The Case · almost 12 months to complete and engaged clinical, social care and support staff from...
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The Case for Change I N T E R M E D I A T E H E A L T H A N D S O C I A L C A R E S E R V I C E S I N D O N C A S T E R Produced by the Intermediate Health and Social Care Needs Review Team on behalf of NHS Doncaster Clinical Commissioning Group and Doncaster Metropolitan Borough Council. May 2016
Transcript of The Case · almost 12 months to complete and engaged clinical, social care and support staff from...
The Case for Change
IN
TERMEDIATE HEALTH
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Produced by the Intermediate Health and Social Care Needs Review Team on behalf of NHS Doncaster Clinical Commissioning Group and Doncaster Metropolitan Borough Council. May 2016
Section 4:Why change?
Section 5:What does good look like?
Section 6:Future vision
Section 3:The needs of people in Doncaster
Section 2:How has the evidence been collected
Section 1:Introductionand background
Contents
Section 1:Introductionand background
1. Introduction
2. Background
3. What is intermediate care?
4. Are intermediate care services effective?
5. Intermediate care services
6. Intermediate care environment
Introduction and background
“Strategically planned, adequate intermediate care capacity should be an essential step for local health and social care commissioners if the whole system is to function optimally.”
Professor John Young (1) National Clinical Director for Integration and Frail Elderly, Steering Group member for National Audit of Intermediate Care
In 2014 the Health and Wellbeing Board and the Joint Adult Commissioning forum in Doncaster identified that they needed to better understand the needs of people being admitted to hospital and using intermediate care services in Doncaster. It was acknowledged that intermediate care services had not been planned as a discrete service but had evolved over time with funding from a number of sources and although individual services reported good outcomes, no one organisation had a comprehensive overview of how the services worked together as a whole. Patient and carer feedback also suggested it was difficult to navigate these services.
Given the challenges of maintaining health and social care services with increasing financial pressure and an ageing population, it was also recognized that intermediate care could play a pivotal role in how the Doncaster health and social care system responds to these challenges.
Consequently the review of intermediate health and social care needs was launched as one of the Better Care Fund schemes of work(2). The aim of the review was to gather evidence about the performance of the current system and clearly identify what the local need for intermediate care is to inform the development of the future service model.
A number of activities have been undertaken as part of the review and these are described in section 2. The most significant of which was a review of the records of 1,027 people who used intermediate care services in 2014 by MDT panels. This took almost 12 months to complete and engaged clinical, social care and support staff from services across Doncaster. The evidence collected in the review has been used to produce this case for change and in the final section the key elements of a future intermediate care offer are outlined.
References: (1) National Audit of Intermediate Care 2014. NHS Benchmarking (2014). (2) Doncaster Better Care Fund plan- DCCG and DMBC 2014 (refreshed 2015 and 2016)
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Introduction and background What is intermediate care?
The definition on the right has been developed by NHS benchmarking, as part of their work on the national audit of intermediate care over the past four years. Although it was recently approved by the Plain English Campaign our review found that in reality intermediate care means different things to different people and there are several other terms that are routinely used in relation to intermediate care including those above.
Are intermediate care services effective?
There is a growing body of evidence that suggests that hospital is not always the best place to meet the needs of older, frail people or people with Dementia and examples of intermediate care being effective in preventing such admissions have been cited in a number of recent publications (3, 4, 5, 6, 7). In particular services that provide an early intervention or a crisis response seem to have a significant impact on reducing admissions.
Some types of intermediate care services have been demonstrated to be more effective than others. For example there is significant evidence that hospital at home and early supported discharge schemes for elderly patients with certain conditions can be a safe, effective and a less expensive option for care and have greater levels of patient satisfaction (3, 7). Telemedicine for some conditions has also been demonstrated as being effective (7) as has telecare (8). There is also a well established evidence base for rehabilitation with people who have had strokes, suffered trauma or have an orthopaedic condition (9).
In general most community based intermediate care services show some impact on quality of life by enabling people to regain skills and abilities in daily living and retain their independence (3,5,7) thus reducing dependency on longer term support services. Social care re-ablement services in particular, have been proven to be effective in reducing ongoing care costs, by as much as 60% in some cases (8).
The evidence base for nurse led bed based intermediate care services is more limited. Although they are thought to be safe they maybe inefficient.(3)
Intermediate care as a concept emerged out of the National Service Framework for Older People in 2001(1) and updated guidance was published in 2009 (2). It was originally conceived as a platform for integration between providers and between health and social care professionals. It was to act as a link between services.
Intermediate Care describes the function of a group of services not a discrete service. The services that make up intermediate care can, and do take many forms, depending on the local context. Generally these services have emerged to fill gaps rather than been designed as a whole (1). Guidance suggests they should be multi professional services with access to a wide range of therapeutic skills.(2)
A range of integrated services to promote faster recovery from illness, prevent unnecessary acute hospital admission and premature admission to long-term residential care, support timely discharge from hospital and maximise independent living.
Intermediate care services are usually time limited, normally no longer than six weeks and frequently as little as one or two weeks. Intermediate care should be available to adults age 18 or over.
National audit of Intermediate Care 2015 (3) NHS Benchmarking (Plain English approved definition)
References: (1) National Audit of Intermediate Care 2015. NHS Benchmarking. (2015) (2) Intermediate Care. Health Service/ Local Authority circular. Department of Health (2001) (3) Intermediate Care- Halfway Home- Updated Guidance for the NHS and Local Authorities. Department of Health (2009) (4) Safe, compassionate care for frail older people. NHS England. (2014) (5) Growing Older Together. NHS Confederation.(2016) (6) Reasons why people with Dementia are admitted to a general hospital in an emergency. Public Health England (2015). (7) Avoiding hospital admissions what does the research evidence say? Kings Fund (2010) (8) A vision for adult social care: Capable communities and Active Citizens. Department of Health(2010) (9) Commissioning guidance for Rehabilitation NHS England (2016
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http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-Purdy-December2010.pdf
187 Rehab assistants or Enablement support workers
98 Nurses
63 Therapists
18 Social Workers
15 Managers
11 Administrators
10 Health Care Assistants
9 Assessment Officers
8 Support Team Managers
8 Case Managers
6 Mental Health Nurses
3 Discharge Nurses
3 Cooks
2 Activity Co-ordinators
A variety of sessions from Geriatricians, Stroke Consultants, Psychiatrists and GPs
4,092 Referrals to core intermediate care services
3,197Referrals for discharge planning to Integrated Discharge Team
693 Referrals for assessment to the Rapid Assessment and Prevention Team in A&E
169 Intermediate care beds in six bed based units
24 CAP (Community Assessment Pathway) beds
2Community teams with a combined caseload of over 200
Introduction and background Doncaster Intermediate Care Services
Workforce
Spend Over £27 million Referrals
Bed-based Services
Home-based Services
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Introduction and background Doncaster Intermediate Care Services
Dedicated intermediate care services Services providing elements of Intermediate CareAssessment Community Services Community Beds
Hawthorn Ward (1) 18 beds
Short Term Enablement Programme (STEPS)Approx. 160 on caseload
Mexborough Montagu Hospital (MMH) Rehab Unit: 56 beds
Falls Service
Community Nursing
Rapid Assessment and Prevention Team (RAPT)
Community Intermediate Care Team (CICT) Approx. 50-60 on caseload
Positive Steps: 33 beds Rowena & Oldfield (2)
Wellbeing Team
Community Therapy Services
Rose House: (3) 8 beds General Practice
Out of Hours
Integrated Discharge Team (IDT)
Early Supported Discharge Teams (Stroke and COPD)
Hazel Ward: 20 beds ECP Service
HEART-Telehealth
CAP Beds (1) 24 beds
Home From Hospital (AGE UK)
Magnolia Ward: 14 beds Telecare
Stroke Outreach Team
Windermere ward: 20 beds Integrated Community Equipment Service
Older Peoples Mental Health
Living Well project
Social Prescribing
Neuro Rehab Outreach Team (NROT)
The dedicated intermediate care services in bold were the main focus for the review and in particular the audit.
The other services were reviewed as part of the stakeholder mapping.
Changes to services during the review period:
(1) In 2014 there were six CAP beds located on Hawthorn ward; they are all now located in care homes.
(2) 12 of the social care assessment beds for people with Dementia were located in Rowena House and Oldfield House until late 2014 when they were transferred to Positive Steps.
(3) Rose House also closed in early 2015 - when all social care rehab & assessment beds were co-located at Positive Steps.
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Introduction and background Doncaster Intermediate Care Environment
Intermediate care services in Doncaster are commissioned by two organisations (Doncaster CCG and Other) and provided by four organisations:
• Rotherham, Doncaster and South Humber Foundation Trust (RDaSH)
• Doncaster Metropolitan Borough Council (DMBC)
• Doncaster and Bassetlaw Hospitals Foundation Trust (DBHFT)
• AGE UK.
There are a number of core intermediate care services that provide assessment and time limited interventions specifically to:
• Maintain people in their own homes
• Avoid a hospital admission (Step Up)
• Facilitate a timely discharge from an acute bed (Step Down).
See columns 1-3 in the table on page 7 for details.
Several other services provide elements of intermediate care or support the intermediate care function. The main ones are listed in column 4 of the table on page 7. In 2014 there were nine different bed based services, two community teams and two assessment teams based in the acute hospital providing dedicated intermediate care services. There are now six different bed based services, three community teams and two assessment teams.
