The Stabilise and Make Safe (SAMS) model aims to bring a new approach to short-term/low-level (but possibly intensive) home care support. The key driver behind the service is to prevent service users entering reablement inappropriately, instead, clearly defined assessment processes will ensure that client’s needs are identified and an appropriate care pathway is assigned.
SAMS is a client-focussed service with each service user having the appropriate level of care assigned at the initial assessment stage (in terms of frequency of visits, length of visits and expected number of weeks in service etc.) and then reviewed regularly to ensure early identification of when a service user can leave the service, requires reduced hours (for a limited time period) or requires a different, perhaps longer term type of care altogether.
An intermediate care service of this design illustrates how key recommendations set out in NICE’s guidance for Intermediate Care including reablement (NG74) can be implemented in practice.
Key recommendations include:
1.3.3: During assessment identifying the person's abilities, needs and wishes so that they can be referred to the most appropriate model of intermediate care, avoiding wherever possible the need for acute hospital admission.
1.3.4: Actively involve people using services and their families and carers in assessments for intermediate care and in decisions such as the setting in which it is provided.
1.7.2: Ensure good communication between intermediate care staff and other agencies. There should be a clear plan for when people transfer between services, or when the intermediate care service ends.
Aims and objectives
Strategic Priority One:
Enhancing quality of Life
Strategic Priority Two:
Delaying and reducing the need for care and support
Strategic Priority Three:
Positive experience of care and support
Strategic Priority Four:
Protecting from unavoidable harm
Reasons for implementing your project
The internal reablement service was an established service in the Council which sat as part of the adult social care service offer. The prime purpose of the team was to maximise peoples’ potential for independence. The service was provided by a team employed directly by the Council who aimed to reduce the need for long term care packages.
Referrals were received from the community via the screening team which usually took between two and three weeks for an assessment to take place. Referrals were also made directly from the hospitals for an assessment. There were thirteen social care assessors that are employed by the Council within the reablement function, two of which were based at Wythenshawe Hospital and two at Trafford General Hospital. Those patients referred from hospital were seen as soon as possible following notification by hospital that an assessment is required and the patient was then assessed in the hospital environment. The remainder of the reablement workers and management worked on a geographical basis within locality teams.
The service underwent a significant review in 2015 resulting in a reduction in staffing levels of approximately half of the previous establishment, down to 52.24 FTE from July 2015. This was based on a full analysis of contact time and service user pathways which highlighted that the internal reablement team were unable to improve the levels of independence of a significant number of clients entering the service and that client contact time was extremely low in comparison to the total working hours, and some 30% below the industry average when compared with other providers.
The recommendations arising from the review were to deliver a far greater impact in enabling far more clients to live independently by improving client contact times, tightening referral pathways and a refocussing of the internal team on outcomes. To ascertain whether these objectives were being achieved, a further full and detailed review was undertaken by the Children, Families and Wellbeing Transformation Programme.
The second review of reablement, concluded that the number of post-acute pathways to care were creating variability in decision making and this lack of clarity was having an adverse impact on outcomes, delays and value for money.
The review of the reablement service showed that the outcomes were not as positive as they could be and that the real cost of providing reablement as an internal Council service costs in excess of £40 per hour of client contact time. This was considerably higher than the cost of comparative services in the external market.
How did you implement the project
The tender process began in September 2015 and following procurement the new SAMS service began in December 2015.
The main strategic objectives were to:
- Improve service quality – by placing greater focus on: person centred approaches; the outcomes of service users; promoting independence; ensuring dignity in care; and safeguarding vulnerable adults.
- Develop the SAMS workforce – by strengthening the approach to workforce development and training, and being clear about the required standards.
- Strengthen the approach to contracting – by being clear with providers about requirements, having robust contracts in place with greater emphasis on quality, standards, performance and monitoring.
- Shape the market – by offering contracts based on specific geographical zones and promoting a sustainable and responsive market.
A group, made up of practitioners, commissioners and project managers looked at how pathways into reablement services had improved over the previous 5 years. They also took the opportunity to look at the reablement best practice that has been developed, from a range of authorities and their own knowledge of the in-house delivery of reablement. The group used all of this learning in the development of a new commissioning model for reablement and a service specification.
The procurement exercise saw providers compete on both quality and price – tenders were evaluated based on a ratio of 60% for quality and 40% for price. The rationale for having providers submit the price they would charge was as follows:
- Using a fixed hourly rate would risk setting the wrong price;
- Allowing providers to set their own block rate per intervention generated true competition in the market, enabling us to secure the best rates that reflected market conditions whilst allowing providers to determine a fair price for care for their individual organisation.
- Flexible pricing recognises that the cost of providing care can differ across providers and geographical zones;
- The proposed evaluation ratio of 60% for quality and 40% for price placed a majority weighting on quality supporting our commitment to quality improvement whilst striking a reasonable balance to ensure best value.
By asking providers to submit the block unit price, the council wanted to utilise the expertise of the individuals who are best placed to make the judgement over potential costs.
The SAMS service
Referrals for SAMS come via an initial assessment with recommendations and work allocated daily to the provider delivering in that locality.
SAMS is offered borough wide, however the 2 providers assemble coverage to two of the four locality areas of the Borough to ensure service users in each area receive a timely service response.
