led project, delivered with our community hospital teams; focused on redesigning our approach to bed based intermediate care (IC). Initially, instigated by the publication of the NICE guidance for intermediate care (IC), a review and benchmarking exercise was undertaken. Following a successful Integrated Better Care fund bid, a new bed-based model was developed, designed and delivered which focused on embedding the key principles of IC in our community hospitals, promoting independence at every contact and preventing premature admission to care.

Our main challenge was that our new approach required significant changes to long standing practice and routines.

The impact was: patients wait less time to transfer (2 days); 28% increase in admissions supporting flow; reduction of length of stay from 14 to 20 days; Increase in patients returning directly home (55% to 69%). Increased staff morale and skill and most importantly positive patient feedback.

Having developed equitable and consistent IC across our Eastern services in relation to crisis response, home based intermediate care and reablement, we recognised that in line with the NICE guidance for IC we needed to review our bed-based IC provision. We carried out a snapshot audit of patients waiting to transfer from our acute hospital who were medically stable, but required the opportunity to optimise their independence before being able to return home.

Key areas were identified as requiring development based on patient experience feedback; patient outcomes; productivity and NICE guidance.

These were the identified areas with corresponding NICE guidance reference:

• Optimising independence at every contact; preventing premature admission to long term care; training and development to deliver core principles of IC (1.1;1.6;1.8);
• Supporting infrastructure; improving referral and assessment to and for IC(1.3;1.4);
• Entering intermediate care (1.5); Person centred planning (1.5.7);
• Agreeing goals (1.5.10); Approach to delivering IC (1.6).

The recommended outcome from our options appraisal was that we implement core IC principles in our community hospitals in order to develop and deliver our bed-based IC offer.

Our challenge was in order to achieve this, significant change in practice and culture would be required within our community hospital teams.

Implementation steps:

• Agreed delivery approach using De Bono’s six thinking hats methodology with senior management.
• Designed model using NICE guidance, AHPs improving flow, patient experience feedback and productivity stats.
• Wrote successful Integrated Better Care bid and achieved funding to deliver the project.
• Using Kotters 8 steps to managing change communicated with teams, the vision of the project, objectives, main deliverables and immediately implemented ‘scrums’ using AGILE methodology to encourage a culture of inclusion and trust to empower the workforce to come up with ideas, previous barriers, actions and solutions.
• AHP project lead with regular ward presence. Introduced AHP/Nurse collaborative leadership approach.
• Created an IC project group to empower leaders to support their teams to deliver objectives; action plan and management of risks and issues. This also enabled sharing learning, good practice.
• Produced Intermediate care dashboard to monitor and share progress.
• Developed comm cells to increase communication in teams - sharing outcomes including person stories.
• Inclusive approach to continuous improvement.
• Adopted new approach to gaining patient experience feedback using survey monkey and involving patients and carers in the service development.
• To achieve the change we had support from the staff on the wards including social care assessors; Chief Nurse; transformation team; admin/project support;local service and clinical managers/directors;practice coaches.

Specific patient involvement:

• Asking patients what activities they would be interested in doing on the ward to maintain their independence, in order to plan our group rehab sessions.
• Ask every patient about their experience following discharge over the telephone – taking on board feedback and taking actions to improve experience and quality of care.
• Weekly senior clinician walk around where everyone is asked what we can do to improve their experience on the ward – taking feedback and implementing learning from experience.
• Patient and carer involvement in developing patient information pack which is given to patients on the ward
• Individual discussions with patients to understand their experience and with consent share wider to help other understand more about our service.

Quality impact:

1. Increased compliance to NICE guidance by approximately 50%.

2. Patient feedback reported 90% recommended our service; were treated with dignity and respect and knew the next step.

3. Shared skill competencies developed across workforce encouraging enabling at every contact and staff increased morale.

4. Increase individual and group activities on wards e.g. breakfast club/exercise groups.

5. Increase in individuals being discharged to their own home from 55% to 69%.

6. Proactive social care provides information and support to patients and care supporting them to make informed decisions about next steps.

Productivity impact:

1. 28% increase in admissions to community hospitals.

2. Reduction in length of stay from 20 to 14days.

3. Reduction in wait time to transfer to unit from 5 to 2days.

In relation to 'AHPs into action' principles I believe this project demonstrates AHPs in action, in most areas. With the main impacts being on improving health and wellbeing and supporting organisational and workforce integration. Evidence based practice was applied across 3 different hospitals with the same impacts and outcomes demonstrating consistency. It evidences that, in just 6 months, AHPs can lead change and further develop by sharing and development their skills and that AHPs can evaluate, improve and evidence the impact of our contribution.

Cost-saving:

It is difficult to quantify whether the initiative was cost-saving. The cost-savings would likely be for social care - as there is a reduced requirement for Package of Care (POC) on discharge (leading to increased independence), and a reduction in the number of people being discharged to a care home. Other potential savings may arise from a reduction in staff sickness and a reduction in Delayed Transfer of Care (DTOC) across the Trust.

Lessons learned/would do again:

• Strong AHP and nursing leadership is required in order to nurture this collaborative approach to practice to ensure all staff groups feel valued.
• When developing skills across the workforce using terminology like 'shared skills' is more helpful than 'generic' skills.
• A rolling training programme for all staff, that includes evening sessions for night staff seemed to be the most productive way to deliver training however finding time to take people offer the ward was challenging.
• Taking away weekly MDT meetings and introducing daily board rounds was daunting at first for teams, but has led to closer team working and better outcomes for patients.
• Regular peer support groups and different approaches to allow teams to feedback and make suggestions is essential to maintaining pace of change; staff morale and sustainability of delivery.
• An inclusive approach like using AGILE 'Scrum' cards helps staff lead the change themselves; overcome perceived barriers to doing things differently; find their own solutions together and hold each other to account in order to deliver action and change.

Lessons learned / would do differently next time:

Would introduce clinical outcome measures (Barthel) sooner to ensure more clinical evidence was available to demonstrate impact before and after delivery.

Overcoming barriers

• The scrums (AGILE model) that were initially implemented were fundamental to identifying and overcome barriers with teams and empowering them to make to lead the changes that were needed– teams were asked to identify any barriers in achieving our vision and the team identified these and  took timely action to overcome them.
• Utilising NICE guidance helped us to achieve support and funding from the Improved Better Care Fund (IBCF) in relation to delivering a project that was based on best practice