The diagram on the right represents the current configuration of services and highlights the complex pathways which exist to access and move between current services.
People who were interviewed as part of the hospital discharge pathway project (HDP) and their carers described a sense of ‘not knowing’ when accessing these services. Staffs who work in the services also find it difficult to know what services are available and how to refer to them.
This complexity provides some evidence of the need for change and was the rationale for the review which has been undertaken to help understand these services better and identify what the future should look like.
Step upStep downOther referrals
DBHFT
Local Authority
Bed Based
Home Based
RDaSH
Primary Care
MMH Rehab Unit
Wards
IDT
OPMH Liaison
STEPS
MAU A&E
RAPT
Complex Assessment
Beds
Home Care Package GPs
Community Nursing
Community MH
Magnolia
Windermere
IC Beds Hazel & Hawthorne
Community Therapy
CICT
Social Care Assessment(Positive Steps, Oldfield, Rose,
Rowena)
Acute
Home or Care Home
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Section 2:How has the evidence been collected
1. Review of Intermediate
health & social care in
Doncaster
2. In depth pathway review
3. Needs review
How has the evidence been collected? Review of intermediate health and social care in Doncaster
• In depth review of 30 patient journeys (part 1)
• Needs review of a statistically significant sample (part 2)
Systematic review of evidence and examples of delivery models
for IC and regalement.
• Desktop analysis of data relating to current IHSC services.
• Participation in two cycles of NAIC Benchmarking.
Visits to current services and 51 interviews with key stakeholders
WORK STREAM 4
Study of IHSC needs WORK STREAM 3
Evidence ReviewWORK STREAM 2
Data collection and analysis
WORK STREAM 1
Stakeholder mapping and engagement
KEY PRODUCTS:
Service Directory & key issues
Patient/ Service user and Carer Engagement• Review of existing patient and carer feedback relating to current IC services.
• 58 face to face interviews undertaken with current patients and carers.
• Linked with Hospital Discharge Pathway Study lead by Sheffield University- In-depth qualitative study, following 22 client journeys from hospital discharge to track the clients and carers experiences along this pathway.
• Collect and analyse evidence relating to the performance of the current IC system
• Clearly identify local need for IC services.
• Systematically evaluate evidence base for IC and models from elsewhere.
• Present the case for change.
• Identify key elements required in the future IC model for Doncaster.
KEY PRODUCTS:
Data report, key findings and recommendations
KEY PRODUCTS:
Literature review 1
Literature review 2
KEY PRODUCTS:Themes from part 1
Profile of needs & future pathways
AIM
SThe review of intermediate health and social care in Doncaster began in 2014 and finished in early 2016. It has involved the following activities. Please use the links to find out more about each work stream and access the key products.
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How has the evidence been collected? In depth pathway reviews (Part 1)
Work stream 4: Study of Intermediate health and social care needs - In depth pathway reviews (Part 1)
What did we find out?
The issue log was analysed for key themes, using an adapted form of
content analysis, and two overarching categories were identified with a
number of sub categories (click here for full details).
Poor communication was the main theme. There were lots of examples
where the number of different record keeping systems used had a
negative impact on the person’s pathway and the ability of staff to
respond appropriately to their needs.
There was also evidence that the current service model adversely affects
the quality of care people receive. For example, the need for lots of
separate referrals to lots of different services causes delays and often
unnecessary referrals are made. Or people were in hospital unnecessarily
because care was not co-ordinated across acute & community services
and appropriate community support was difficult to access, delayed or
unavailable.
What did we do?
Nine GPs from across the five Doncaster localities identified patients who
had recently used intermediate care services or were in their top 2%
risk profile and had an unplanned admission(s) in past six months.
30 people gave their consent.
Five multi-disciplinary, multi-agency desk top reviews were held to review
these journeys. Each review required access to at least four electronic
record systems and up to four sets of paper notes in order to see all the
elements of the person’s journey.
27 timelines were produced and a log of 149 issues.
See full methodology for more details.
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How has the evidence been collected? Needs Review (part 2)
Work stream 4: Study of Intermediate health and social care needs - Needs Review (part 2)
What did we do?
1027*records were reviewed from 16 touch points along the intermediate pathway to capture a picture of people’s needs when they were referred to the following services.
A&E/ MAU (over 75)
STEPS Step Up (SU)
STEPS Step Down (SD)
Hazel Step Down (SD)
Positive Steps
RAPT CICT Step UP (SU)
CICT Step Down (SD)
Magnolia Rose
Windermere Hawthorn Step Up (SU)
Hawthorn Step Down (SD)
MMH Rehab Centre
Rowena
Oldfield
This was followed by 78 Multidisciplinary; multiagency panels held over 10 months to review the needs captured and identify future optimal care packages. 71 health and social care staff involved in the panels including:
Nurses
Mental Health representatives
Social care staff
Therapy staff
Community & Voluntary Sector staff
Geriatricians
GPs
*A statistically significant sample of the total number of referrals made to these services in 2014, using the Clopper-Pearson method to give a 95% confidence rate and a 10% margin of error.
Terms used to describe the sample from the needs review.
Sample description What was this sample designed to represent? 100% represents
Whole sample All referrals to core intermediate care services in 2014
4,091
A&E sample All A&E or MAU attendances by over 75 year olds in 2014
13,542
Step Up sample All referrals to intermediate care services to avoid an admission or maintain someone at home
1,067
Step Down sample All referrals to intermediate care services to facilitate discharge from an acute ward.
3,024
Study methodology
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Section 3:The needs of people in Doncaster
1. Where do people who use IC services live?
2. Age, Gender, Ethnicity and residential status
3. Pre-existing/ Long term conditions
4. Previous level of functioning and reason for contact with services
5. Needs of people when they access intermediate care
6. Summary profile
7. Type and levels of need
The needs of people in Doncaster Where do people who use Intermediate Care services live?
This map is reproduced from Ordnance Survey material with the permission of Ordnance Survey on behalf of the Controller of Her Majestys Stationery Office (c) Crown copyright. Unauthorised reproduction infringes Crown copyright and may lead to prosecution or civil proceedings. License Number 100019782. 2014.The map may contain Aerial Photography Supplied by the GeoInformation Group (c) 1997, (c) 2002, (c) 2005, (c) 2007.
Intermediate Care Needs - Provision/demand
LegendMexborough Montagu
DRI
Positive Step
Oldfield/AIM
Hazel, Hawthorne & Magnolia Ward
Rowena/AIM
Rose House Assessment Beds
Residential and Nursing Homes
Clients in receipt of IC
Deprivation ScoreBetter Than Average
Slightly Better Than Average
About Average
Slightly Worse Than Average
Worse Than Average
The map on the right plots Doncaster Intermediate care services and the postcode of its users* in 2014 against deprivation scores. There are several clusters of higher demand and there is a correlation between service user area of residence and above average rate of deprivation. Doncaster is also ranked 39th most deprived local authority out of 326 areas nationally.
It also shows the location of bed based services in 2014. It appears that Doncaster Intermediate Care bed based services are situated diagonally through the centre of Doncaster, from south/west to north/east.
The majority of people who have received an intermediate care service in 2013/14 come from areas surrounding these beds based services.
*It was only possible to use data from users of social care intermediate care services to produce this map. It does not represent
where users of health services reside as it was not possible to utilise postcode data for that group due to organisational
governance procedures.
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The needs of people in Doncaster Age, gender and ethnicity
The chart below shows the demographics of the sample reviewed by the MDT panels, alongside national and local population data. In general the sample was representative particularly in terms of age, gender and residential status. Although the sample was not representative of the ethnicity of the Doncaster population it is not yet clear if it was representative of those who use intermediate care services.
The low percentage could indicate that people from BME backgrounds are under-represented in intermediate care services or it could be due to difficulties collecting ethnicity data for at certain touch points. It will be important to investigate this further to ensure that future services are designed to meet the needs of everyone in Doncaster.
The sample reviewed Referrals to Intermediate care services
Doncaster population National data Future
Gender 38% Male
59% Female
Anecdotally staff report that they have more women than men on their caseloads. The data has not been collected to support this.
There are fewer men than women aged over 75. There is half as many men as women aged over 85 years in Doncaster.(1)
Not Known Although women do currently live longer the gap between male and female life expectancy is falling.(2)
Age 18-64 6.4% 7.9% 83% (1) 5.4% used IC services in NAIC (3) Life expectancy will continue to increase resulting in greater numbers of older people than ever before. Predicted to increase by 19% for people over 65 and 40% for people over 85 by 2025. (2)
65-84 46.8% 49.7%
17%(1)
46.3% in NAIC (3)
85 + 43.4% 42.4% 48% in NAIC (3)
Ethnicity Just over 1% of the sample were from Black & Minority Ethnic (BME) backgrounds. This was made up of people from Indian, Caribbean & other white ethnic groups.
*It was only possible to collect
ethnicity for 80% of the sample.
Not known- need to do further work to understand if our sample is representative of the take up of Intermediate Care services by people from BME backgrounds.
The population of older people from BME backgrounds in Doncaster is 2.9%.
The proportion of the total population in Doncaster classified as ‘White British’ equates to 91.8%. Those from BME backgrounds represent 8.2% of the total population. (4)
The average proportion of the population who are older people from BME communities nationally 8.4%.