The delivery of SAMS is flexible and responsive and therapy led to meet the needs of the individual service users. This means that some clients will be with the service for just one week, whilst others may remain for longer. The core delivery model for SAMS involves letting care to the market in three-week blocks. Once a client is placed with a provider, the initial payment will cover a period of three weeks. If the provider can make the person safe before the three weeks are up, then that person can be discharged from the service and the provider will still receive a payment for three weeks care. If the client is still with the service at the end of the initial three-week period, a review (which will be conducted in conjunction with a Trafford Council Social Care Assessor) should take place with one of the following outcomes:
- The client can be discharged from the service (to home without support).
- The client can be discharged to another care service (this would happen where the review identifies that a further period in SAMS will not be beneficial and the client does not have enough independent capacity to stay at home without care).
- A request would be made for a further period of care of up to 1 week which would be reviewed by commissioners and operational staff.
To ensure that the service remains flexible, the client’s progress is reviewed regularly. The main purpose of this is to ensure that service users can be discharged from the service at the earliest (but safest) opportunity. However, it is the statutory responsibility of the Council to undertake an assessment prior to care package removal; therefore a final assessment will be signed off by a Trafford Council Social Care Assessor.
Revised SAMS eligibility criteria:
Since 1st August 2017, SAMS is now mandatory for all adults entering adult social care, who live in Trafford. People are referred because of their needs and not their medical diagnoses.
All referrals are deemed appropriate, including people who require two carers, except those where the person:
- Does not consent to referral and participation in SAMS;
- Is on the End of Life pathway and is unlikely to benefit from a programme of reablement;
- Has accessed SAMS support more than three times in the last year.
People will not be excluded from SAMS on the basis of a dementia diagnosis, complex learning disability or a brain disorder. They will be assessed on the basis of their needs and strengths, without prejudice about their potential to be ‘reabled’.
Providers are required to report on a number of performance measures in order to understand the achievements and progress of the service in meeting individual outcomes. These have been shaped as the service has progressed and are updated as necessary by Trafford Council, providers and social care assessment teams.
1) The providers are required to collate performance outcomes, as outlined below and in the Performance Framework and complete any quality assurance or self-assessment documents as required.
2) Further to issues or failed outcomes, Commissioners launch the Service Improvement Process.
3) The quality of service delivery by the providers is assessed based on:
- Quarterly monitoring
- Spot checks
- Analysis of compliments and complaints
- Service User feedback
- Safeguarding Adults
- Customer feedback
- CQC compliance.
4) Trafford Council has adopted the National Institute Clinical Excellence (NICE) dementia standards.
5) Commissioners and partners have developed a Quality Monitoring Spot Check Tool which will evidence the service users experience and outcomes this approach will commence in October 2017.
Stabilise and Make Safe KPI’s / Performance Outcomes
- Number of inappropriate referrals and source.
- Percentage (and numbers) of service users with no further homecare package required at the end of SAMS.
- Percentage (and numbers) of service users who still required a homecare package at the end of the SAMS phase, further categorised by:
- Those whose assessed homecare package at the start was reduced by the end of SAMS
- Those whose assessed homecare package at the start was maintained by the end of SAMS
- Those whose assessed homecare package at start was increased by the end of SAMS
- Percentage of service users who complete in:
- 1 to 2 weeks
- 2 to 3 weeks
- Beyond 3 weeks
- Percentage of service users who complete quicker than planned
- Percentage of service users who complete longer than planned
- Percentage of service users who did not complete as planned, further categorised by reason/destination:
- Went into long term care
- Went into another form of short term care
- Average length of time in service
- Number of service users who enter the service from:
- Hospital discharge
Net of client contribution savings £757k, these were split between full year effects from 2015/16 and part-year effect of 2016/17.
Net of client contribution savings to date of £1.271m, these are split between full year effect from 2016/17 and Part year effect of 2017/18.
Most of the savings to date in 2017/18 are from the full year effect from 2016/17. Obviously the projected savings will change month on month.
- 70 per cent of people achieve full independence. 10 per cent remaining the same, 10 per cent resulting in an increase in the care package and 10 per cent fail to complete (usually due to re-admittance to hospital).
- Reduced length of stay in hospital, preventing the risk of infection and/or loss of skills.
- Greater independence and confidence.
- Improved responsiveness – service accessed within 1–3 days of referral.
Key learning points
Trafford is a unique borough with a thriving economy and a highly skilled workforce. This has contributed to one of the challenges we face and continue to face which is the lack of homecare capacity from the independent market for service users who require long term homecare after a SAMS intervention. This results in a bottleneck in the service which reduces capacity and increases Delayed Transfers of Care (DTOCs).
Block contracts have been offered to the SAMS providers to enable them to advertise and offer an enhanced rate of pay to support and manage the throughput from SAMS. To date, recruitment has been unsuccessful, but is on-going.
There are some disparities which have been identified with the content of the referrals being made from social workers, which have impacted on delays for accessing the intervention. Development of the SAMS service is on-going and includes carrying out roadshows at all the identified locations to support the social work teams. This approach will enable them to improve the quality of the referrals and explain the journey and pathway requirements for each referral. Commissioners have worked in partnership with the providers to develop a service user leaflet which explains what to expect from the SAMS service. Providers will distribute the leaflet on commencement of the intervention.