The project was to expand the existing intermediate care offer and to bring together the separate therapy and reablement elements of the offer. Three organisations worked together to redesign and address key issues and problems in the existing offer that were resulting in Bristol having a poor DTOC rating nationally and placing too many patients directly into long term care before providing a period of intermediate care and assessment in their own home. We actively engaged with the NICE guidance (NG27 & NG74) to help us address these issues and put in place a new jointly commissioned and jointly delivered Home First service.
- Transition between inpatient hospital settings and community or care home settings for adults with social care needs (NG27)
- Intermediate care including reablement (NG74)
- Intermediate care including reablement (QS173)
- Transition between inpatient hospital settings and community or care home settings for adults with social care needs (QS136)
Aims and objectives
Bristol City Council, Bristol, North Somerset, South Gloucester CCG (BNSSG), and Bristol Community Health along with their acute partners North Bristol Trust and University Bristol Trust came together to:
- Start to address very poor Delayed Transfers of Care (DTOC) ratings
- Provide a more joined up community response to supported discharge
- Provide an improved intermediate care offer that allows Bristol to provide a modern Discharge to Assess (D2A) service to patients
- Move away from assessments for ongoing health and care support in an acute setting which is the key reason for high levels of DTOC and poor outcomes for patients
In the work supported by iMPOWER consulting we used and referenced NICE guidance, specifically NG27 and NG74, along with the accompanying quality standards QS136 and QS173.
Being able in our wider stakeholder communications to reference that we used NICE guidance in our design processes and in creating our Standard Operating Procedures (SOP) gave us the ability to give challenging messages with the backing of NICE credentials. This was particularly helpful when communicating changes with the acute providers.
Reasons for implementing your project
Bristol has a population of around 460,000 with increasing needs and two major hospitals with emergency departments admitting up to 400 people a day during the week. NHSE and NHSI have been taking a detailed look at Bristol as a health and care system and asking for marked improvements around the city’s DTOC rates, which at one point were among the worst in the country. There continued to be multiple routes out of the hospital and therapy and personal care routes back home remained assessed and supported separately which caused delays and did not align to the whole system approach that the Better Care Local Plan and STP had been advocating.
A year or two back around 22% of all new clients (never previously known to social care) who were supported out of the hospital were being assessed in hospital and transferred straight into long term care. The high number of assessments while people were still in hospital created delays and wasn’t achieving social cares objectives to maximise people’s independence and to have home as the default best option for any supported discharge. This was also putting increasing pressure on fragile adult social care budgets with people entering into long term bed-based care earlier than required had they been offered the right level of intermediate care at home.
The three organisations came together to find solutions and to redesign our existing provision. It was important for the confidence of the wider system and stakeholders that we brought together examples of best practice and evidence of what works. Along with papers from the Kings Fund, SCIE, the Nuffield trust and the work centrally that had produced the High Impact Change Model. However, we leaned particularly heavily on the recent set of guidance from NICE which gave us a set of principles through which to make our improvements
Guidance from NICE that we referenced in our work included:
1.5.2 The discharge coordinator should be involved in all decisions about discharge planning.
1.5.3 Health and social care organisations should agree clear discharge planning protocols.
1.5.11 Ensure that people do not have to make decisions about long-term residential or nursing care while they are in crisis.
1.5.20 A relevant health or social care practitioner should discuss with the person how they can manage their condition after their discharge from hospital.
1.5.26 Consider early supported discharge with a home care and rehabilitation package provided by a community based multidisciplinary team for adults with identified social care needs.
1.6.1 Ensure that a range of local community health, social care and voluntary sector services is available to support people when they are discharged from hospital.
These (and others!) helped us build the key principles around our design work and were used to discuss with the providers of the services in Bristol City Council and Bristol Community Health. are packages and placements.
The argument for investment was simply that the system would jointly achieve savings and make better use of existing resources if we could:
- Reduce length of stay for patients who were medically fit for discharge (The estimated cost of a patient day in a hospital bed is £400 per dayl)
- Reduce, delay and prevent the need for long term care packages and placements through greater use of reablement and rehabilitation services through a joint Home First Offer (The estimated cost of a single care home placement is £40,000 per year, for Domiciliary Care it is estimated to be over £10,000 per year)
How did you implement the project
We decided to take a joint paper to A&E delivery Board asking to use targeted investment to work to bring Bristol Community Health’s ‘Pathway 1’ discharge offer (Rehabilitation) together with personal care support provided by Bristol City Council’s in house reablement service.
New investment in the Home First Service of £600,000 was made through the Improved Better Care Fund (iBCF) specifically to bolster the personal care element of the service which could then sit alongside the therapy service and be able to take out a wider range of patients than previously had been possible.
Once the principles and investment for this new service called Home First were agreed we set up two groups:
- Home First Implementation Group – with operational managers facilitated by iMPOWER to drive the design and set up of the new service (fortnightly)
- Home First Oversight Board – with senior stakeholders across Bristol City Council, BNSSG CCG and Bristol Community health to unblock any issues, make clear decisions and communicate changes to the wider system (fortnightly)
These groups worked together across organisations to agree the recruitment, structures, criteria, processes, patient flow and key performance metrics which are all now signed off and captured in the standard operating procedures for the Home First service. The service will be scaling up from going live in November 2018 to be able to take up to 42 patients out of the hospitals each week.