The national average in the total population is 80.45% (4)
In the 2011 census there were 4.7% more people from BME backgrounds in Doncaster than in 2001. These were predominantly working age adults or younger. As this population gets older the demographic using intermediate care will also change.
Residential status 57% live alone Not known 61% of females aged over 75 live alone and 34% of males aged over 75 (1)
3.5 million people over 65 live alone. 2 million people over 75 live alone. (5)
This is expected to increase in Doncaster by 12% for women and 21% for men by 2020.(1)
References: (1) Older People in Doncaster- Statistical overview. Public Health DMBC (2016). (2) Tomorrows world the future of ageing in the UK. ILCUK (2016). (3) National Audit of Intermediate Care 2014. NHS Benchmarking (2014). (4) Doncaster Joint Strategic Needs Assessment (2014) (5) Growing Older Together. NHS Confederation.(2016)
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The needs of people in Doncaster Pre-existing health problems and long term conditions
The majority of people in the sample were older people with long term conditions or multiple morbidities for whom purely disease specific pathways do not work. People with long term health conditions now take up 70% of the health services budget not illnesses susceptible to one off cure (1) and they will likely require the most support and treatment across the health and social care system (2, 3).
• 83% had two or more long term or pre-existing conditions
• 63% had three or more long term or pre-existing conditions
• 41% had four or more long term or pre-existing conditions
• Only 7% had no long term or pre-existing conditions
Nationally the data suggests that people over 75 live with on average three long term conditions (3). Public Health data for Doncaster shows that there are more people who report living with three or more long term conditions in Doncaster than the national average (4). With a growing older population these numbers are likely to increase in the coming years. Doncaster also has higher than average prevalence of COPD, Asthma and Diabetes (5).
References: (1) NHS Five Year Forward View NHS England (2014) (2) Commissioning for Value- where to look Doncaster CCG Right Care (Jan 2016) (3) Growing Older Together. NHS Confederation.(2016) (4) Older People in Doncaster- Statistical overview. Public Health DMBC (2016) (5) Doncaster Joint Strategic Needs Assessment (2014)
MOST COMMON PRE EXISTING AND LONG TERM CONDITIONS Taken from past medical history.
Hypertension 34%
Heart problems (incl CCF/LVF/Heart Failure/Angina, MI, Heart Disease, Pacemaker) 30%
Arthritis 21%
Respiratory Problems (COPD & Asthma) 21%
Diabetes 20%
Sensory Impairment (incl blind, deaf, visual/ hearing problems) 18%
Dementia 18%
CVA/TIA 16%
Cancer 15%
History of falling 14%
Atrial Fibrillation/CVD/Tachycardia 13%
Mental Health problems 11%
Chronic Kidney Disease 10%
Previous Knee or Hip Replacement 10%
Thyroid problems 8%
Osteoporosis 7%
Cognitive Impairment (Not Dementia) 6%
Hypotension 4%
Parkinson’s Disease 3%
Independent Commission on Improving Urgent Care for Older People 2016 (3)
With increasing age people tend to live with multiple long term conditions…. yet we have designed much of our primary and acute care system and evidence- based guidelines around single conditions in otherwise fitter and younger people. For people with multiple long term conditions or ‘multi morbidity’ we need a very different style of medicine geared up around individuals needs and not a medical model or disease- focussed approach.
Dementia/ Cognitive Impairment
NHS England state that around one quarter of people admitted to hospital have Dementia(1). The number in our sample was slightly smaller than this, although when combined with those identified as having support needs around cognitive impairment not a formal diagnosis it increased to 26% and will have included those without a formal diagnosis and those part way through the assessment process for Dementia.
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The needs of people in Doncaster Previous level functioning and reason for contact with services
Previous level of functioning
Prior to coming into contact with services a significant proportion of the sample were living at home independently (20%), mobile (25%) and transferring without any aids or assistance (20%). 33% had some informal support from family and friends and 51% used a walking aid of some description (walking stick or a frame).
22% already had a formal package of home care and a further 14% had some other type of formal support or care at home e.g. nurses, support workers, therapists.
3% required assistance of one or two people prior to this contact and 2% were fully dependent. A small number were wheelchair dependent and it was not possible to identify previous level of mobility for 13% of the sample.
Only 2% of the sample lived in a care home prior to the episode reviewed. The majority of these were in the A&E sample. Traditionally Intermediate care services do not work with people who are already in a care home. (See section 7 for further discussion regarding care homes).
Reasons for contact with services
The main reasons why people in the sample reviewed attended A&E, were admitted to hospital or were at risk of an admission were;
1. Falls (29%)
A fall or falls was the main reason people in the review sample had come into contact with services for the episode of care being reviewed. The number of falls in the Step Up sample was slightly higher than the Step Down sample and 38% of the A&E sample had attended due to a fall. Falls also accounted for 2,861 calls to Yorkshire Ambulance Service (YAS) in Doncaster last year and falls were number five in the top five presenting conditions for Emergency Care Practitioners in the area. YAS conveyed 56% of the people they saw due to falls in Doncaster to hospital last year.
Almost a third of those who came into contact with services because of a fall (31%) also had some type of fracture; the majority of these were hip fractures (or fractured neck of femur).
An additional 4% of the whole sample came in to contact with services due to a fracture. It is likely that for some of these a fall was also the cause of the fracture but it had not been recorded in the notes reviewed.
12% of those who had fallen also had an infection, usually a urinary tract infection (UTI) or confusion recorded as well. 2% of those who had fallen also had a blood screen imbalance noted for example high or low potassium, sodium or iron levels.
2. Local Infection (6%)
Urinary tract infections, chest infections, pneumonia, cellulitis and other local infections caused this episode of care for 6% of the whole sample. These are all ambulatory care sensitive conditions or connected to conditions that are(1) so it is perhaps surprising that there was a higher percentage of people with local infections in the sample stepping down from an acute admission than in the step up sample.
3. Planned surgery (5%)
These were predominantly in the step down sample and usually referred for rehabilitation in bed based intermediate care services. Just under half of these referrals came from Park Hill Hospital, who are commissioned to carry out routine elective joint replacement surgery in Doncaster. This cohort would benefit from being referred to intermediate care services prior to their surgery so plans can be put in place for them to receive any rehabilitation following their procedure at home.
4. Generally unwell and/or reduced mobility (5%)
This group of non-specific reasons was most prevalent in the step up sample. Reduced mobility was the most common reason for GPs referrals to step up services.
5. Social reasons and carer breakdown (5%)
For some of the sample contact with services came when their carers became unwell, they could no longer cope with their caring role or they were temporarily unavailable. Changes in home environment or to social circumstances could also trigger contact as could a gradual deterioration in the ability to cope with activities of daily living and self-care. Continued...
References: (1) Emergency hospital admissions for ambulatory care sensitive conditions: identifying the potential for reductions. The Kings Fund. April 2012
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The needs of people in Doncaster Previous level functioning and reason for contact with services
6. Confusion and behavioural symptoms of Dementia (4%)
Often this was linked to number 5, with either carers being unable to cope with the confusion or behavioural symptoms or risk issues connected to confusion and cognitive impairment meaning people were not safe in their home environment. For others the confusion may have been due to delirium.
Other reasons for contact with services:
• Stroke (3%)
• Short of breath (3%) and respiratory conditions (1%)
• End of life care (3%)
• Collapse (2%)
• Chest pain (1%) and cardiac conditions (1%)
• Neurological conditions (1%)
• Abdominal pain (1%)
Why were people referred to intermediate care services?
In addition to identifying why people in the sample came into contact with services, a summary of the reasons why they were then referred to intermediate care services is listed in the table on the right. This provides an insight into what referrers understand the aims of intermediate care to be and highlights some of the complexity and confusion regarding terminology used in these services.
There is significant overlap between many of these reasons as it is unclear exactly where rehabilitation becomes re-ablement, and where re-ablement stops and it becomes support with ADLs. Although there were clearly some referrals that were for rehabilitation, others stated rehabilitation but the needs of the person being referred were identical to those of another referral made for re-ablement. Referrals to improve mobility and exercise could be classified as re-ablement or rehabilitation depending on the needs of the person being referred. Whilst some referrals were specifically to assess for a future care package, this is often an integral part of all re-ablement referrals.
Some intermediate care services specialise in offering either ‘rehabilitation’ or ‘re-ablement’ and sometimes re-ablement is sub divided into social care or therapy led re-ablement.
The review found that this complexity can often mean that the reason for referral is often recorded in a way that meets the specification of the service rather than describing the needs of the person.
3% of all referrals to intermediate care were for end of life care. Although it is acknowledged that the needs of people in intermediate care services do change and people do sometimes require end of life care whilst with the service, it is not a typical reason for referral to intermediate care services. These referrals were predominantly in the step up sample and due to a local arrangement, between community nursing and CICT, to support people in the final days of life. There were also some occasions where STEPS received referrals for this type of support. Since the period reviewed, a new end of life service has been commissioned in Doncaster so these numbers may have reduced recently.
Reason for referral to Intermediate Care services
1 Rehabilitation 13%
2 Re-ablement 11%
3 Assessment for future care package 11%
4 Support with activities of daily living (ADLs) 10%
5 Improve mobility/re-ablement 9%
6 Improve mobility/ exercise 6%
7 Not known 4%
8 Carer support 3%
9 End of life care 3%
10 Neuro rehab 2%
11 Stroke rehab 2%
12 Specific nursing/ clinical need 2%
13 Assessment for care home 1%
14 Therapy assessment 1%
15 Assessment of Cognitive functioning 1%
16 Assessment under MH Act 1%
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The needs of people in Doncaster Needs of people referred to IC services
FactorsLevel of Complexity (see descriptors here)Long term conditions NK NA Minimal Low Medium High Very HighPressure area/wound care NK NA Minimal Low Medium High Very HighPain/Symptom control NK NA Minimal Low Medium High Very HighBreathing NK NA Minimal Low Medium High Very HighContinence NK NA Minimal Low Medium High Very HighNutrition NK NA Minimal Low Medium High Very HighFeeding + Drinking NK NA Minimal Low Medium High Very HighCognition/ Memory NK NA Minimal Low Medium High Very HighMental Health NK NA Minimal Low Medium High Very HighCommunication NK NA Minimal Low Medium High Very HighMobility NK NA Minimal Low Medium High Very HighTransfers NK NA Minimal Low Medium High Very HighPersonal Hygiene NK NA Minimal Low Medium High Very HighDomestic activities NK NA Minimal Low Medium High Very HighHome environment NK NA Minimal Low Medium High Very HighSocial needs NK NA Minimal Low Medium High Very High
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Complexity Rating Tool*The data collected as part of the review included a summary of the types and level of health and social care needs of patients who use existing services. This was done using a complexity tool to rate the level of need recorded in the patient’s record when they arrived at that service or touch point. The list of the needs and available ratings can be seen in the example opposite. The full descriptors for each level can also be viewed here.
Generally a rating of ‘Low’ means someone has needs but is self-caring, with some equipment, adaptation, supplies, occasional monitoring or support of family and friends. A rating of ‘medium’ or above indicates a need that requires some form of physical assistance, support or intervention. ‘Very high’ means a person is fully dependent on others.
Due to the variation in the way people’s needs are recorded by different teams and what is assessed at each touchpoint it was not always possible to collect data on all of the needs for the full sample. For example; social needs are not always well assessed- it was not possible to capture an assessment of social needs for over 30% of the sample. Nor were carers needs always recorded. A number of patients also had support needs around medication, but it was difficult to identify the exact numbers as many of the bed based services are required to administer medication regardless of need due to hospital protocol. So at the point when they were reviewed many patients were receiving support even when they did not require it. Consequently this has not been included in the analysis.
However there is a consistent pattern of need for the majority of people (see pages 20-21) who use intermediate care services. They often have on-going needs related to their long term conditions or chronic illness but are not acutely unwell. The most significant needs of this group of people are mobility, transfers, support with domestic activities of daily living and personal care. It is likely that their home environment needs some assessment, equipment or minor adaptation and they are often at risk of social isolation. Some people also have needs which may require nursing intervention or care. For example needs around pressure care, surgical or other wounds, pain relief and medication administration. These are not often the person’s main needs at the point of referral to IC services. Continence is an issue for a significant number of people also.
A summary profile of the full 1,027 sample is on the following page. This data is also available for each touch point as is the graph on page 21.
*Complexity tool based on RDaSH’s Community Nursing Complexity Rating Tool, descriptors from the modified
Barthel Index, Social Care Needs assessment & eligibility criteria, Integrated Discharge Team fact find document
and a variety of wellbeing & mental health assessment tools.
19
The needs of people in Doncaster Summary profile
1 2 3 4 5 6 7 8
9 10 11 12 13 14 15 16
Long term conditions
Mental Health
Pressure area/wound care
Communication
Pain/Symptom control
Mobility
Breathing
Transfers
Continence
Personal Hygiene
Nutrition
Domestic activities
Feeding + drinking
Home environment
Cognition/Memory
Social needs
83% had two or more pre-existing health conditions.
30% had heart problems prior to this episode.
34% had hypertension
21% had respiratory problems
21% had arthritis
20% had diabetes
19% required regular interventions as a result of long term condition(s) or chronic illnesses) and just over half (46%) needed regular monitoring and investigations as required.
19% had needs relating to pain and symptom control and needed more than simple analgesia.
Often nothing specific was written regarding pain or symptom control and therefore a number of ‘nulls’ were recorded. The review team believe that in the majority of these cases no record of need meant no need.
Breathing problems were affecting the mobility or exercise tolerance of 9% so that they required regular interventions .
3% were on intermittent oxygen therapy and 0.5% on constant oxygen therapy.
Often nothing specific was written regarding breathing and therefore a number of ‘nulls’ were recorded. The review team believe that in the majority of these cases no record of need meant no need.
24% had broken skin as a result of a wound (surgical or other) or a pressure sore.
Just over half (51%) had some type of bowel, bladder or continence problem.
Ranging from occasional incontinence (32%) to those needing regular interventions (19%).
14% needed nutritional assessment or monitoring.
The review team felt that this was not routinely assessed by all touch points so there maybe greater need than this.
14% needed prompts or physical assistance with feeding or drinking or a modified diet.
2% of these were fully dependent.
Almost a third needed partial assistance with personal care. (31%)
A further 15% required significant support with personal care.
26% had private or informal arrangements in place to manage domestic activities.
57% needed formal support with domestic activities (including meal preparation) at least once a day.
57% lived alone.
20% lived independently,
33% were managing with informal support of friends & family and 22% already had a homecare package
15% needed an assessment of their home environment or housing advice. Only 4% had significant issues with their accommodation.
34% were either at risk of social isolation or required some monitoring or support to access social activities.
8% had a complex social situation with safeguarding or risk issues.
67% had informal carers identified and over a third of these (41%) needed some form of carer support or their own care package
59% were previously independent with transfers and 16% were independent with adapted furniture or equipment.
Only 7% were already dependent on others for assistance.
On assessment 47% needed assistance with transfers.
25% were previously independently mobile and 51% were mobile with a walking aid.
At the point of contact 28% were assessed as independently mobile with a walking aid, 36% required assistance or supervision of one, 13% needed two and/ or equipment and 7% were not mobile.
41% were at risk of falls
13% had low level mental health needs, including mild anxiety symptoms and occasional low mood. Another 10% had mental health symptoms that were having an impact on some aspects of their life and required medication or more formal psychological therapy or regular monitoring.
For another 7% their mental health was seriously affecting their ability to carry out daily living activities and their symptoms were causing them distress. Sometimes their behaviour put them or others at risk.
23% had mild communication difficulties but were managing with the help of a hearing aids, glasses and/ or occasional monitoring.
15% needed a little more time, extra explanations and/ or support with some activities due to communication problems or sensory impairment.
4% had difficulties conversing on a basic level often due to cognitive impairment or were dependent on others due to significant visual or hearing impairment.
18% had an existing diagnosis of dementia
6% were previously known to have cognitive impairment.
On assessment 26% had needs around cognition/ memory that meant they required some support
20
The needs of people in Doncaster Type and levels of need across entire sample
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Long term conditions
Pressure area/
wound care
Pain/symptom control
Breathing Continence Nutrition Feeding + drinking
Cognition/ memory
Mental health
Communication Mobility Transfers Personal Hygiene
Domestic activities
Home environment
Social needs
60%
Type of need Minimum Low Medium High Very High Null
50%
40%
30%
20%
10%
0%
21
Section 4:Why change?
1. Complexity of current services.
2. Duplication
3. Preventing hospital admissions and unnecessary A&E attendances
4. Balance of step up and step down services
5. Balance of bed based versus home based services
6. Responsiveness of current services
7. Helping people stay as independent as possible for as long as possible
8. People’s experiences of services
9. Integration/whole person approach
10. Workforce
The Case for Change
What needs to change?
Single point of access. Single assessment process. Simpler service model.
1. Complexity of current services 18
Several points of access and multiple assessments
There are at least six ways to access intermediate care services, depending on where the person is at the time of referral and the person or team making the referral. Some of them are direct and others are via an assessment team like IDT or RAPT.
Each of these involves a slightly different type of assessment process and because information does not routinely travel with the person (see following page) they can often be subjected to more than one of these within a short time frame.
STEPS SU
Self/carer A&E/MAU/CDUGP in and
out ofOther health professional
(community based)Hospital based services Hospital based therapists
Adult Contact Team (ACT)
IC a
sses
smen
t &
re
ferr
al p
oint
s
RAPT A&E Single Point of Access (SPA) RDaSH
SPOC assessment
IDT assessment hospital based Direct referral to Magnolia
Hawthorn SUCICT SU and SD
WindemereCommunity
nursingMH crisis STEPS SD
Hawthorn/ Hazel SD
MMH rehab Positive steps Magnolia
YAS/ECP
Single point of contact (SPOC)
Step up Step down
Felt like I was assessed for the same care over and over.
Patient quote from face to face interviews.
23
The Case for Change 1. Complexity of current services
What needs to change?
Single point of access, single assessment process, simpler service model, care planned round the individual’s needs rather than service led responses.
Common pathways and choice
The current system is so complicated it makes it difficult for those referring into services to access the right care and support. However the review found that there were a number of common pathways and people tended move between a particular combination of services (see opposite).