The service key objectives were defined early in the process:
- To ensure that where possible any assessment of ongoing support needs is made at home rather than in the hospital setting, unless the clinical condition dictates the person needs to be in hospital for this to take place.
- Home First will be a 5-10 day service, designed to bring people out of hospital and into their own home for a period of settling, stabilisation and assessment.
- The Home First service enhances the existing commissioned slots (Bristol patients from across both Trusts) of 8 per day Monday to Friday and 2 over the weekend.
- It is an integrated service working in partnership between Bristol City Council (BCC) and Bristol Community Health (BCH) and involves therapists, nursing and personal care / reablement support.
- It is anticipated that the Home First service will lead to fewer patients waiting in hospital for assessment, and fewer going into bed based provision when their needs could have been met in the community.
- There is commitment to have one shared view to manage flow, entry and exit from Home First, through daily huddles.
- Home First aims to commence the service within 24 hours of the ICB decision being made
These were built upon national best practice which NICE is a key contributor. Slides like those below helped us make the case and work with the teams to generate the right solutions. The work produced nationally such as the High Impact Change Model, SCIE and NHS guidance on integrated care are all complimenting the vision for discharged to assess and more support to be community based.
Home First as a new service wasn’t put together in isolation. We wanted to learn from NICE’s guidance that any intermediate care service should be part of a wider joined up offer taking a more holistic view.
1.2.1 Consider making home-based intermediate care, reablement, bed-based intermediate care and crisis response all available locally. Deliver these services in an integrated way so that people can move easily between them, depending on their changing support needs.
1.2.2 Ensure that intermediate care is provided in an integrated way by working towards the following:
- a single point of access for those referring to the service
- a management structure across all services that includes a single accountable person, such as a team leader
- a single assessment process
- a shared understanding of what intermediate care aims to do
- an agreed approach to outcome measurement for reporting and benchmarking
To do this we worked with wider partners including the neighbouring councils of North Somerset and South Gloucester that come under the same CCG footprint to develop a diagram that illustrated the intermediate care offer right across the patch.
The diagram in the supporting documents has now been shared with all the wards across both hospitals to highlight a more joined up and integrated route out of hospital. It helps us achieve many of principles proposed in the NICE guidance.
This initial investment will be reviewed as part of a wider BCF review for the financial year 2019/20 and a proper Home First budget will be created should the implementation prove to be successful, but early data is very encouraging.
The week before Christmas which is one of the busiest times of year for the hospitals 38 patients were supported home through the Home First Service. This is a marked increase to the numbers previously being supported out through separate intermediate care services in rehabilitation and reablement where numbers per week were closer to 20 to 25. Without this new intermediate care capacity these patients may well have had to stay in hospital over the Christmas period and wait for full social care assessments. There would almost certainly have been an increase in the number of these patients who would have become a DTOC. 55% of the 38 patients supported out with Home First received personal care alongside their rehabilitation needs as a direct result of the recent recruitment and direct investment made through the iBCF.
With the service only having been live for a couple of months it is too early to make statements about to long term impact of these changes to the health and care system in Bristol. However, early indications are positive with and joint working is proving to have an impact on who intermediate services can support and safely discharge back home.
We have a set of shared KPIs in place which will help to tell us how the service is performing
- How many patients went to the preferred discharge route (which will help us with capacity and funding for the future)
- Activity levels against a 42 patients a week target final target once fully staffed
- Speed of supported discharge against a 48 hour target
- That all clients get a first visit from a clinician and receive proper goal setting in their home environment
- That an exit plan is in place within 72 hours of them being discharged into the service
- The numbers that are able to self-manage and remain independent in their communities following the Home First service
We have attached some early data, but in February we will be fully staffed and have one quarter's data to review, which will start to give us a more concrete picture.
Key learning points
- Bringing together different organisations to deliver something together needs real senior investment in time and energy to drive it through
- All sides have to share in the purpose and principles of what you are trying to achieve
- The patient needs to be more important in the narrative than individual organisational cultures and practice to allow the space for change
- Senior leaders have to take some risks they have to try something new its so easy to use organisational barriers, funding barriers, IT and workforce barriers to find a reason not to do something different. Its much tougher to find solutions and take action
- The Trusts are still disproportionately powerful in the overall system counter to the NHS FYFV. This is no one’s fault as it’s very long standing and cultural but community provision needs a more equal voice in the discussions and debates about service transformation
- Get the people that will actually be delivering the service in a room together. Carve them out some time. Let them come up with some of the solutions and design the ‘how’ once senior leaders have set out the ‘what’
- Don’t formalise too early. Use pilots to test and shape work. The structures around CCG and Council sign off and decision making for permanent funding of new services is too slow to be able to keep up the impetus and pace of reform.
- Explain to the Trusts not all discharge support services are equal. Placing someone directly into a long-term care home placement is bad for them, puts undue pressures on the family/ carer to make snap decisions, means longer in hospital and results in increased DTOCs. So that why Trusts need to support the Discharge to Assess model