A lot of time and resource goes into assessing where people need to go but the similarity of needs across many of these services (see page 26 for more information) suggests that need is not the most significant factor in determining a person’s pathway. In addition to this several teams offer similar types of interventions (see section 4.2) so there is often more than one way to access the right support for someone. Although the preferences of people who are using the service are sought and carers views considered at times the complexity of the current system means decisions about where people go and which support they receive are more likely to be based on:
• Staff, service user and carer awareness of services available.
• Past experience of those making the referral or doing the assessment.
• Relationships/ history of services. Services provided by the same organisation traditionally refer to each other. E.g. Hazel/ Hawthorn and CICT
• Most direct or ease of access. For example RAPT has direct access into STEPS and Hawthorn but not CICT.
• Capacity in the system. The average occupancy for the bed based services varies from service to service and there are many peaks and troughs across the year. When combined with delayed discharge data and the average waiting times to access some services it is clear that capacity plays a significant role in determining where people go.
RAPT Hawthorn 61% Hawthorn step up sample referred by RAPT
STEPS 15% of RAPT sample referred to STEPS
CICT 5% of RAPT sample referred to CICT
Acute Wards STEPS 92% of STEPS SD referrals from acute wards
CICT 8% of CICT SD referrals from acute ward
MMH rehab STEPS 12% of MMH sample referred to STEPS on discharge
CICT 2% of MMH sample referred to CICT on discharge
Hawthorn/ Hazel Step Down
STEPS 6% of Hazel and Hawthorn SD sample referred on discharge
CICT 19% of Hazel and Hawthorn SD sample referred on discharge
Accessing information and finding out about services could be a matter of chance or luck and was generally more difficult for the socially isolated participants in the study.
Doncaster Hospital Discharge Pathway Study, Interim findings. October 2015
24
The Case for Change 1. Complexity of current services
What needs to change?
Shared IT system across all intermediate care teams or interoperability between IT systems
Recording and IT systems
The complexity in current intermediate care service provision is also reflected in the systems and processes for record keeping and sharing information. The review found that patient information is not always accessible or proactively shared between services.
Multiple IT systems also add to poor communication and often lead to duplication and inefficiencies. There are currently six electronic systems that may contain information about a patient during a single episode of intermediate care; SystmOne, JACS, Symphony, EMIS, Care First and Silverlink. The chart below highlights how different organisations, teams and even professions within teams have different ways of recording information.
Electronic record keeping systems across the intermediate care pathway.
GP services
(depends on practice)
SystmOne
EMIS
A&E and MAU Symphony + Paper based notes
RAPT Paper assessment- filed by RAPT
IDT Paper based fact finds - scanned onto Care First, faxed to bed based
services and filed by IDT.
Mexborough and
Montagu Hospital
(MMH) Rehab Centre
JACs - Nurses and Doctors only
SystmOne - Therapists only
Medical notes - Doctors and Therapists
Ward notes - Nurses, Therapists and Support staff.
Hazel and Hawthorn SystmOne - Therapists and Nurses
Paper based ward notes - all ward staff
Positive Steps Care First. Paper based unit notes. OPMH liaison- Silverlink
CICT SystmOne
STEPS Care First. Paper notes scanned into Care First
Example from data collection for the needs review: IDT fact finds
The IDT fact find is a paper based assessment document, completed by IDT members when they assess someone for discharge on an acute ward. When fully completed it provides a comprehensive summary of a person’s need along with a rationale for why a particular discharge pathway has been recommended.
The fact finds have to be scanned into Care First to be transferred to social care services or faxed to the relevant bed based service. This process is dependent on the availability of admin staff and can sometimes be delayed. If CICT is involved they do not routinely receive the IDT fact find nor would the GP. The originals are filed by IDT at Doncaster Royal Infirmary separate to the person’s medical records.
The result is that valuable assessment information does not travel with the patient, cannot be used to inform care planning and has to be repeated further down the pathway.
Example from in depth pathway reviews: Therapists at MMH rehab centre.
Therapists at MMH Rehab Centre record their notes in three separate places:
1. SystmOne - so that community colleagues can see they have been seen by a therapist at DBHFT. This can’t be accessed by nurses at the centre.
2. The Rehab Centre paper based ward notes, in order to communicate with the rest of the MDT.
3. The paper medical records, to communicate with the medical team.
25
The Case for Change 2. Duplication
As described in Section 1 there are lots of separate teams that make up the intermediate care service and as we saw in the previous section each of them has their own referral and assessment process. The review also identified that most of these teams work with people who have a very similar profile of needs (see graph below).
Percentage of patients with medium, high or very high level of need by touchpoint
MMH SD
Postive Steps SD
Hawthorn ward SD
Hazel ward SD
More detail
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Long term conditions
Pressure area/
wound care
Pain/symptom control
Breathing Continence Nutrition Feeding + drinking
Cognition/ memory
Mental health
Communication Mobility Transfers Personal Hygiene
Domestic activities
Home environment
Social needs
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
CICT SU
CICT SD
STEPS SU
STEPS SD
More detailKey: SD = Step Down SU = Step Up
Oldfield SD
Rose House SD
Hawthorn ward SU
RAPT
26
The Case for Change 2. Duplication
As part of the stakeholder mapping teams were asked to provide a service description. A review of these alongside the needs of the patients reviewed indicates that some teams are carrying out very similar functions with people with similar needs.
EXAMPLE 1:
Short Term Enablement Team (STEPS) and Community Intermediate Care Team (CICT)
A. Service descriptions, taken from the service directory.
Short Term Enablement Team (STEPS)
Community Intermediate Care Team (CICT)
Assessment for Social Care support need, activity of daily living needs or provision of low level of equipment.
Offers rehabilitation and re-enablement to return the patient to an independent state with the ability to cope with daily living at home.
Time allocated according to client need free for up to six weeks.
Target intervention period is six week.
Support in their own home to regain their everyday living skills to live independently.
The service is delivered in the patient’s own home environment
Seven days a week service. 6am-11pm The service is provided seven days per week, 7am - 6pm (limited therapy cover over weekend)
27
The Case for Change 2. Duplication
Short Term Enablement Team (STEPS) and Community Intermediate Care Team (CICT)
B. Percentage of patients with medium, high or very high level of need in the CICT and STEPS samples
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Long term conditions
Pressure area/
wound care
Pain/symptom control
Breathing Continence Nutrition Feeding + drinking
Cognition/ memory
Mental health
Communication Mobility Transfers Personal Hygiene
Domestic activities
Home environment
Social needs
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
CICT SU
CICT SD
STEPS SU
STEPS SD
This graph shows a similar pattern in the type and level of needs of people who use these two services. The only exceptions being:
• STEPS work with more people with Dementia or Cognitive Impairment. CICT does not routinely work with people with Dementia, due to it having had more of a focus on physical rehabilitation, which is not always considered suitable for people with cognitive impairment.
• CICT also provides a rapid, intensive response to patients in the final days of life. These patients are more dependent than the rest of their caseload, accounting for the peaks in feeding and drinking & personal hygiene in the CICT SU line on the graph. Approximately 19% of referrals were referred specifically for end of life (EOL) care; until either an EOL care package can be put in place or for a rapid response as the person was in their final days.
28
The Case for Change 2. Duplication
Short Term Enablement Team (STEPS) and Community Intermediate Care Team (CICT)
C. Reason for referral to CICT and STEPS
The graph opposite shows the reasons for referral to STEPs and CICT identified in the review.
It highlights approximately a quarter of the CICT referrals reviewed were for rehabilitation or therapy assessment /intervention.
The majority of CICT referrals (53%) were for re-enablement or practical support with activities of daily living (ADL).
These were also the main reasons for referral in the STEPS sample accounting for 74% of referrals.
As well as re-ablement and ADL support, STEPS also received a proportion of referrals (8%) for assessment for future care package, although this was also seen in the CICT sample (6%).
As described on page 18 there is a significant overlap between the different reasons for referral captured in the review. The separation of rehabilitation and re-ablement can be artificial in the context of intermediate care as people may require elements of both.
Well over half of the sample for these two teams (64%) were referred for re-ablement or support with activities of daily living. e.g. personal care or meal preparation.(Percentage of sample for that touchpoint)
EOL Assessment Therapy
Rehab Falls Improve mobility &
exercise
Improve mobility &
support with ADLs
Mobility & re-ablement
Re-ablement Support with ADLs
ADL support to carer support
Access for future care
package
Social care assessment
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
CICT SU
CICT SD
STEPS SU
STEPS SD
29
The Case for Change 2. Duplication
There are also similarities between some of the bed based step down services, Hawthorn, Hazel, MMH general rehab beds and Positive Steps. All three services describe themselves as providing ‘bed based rehabilitation and re-ablement interventions’. The graph below shows a very similar pattern of needs across all these services. The only exception is more people with needs around Cognitive Impairment and mental health is higher at Positive Steps than the other units. Positive Steps is the only bed based service to cater specifically for people with Dementia or Cognitive Impairment.
The other services tend not to accept Dementia patients due to the difficulties engaging them in a formal rehabilitation programmes. As the number of people with Dementia is going to continue to rise all services and staff in intermediate care in the future will need to be able to respond to the needs of people with Dementia. The review also suggests that bed based intermediate care services may need to shift their focus to maximising and maintaining the functioning of the most complex patients rather than providing more traditional physical rehabilitation for higher functioning people, as this is often better delivered by a home based service. (See section 2.5 for further discussion on this)
Percentage of patients with medium, high or very high level of need by touchpoint
EXAMPLE 2: Step Down bed based services
MMH SD
Postive Steps SD
Hawthorn ward SD
Hazel ward SD
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Long term conditions
Pressure area/
wound care
Pain/symptom control
Breathing Continence Nutrition Feeding + drinking
Cognition/ memory
Mental health
Communication Mobility Transfers Personal Hygiene
Domestic activities
Home environment
Social needs
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
30
The Case for Change 2. Duplication
The main difference between all these core intermediate care services appears to be that there are certain skills that can be accessed in a particular team and not in another. For example:
• Therapists are available in CICT but not in STEPS.
• Geriatricians can be accessed at MMH General Rehab but were not accessible at Hawthorn and Hazel until recently or at Positive Steps.
• Hazel, Hawthorn and MMH Rehab have 24 hour nursing staff. Positive Steps is supported by the community nursing service.
• Homecare can be more easily set up from STEPS because they can do the relevant assessments but is more difficult for CICT to arrange this as the majority of staff cannot do these assessments.
Because of the complex needs of people using the services we saw several examples where people were in one particular service but needed the skills or expertise available in another team. For example:
• There were people on the STEPS caseload that could have benefitted from therapy input into their re-ablement programme or more formal rehabilitation, but this could only be accessed by a referral into CICT or community therapy, (for which there is a wait of several weeks). We also saw some people who had six weeks of STEPS followed by six weeks of CICT input as a result of this.
• People in Positive Steps a social care unit often needed better access to nursing input and medical review.
• People in Hawthorn, Hazel and MMH Rehab who needed access to social care assessment. On occasions people were transferred between bed based services to access this.
The current configuration results in duplication, waste and is an inefficient use of resources. It also causes delays for patients as people wait to be assessed or transferred between the different services and makes it even more difficult to navigate. In the future, fewer teams providing health and social care rehabilitation and enablement with flexible access to a range of skills and expertise would improve people’s experience of intermediate care, facilitate more timely access to appropriate assessment and support and increase efficiency.
What needs to change?
Fewer teams, more efficient service configuration. Integrated health and social care teams to provide flexible access to range of skills
SUMMARY
31
The Case for Change 3. Preventing hospital admissions and unnecessary attendances at A&E
There are times when a frail older person requires care in hospital and that is exactly the right place for them to be. However we know that frail older people are at greater risk of experiencing significant harm if admitted to hospital as an emergency - particularly when they are delayed in an emergency department.
Safe, Compassionate Care for frail older people. NHS England 2014 (1)
Over two thirds of people who are admitted to hospital in England are over 65 (2). In Doncaster the number of over 75 year olds being admitted to Doncaster and Bassetlaw Hospitals Foundation Trust acute wards has increased over the past three years, from 18,152 in 2013 to 20,691 in 2015. The number attending A&E from that age group has stayed about the same but once at A&E the likelihood of them being admitted has increased slightly. Just under half of those over 75 year old who attend A&E are admitted and they tend to stay longer once on a ward. The average length of stay in Doncaster is almost three times longer for over 75s than for those under. 77% of all readmissions within 30 days are also over 75 year olds.
As cited on page 5, it is now widely accepted that hospital is not always the best place for older people. The longer they stay the more likely they are to develop problems secondary to the reason for admission, muscle strength reduces and skills in activities of daily living can be lost due to lack of opportunity to practice, often making it much harder for them to make the transition home. (1, 2, 3, 4, 5)
In view of this the MDT expert panels were asked to identify where they thought an A&E attendance could have been prevented or where an acute admission could be avoided and what would need to be in place instead.
Preventing A&E attendances
For the A&E/ MAU sample of over 75 year olds it was identified that 61% of the patients reviewed could have avoided an A&E attendance if a rapid or urgent response and more intensive short term support had been available in the community. As our sample was designed to give a 95% confidence rate and a 10% margin of error (either way) this suggests that somewhere between 50% and 70% of A&E attendances for over 75s could potentially be prevented if intermediate care services were reconfigured to provide more step up support as discussed earlier. It is also acknowledged that the reasons why people attend A&E are varied and complex and that simply adding a rapid or more intensive response in the community will not automatically reduce A&E attendances alone. It is important that any future development of intermediate care services is well connected with urgent care and primary care so that it is part of a whole system approach to changing behaviours and developing alternatives to A&E.
Reducing admissions
Nationally it is has been identified that 30% of acute admissions could potentially be avoidable (3). Of the people reviewed who were stepping down from hospital the expert panels identified that approximately 18% of these admissions could have been avoided altogether. However that sample did not include those who were admitted and went home without support from intermediate care, but may have benefitted from a step up response upstream to avoid an admission. In order to capture that group a sample of people over 75 who attended A&E in 2014 were also reviewed. 35% of that sample were admitted to hospital in 2014.
However the MDT expert panels identified that only 15% of the sample would have needed an acute admission if appropriate step up services were available in the community, which means around 57% of admissions of over 75 year olds from A&E or MAU could potentially be avoided.
See chart on next page.
References: (1) Safe, compassionate care for frail older people. NHS England. (2014) (2) NHS Five Year Forward View NHS England (2014) (3) National Audit of Intermediate Care 2015. NHS Benchmarking. (2015) (4)
Reasons why people with Dementia are admitted to a general hospital in an emergency. Public Health England (2015). (5) Growing Older Together. NHS Confederation.(2016)
32
The Case for Change 3. Preventing hospital admissions and unnecessary attendances at A&E
What needs to change?
Increasing the capacity and responsiveness of step up intermediate care services could reduce both the number of older people who attend A&E and the number of hospital admissions.
Percentage of A&E attendances, admissions and intermediate care bed stays identified by the expert panels as avoidable if a more reactive home based response was available (by sample type).
Rap
id/u
rgen
t H
om
e b
ased
res
po
nse
Rap
id/u
rgen
t H
om
e b
ased
res
po
nse
Rap
id/u
rgen
t H
om
e b
ased
res
po
nse
A&E/MAU sample (75 years and over)Step Up sample Step Down sample
57% of those who were admitted could have
avoided an acute admission if this response had
been available
18% of those who were admitted could
have avoided an acute admission if this response
had been available
79% of those who were admitted to a step down bed
could have been supported at home if a different response
had been available
82% of those who were admitted to a step up bed could have been supported
at home if a different response had been available
61% could have avoided A&E attendance if this
response had been available
Went into A&E or MAU
Went into an acute bed
Destination of 2014 sample
Touch point reviewed
Patient Pathway
% of potentially avoidable acute
attendances at A&E and intermediate
care beds
Future Response
(from expert panel)
53%57% 41%
100%
Went into an intermediate car bed
72%
Went into an intermediate car bed
38% 35%
Went into an acute bed
100%
Inte
nsi
ve/s
ho
rt t
erm
H
om
e b
ased
res
po
nse
Inte
nsi
ve/s
ho
rt t
erm
H
om
e b
ased
res
po
nse
Inte
nsi
ve/s
ho
rt t
erm
H
om
e b
ased
res
po
nse
31%43% 46%M
ediu
m t
erm
H
om
e b
ased
res
po
nse
Med
ium
ter
m
Ho
me
bas
ed r
esp
on
se
Med
ium
ter
m
Ho
me
bas
ed r
esp
on
se
21%60% 64%
Inte
rmed
iate
C
are
bed
bas
e
Inte
rmed
iate
C
are
bed
bas
e
Inte
rmed
iate
C
are
bed
bas
e
6%7% 16%
Acu
te
Ho
spit
al b
ed
15%
Acu
te
Ho
spit
al b
ed
3%
IN THE COMMUNITY ATTEND A&E/MAU ACUTE ADMISSION DISCHARGE
33
The Case for Change 4. Balance of step down and step up
The first of the pie charts to the right shows the percentage of intermediate care referrals in 2014 that were for step up (to avoid a hospital admission) and the percentage that were for step down (to facilitate discharge). It shows that almost three quarters of the Doncaster intermediate care resource was used to help people step down from acute hospitals and just over a quarter in avoiding admissions. The current balance reinforces the need for an acute admission in order to access support when there is a growing body of evidence that this can in fact have a detrimental impact on older and frail people as well as being an inefficient use of acute care resources (1, 2). See section 4.3 on avoiding acute admissions for further discussion about this.
The second pie chart allows comparison between Doncaster’s services and the balance of provision nationally, as estimated in the national audit of intermediate care(3). Chart 2 does not necessarily represent the ideal scenario but it does suggest that it is possible to have a more balanced provision than Doncaster currently has. The outcome of the reviews by our expert panels further supports the notion that a more even balance of step up and step down services would be possible in the future if a more responsive step up service was available (pie chart 3). The panels identified that the optimal pathways for 52% of the sample should have been to avoid an admission (step up) and 42% should have been step down pathways. A further 5% could not be identified due to insufficient information.
The NHS Confederation’s recent report on improving urgent care for older people ‘Growing Old Together’ emphasises the need to strengthen and invest in health and social care services outside hospitals in order to meet the needs of the population and offer more viable alternatives to hospital admission that enable people to remain in their own homes and communities. (1)
What needs to change?
An increased focus on prevention and avoiding admissions, care closer to home and a more even balance of step up and step down services.
References: (1) Growing Older Together. NHS Confederation.(2016) (2) Reasons why people with Dementia are admitted to a general hospital in an emergency. Public Health England (2015). (3) National Audit of Intermediate Care 2015. NHS Benchmarking. (2015)
2. National
Audit of IC (2)
1. Doncaster
2014
Step down Step up Unknown
3. Doncaster
- future
34
The Case for Change 5. Balance of bed based versus home based services
In 2014 there were 169 intermediate care beds in Doncaster (not including CAP beds), this has reduced to 161 since Rose House closed. However when benchmarked nationally this is still much higher than other areas. Doncaster has around 20% more IC beds per 100,000 weighted population than the national average(1).
The review suggested a smaller bed base may be possible if more flexible reactive community services were available.
Pie chart 1 shows the referrals for bed based services and home based services in Doncaster in 2014. When compared to the national data on use of bed versus home based services in chart 2 there is a significant difference. This was reinforced by the review which suggested that it would be possible for Doncaster to shift the balance in favour of more community based services. The expert panels identified home based support as the optimal care pathway for 81% of the sample (chart 3).
The type of bed base needed in the future.
Of the 13% that the panels identified as needing a bed based response the majority needed a general intermediate care bed. A very small number required specialist beds. These included; stroke rehab beds, medical rehab beds, specialist assessment beds for organic illness and neuro rehab beds..
GENERAL INTERMEDIATE CARE BEDS
Of the people identified by the panels as requiring a general bed based response 37% of them had a diagnosis of Dementia or were known to have cognitive impairment before the episode being reviewed and on assessment over half of them (57%) had support needs related to cognitive functioning or significant memory problems. This included people who were recovering from delirium, those who had not yet been diagnosed with Dementia and people with cognitive impairment of a different cause. 14% had a mental health diagnosis prior to admission and 9% had current needs related to their mental health or significant risk issues or safeguarding concerns (25%).
Continued...
2. National
Audit of IC (2)
1. Doncaster
2014
Bed-based Homed-based Unknown
3. Doncaster
- future
References: (1) National Audit of Intermediate Care 2014. NHS Benchmarking (2014) (2) National Audit of Intermediate Care 2015. NHS Benchmarking. (2015)
35
Stroke Rehabilitation beds are part of the stroke pathway. This would be dependent on community intermediate care bed based services working jointly with specialist teams to enhance their capacity to provide home based rehabilitation at the required level of intensity. For example rehabilitation and support plans developed and reviewed by stroke therapists but delivered by intermediate care re-ablement and rehab workers.
The expert panels identified that a significant number of people admitted to Magnolia’s specialist neuro rehab beds in 2014 could have been supported at home. Again a future model where community based intermediate care services work jointly with the specialist neuro outreach team to deliver appropriate interventions could enhance their capacity and allow them to support people at home earlier. Approximately 25% of the Magnolia sample did need a specialist neuro rehab bed as did some of the sample from MMH Rehab Centre. The review found that people could be transferred to either MMH Rehab Centre provided by DBHFT or Magnolia provided by RDaSH for bed based neuro rehab depending on where there was capacity. There is some overlap in the specifications for these two services as both are commissioned to provide elements of specialist rehabilitation in keeping with BRSM guidelines. People at MMH for neuro-rehab and stroke rehab and those at Magnolia had a similar profile of needs (see graph on following page for detail). Further analysis of this may be appropriate in the future.
Medical Rehabilitation. The Rehabilitation Centre at Mexborough Montagu Hospital provides general rehabilitation beds as well as stroke rehab beds. People in these beds are under the care of a Consultant Geriatician and a joint team of therapists and nurses provide day to day care and rehabilitation. Onsite medical cover is provided during the day and the unit is covered by DBHFT’s on call medical cover overnight. These beds are designed for people who are not acutely unwell but have on going medical needs and require rehabilitation. In the MMH rehab sample 69% went into a medical rehab bed, when reviewed by the panels only 6% were identified as requiring this level of input. The other 41% could have gone home with appropriate support available in the community and 13% could have had their needs met in a general intermediate care bed.
Further details about what a future bed based response will need to provide will be included in the final section of this document and will also be explored further in the design phase.
The Case for Change 5. Balance of bed based versus home based services
Consequently in the future the general intermediate care bed base will need to include provision that is able to meet the needs of people who have Cognitive impairment, Dementia and Delirium and be equipped to support people with mental health needs and some challenging or risky behaviour. Recent data from DBHFT on delayed discharges indicates that there is increasing demand for this type of bed. Positive Steps currently has 22 Dementia assessment beds and in recent months access to these beds has been one of the main causes of delay for people waiting to leave acute care, with at times other beds that do not take people with Dementia empty. Currently the Dementia assessment beds are staffed by social care staff who have had some training in working with people who have Dementia and they have access to the mental health liaison service. In the future mental health expertise would need to be an integral part of the establishment.
SPECIALIST INTERMEDIATE CARE BEDS
In addition to those who needed the general bed based response some specialist responses were also identified. The needs of the patients who required these more specialist responses were quite distinct from the needs of the general patients.
The step up sample reviewed included: a Specialist assessment facility for people with organic illness which provides formal assessment for people with cognitive impairment/ organic illness in a safe environment, access to a Psychiatrist and specialist behaviour management. The panels identified that the majority of the sample admitted to Windermere did not need this high intensity facility. Instead they could have been supported in a general intermediate care bed based unit if it was equipped to meet needs of people with Dementia, as described above, or remained at home if a more reactive, intensive response was available (see section 2.3). Only 28% of the Windermere sample were identified as requiring this type of specialist bed in the future. However it is possible that the total numbers of patients who require this type of specialist response may be slightly higher as Mallard ward at Doncaster Royal Infirmary also specialises in supporting people with Dementia and complex needs and it is possible that some of these patients have similar levels of need. Further review would be needed to confirm this as the study did not specifically look at people admitted to Mallard ward as it is considered an acute ward not an Intermediate care service.
36
The Case for Change 5. Balance of bed based versus home based services
Magnolia, MMH stroke and MMH neuro rehab beds
Percentage of patients with medium, high or very high level of need by touchpoint
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Long term conditions
Pressure area/
wound care
Pain/symptom control
Breathing Continence Nutrition Feeding + drinking
Cognition/ memory
Mental health
Communication Mobility Transfers Personal Hygiene
Domestic activities
Home environment
Social needs
MMH Rehab Stroke
MMH Rehab Neuro
Magnolia SD
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
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The Case for Change 5. Balance of bed based versus home based services
Cost of bed based services versus home based services
One of the key findings in the National Audit of Intermediate Care 2015 (1) was the cost of different types of intermediate care services per service user. It suggested that bed based services cost almost four times that of home based or community re-ablement services.
In Doncaster community services account for approximately 51% of the total number of referrals into intermediate care however it is estimated that just 13% of the total spend on intermediate care goes on these home based services. This would indicate a similar picture in Doncaster to that described in the national audit.
These initial figures suggest that there is some potential to shift investment from bed based services to increase the range and capacity of community services. Nationally it is recognised that there needs to be a shift in investment from acute care to community based alternatives and various delivery models are being tested as part of NHS England’s vanguard programme (2,3,4). The challenge will be managing the transition from one to the other and the cost of double running during this time.
More detailed financial modelling is planned to explore exactly what is possible within Doncaster (see Next Steps)
Crisis response
£521
£1,205
£5,672
£1,484
Home based Bed based Re-ablement
What needs to change?
Fewer bed based services and more home based services. Shift the focus to ‘try for home first’
References: (1) National Audit of Intermediate Care 2014. NHS Benchmarking (2014) (2) Growing Older Together. NHS Confederation.(2016) (3) NHS Five Year Forward View NHS England (2014) (4) NHS Five Year Forward View NHS England (2014)
Cost per service user(taken from National Audit of Intermediate Care Report 2015)
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The Case for Change 6. Responsiveness of current services
Doncaster does not currently have a rapid or crisis response as part of its home based intermediate care offer, the rapid responses are currently in A&E or on discharge from hospital. The review identified that this type of response would be essential in a future service. NHS England recommends that frail, older people should have access to rapid support close to home in a crisis (2) and there are several examples of other places who have introduced a rapid or crisis response and evidence that it is effective in preventing admissions (1).
Doncaster does have a comprehensive crisis response and intensive home treatment service for working aged adults with functional mental health problems. Although elements of this are accessible for older people the same type of response is not yet consistently available for people with Dementia. In the review there was a number of crisis, step up admissions to Windermere that the panels felt could have been avoided had this type of reactive, intensive home based response been available.
Most of the more ‘rapid’ responses are set up to respond after a patient attends A&E or when already admitted (e.g. RAPT/ SPOC) but are not available when a patient is being ‘stepped up’ from the community. STEPS provide a very responsive service for people being discharged from hospital, often they will assess within four hours of a person leaving the ward. However there is a significant difference between that and the time taken to assess step up referrals. Some of the people reviewed were referred to STEPS and then admitted before the assessment took place.
What needs to change?
The development of a rapid/crisis response in the community to provide prompt assessment and intervention to maintain people in their own homes.
For many over 75s with multiple conditions and
frailty, a quick response at points of crisis in
their health can make a significant difference.
The NHS Atlas of Variation suggests that
medical assessment within two hours, together
with treatment, supportive care and
rehabilitation, is associated with lower
mortality, greater independence and a reduced
need for long term care.
Commission on Improving Urgent Care for Older People 2016. (1)
Average waiting time from referral to
admission/assessment (days)
STEPS (Step Up)
6.8 days
1.7 days
STEPS (Step Down)
References: (1) Growing Older Together. NHS Confederation.(2016) (2) Safe, compassionate care for frail older people. NHS England. (2014)
Although not part of their core intermediate care function CICT do provide a rapid and responsive service when they pick up a referral for end of life care from community nursing. This, along with STEPS current work on reducing response times for step up referrals, demonstrates there is potential to develop this further in a future model.
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The Case for Change 7. Helping people stay as independent as possible for as long as possible.
During the course of the review, the Care Act 2014 (1, 2) came into force. It’s focus is on meeting needs not just providing care, with an emphasis on ‘preventing escalation’ and helping people stay independent for as long as possible. It requires local authorities to invest in services that prevent the need for care and to take a more integrated health & social care approach to doing this. As well as the benefits to the individual of staying at home and remaining independent there is also a need to reduce the spend on long term care nationally and locally. Doncaster currently has higher than average number of admissions to care homes and more people in receipt of homecare (see table below).
The development of a more integrated intermediate care service could help fulfil some of the duties of the Care Act and potentially reduce spending on longer term care in Doncaster.
Number of people in Care Homes (2015)
Number of people receiving Home Care (2015
Doncaster (actual) 1,085 3,525
Yorkshire & Humber (average) 727 2,927
England (average) 669 2,808
Care Homes and Intermediate care
A&E attendances and admissions to hospital from Care Homes
Approximately 19% of those who attended A&E in 2014 came from a care home. 19% of the A&E sample of over 75 year olds in the review also came from a care home. The majority of these people returned to the same care home from A&E or MAU (11%). Some were assessed by RAPT before returning to the care home, and the other 8% were admitted to an acute ward. It was identified that many of the attendances at A&E by people from care homes could have been avoided if the rapid response and multi-disciplinary assessment described in the final section of this document was also available for care homes. This is something which is being developed in other areas(3) but would need further exploration.
Discharges into care homes from intermediate care services
Most people admitted to hospital from a care home will be discharged without any input from intermediate care services back to the care home, as they don’t traditionally support people in care homes, with the exception of RAPT. However 8% of the whole sample were discharged from intermediate care into a new care home. These were all discharges from intermediate care bed (2% of the step up bed sample and 23% of the sample admitted to a step down bed based services). Of those discharged to a care home the panels identified that over half would not need to go into a bed based service if an alternative home based response was available (see page 33). Although not specifically captured by the review it could be assumed that where an admission to a bed based service was identified as avoidable that would mean that the individual could be supported to remain at home for longer and consequently admission to a care home also prevented or delayed.
It has already been identified that Doncaster has more intermediate care bed based services than other areas. It also has a high number of admissions to care homes compared to the national average. It is well documented that the longer older people, especially those with Dementia or cognitive impairment, stay away from home the harder it is for them to return. So it is possible that there is a link between the current balance of bed and home based intermediate care services and the number of care home admissions. This needs further exploration but there is an indication that reconfiguring services to increase the options for home based intermediate care to maintain people at home, will not only have an impact on the number of people being admitted to hospital but could potentially reduce or delay admissions to care homes.
People on route to care homes
A review of research into factors which are predictive of institutionalisation identified a profile of needs very similar to the needs of the sample reviewed (4) See table on the following page. People who use intermediate care services have many of these risk factors and could potentially be on route to residential care. Therefore it is important that intermediate care addresses these risk factors with a view to preventing or delaying admissions to care.
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The review found that the relationship between home care and intermediate care is crucial. Homecare needs to be able to sustain improvements people make in intermediate care services and homecare workers need to have access to appropriate assessment and advice when they encounter someone who has fallen or is becoming unwell. There are plans to commission a more enabling and flexible home care service for Doncaster as part of the ‘Help to Live at Home’ project which provides an opportunity to strengthen the connection between these two services in the future.
Social care re-ablement has been proven to be effective in reducing the need for home care by up to 60% (5).The STEPs team in Doncaster are already providing this type of intervention, and it is particularly effective in reducing the need for homecare for people coming out of hospital. However there is evidence it could be even more effective in reducing the need for homecare if it was more accessible earlier in the pathway, as a preventative measure and as part of a rapid response.
Supporting carers and maintaining social networks
Informal carers play an important role in enabling people to stay in their own home and in maintaining their social networks. 67% of the sample reviewed had an informal carer or carers and 33% had been managing with just the support of their informal carer(s) prior to the episode reviewed. The Care Act 2014 (1) outlines the duty of local authorities to ensure the needs of carers are assessed and emphasises the importance of supporting them in their caring role in order to prevent them reaching a crisis. In the review around 16% of the sample had carers who were identified as requiring a carer’s assessment when they were referred to intermediate care. In current services this is usually carried out by a social worker or social care wellbeing officer and other staff will refer on for this. In the future assessing the needs of carers should to be an integral part of intermediate care and supporting carers a core skill for those working in the service. The work to develop a trusted assessor model will help facilitate this. The importance of social networks was also very evident in the hospital discharge pathway project, with family, friends, neighbours and other support often making the difference for participants in the study. In the future intermediate care services configured around geographical locations could potentially promote better links with local community resources which can be mobilised to help people stay connected to their social networks.
The Case for Change 7. Helping people stay as independent as possible for as long as possible.
Current services are very good at assessing activities of daily living and providing re-ablement to maintain or increase independence but we have seen how mental health needs can sometimes be missed and needs around social isolation are often unmet (see section 4.8). Incontinence is another significant risk factor and was an issue for just over half of the review sample. It is not just the condition itself but also the secondary factors, for example; links to UTIs and falls, anxiety and the stress it puts on carers. It is often cited as the tipping point for carers. Consequently, practical support for carers around continence, access to continence assessments, advice and supplies should be an integral part of intermediate care services. Links with the sensory team and expertise to help people with visual impairment need to be strengthened (18% of the review sample had sensory impairment). All who work in the service also need to be able to provide a basic level of falls assessment and advice, with easy access to specialist falls services where needed. (see page 17).
Home Care and intermediate care
22% of the sample were already receiving home care prior to the episode reviewed. 10% of the sample had a new homecare package on discharge from the touchpoints and 3% had an increased care package. It is unlikely that this reflects the full picture as it was not always possible to capture follow up arrangements from the records and in some cases people were referred onto another time limited service, sometimes delaying the need for an ongoing care package.
Most studies on the factors that are statistically predictive of institutionalisation identify the following:
1. Age
2. Dementia/ Cognitive impairment
3. ADL restriction
4. Number of family members
5. Living alone
6. Gender
7. Previous usage of services
8. Diagnosis e.g. stroke
9. Falls
10. Continence problems
11. Depression.
12. Visual impairment
Taken from Oxford County Councils review of research into reducing care home admissions (4)
41
The Case for Change 8. People’s experiences of services
What needs to change?
Initial patient & carer engagement took place as part of work stream 1 (stakeholder mapping) including:
• Review of existing patient & carer feedback relating to current IC services.
• 58 face to face interviews undertaken with people using/ caring for someone using a community IC service (70%) or in a bed based IC service (30%).
Key themes from interviews.
• Did not know about services that could have supported them at home before going into hospital only became aware of them after admission.
• Need for more information & signposting about local services and what on-going support is available (both clinical & non clinical services).
• Lack of communication/ integration between services
• Lack of consistency of staff delivering support at home.
• Perceived staff shortages in bed based services.
• Positive feedback about:
- staff supportiveness & relationships.
- level of service received
- feeling safe & reassured.
The full report can be accessed here.
Hospital Discharge Pathway Study
Running parallel to our review has been the Doncaster Hospital Discharge Pathway Study lead by Sheffield University. Also commissioned by the Better Care Fund in Doncaster, this is an in-depth qualitative study of the Hospital Discharge Pathway (HDP) and associated discharge pathways. The project team have followed 22 client journeys from hospital discharge to track the client and carers experience, impacts and outcomes and provide a unique insight into what navigating the health and social care system feels like.
Although this study is not yet complete, the interim findings reported in October 2015 identified some emerging themes which have implications for future intermediate care services. These are;
1. Improve practical help to get out and about and provide additional support to (re)start socialising/ activities.
2. Re-examine routine ways of communicating with clients to improve their understanding of what is happening to them and the services they are receiving.
3. Improving the ways in which client’s autonomy is respected and recognised by services and ensuring care is person-centred, flexible and holistic.
One of the timelines produced by the team conducting the Hospital Discharge Pathway Study team is on the following page. This describes the experience of Audrey who the team first met at Positive Steps following an acute admission.
The full report can be accessed here
A more person centred approach. Greater involvement and empowerment of those who use services and their carersSimpler services and better, more appropriate communication about what is available and help people using services.
42
The Case for Change 8. People’s experiences of services
Quotes
Key MessageAudrey is very lonely, doesn’t like to make a fuss and often puts on a ‘brave face’. She wants to go home and remain as independent as possible. Although Audrey has support through family and her church network she doesn’t really like to ask for help or bother people with her problems. Although her practical needs are taken care of, her loneliness deteriorates during the study and her emotional needs are not identified until the researcher intervenes.
It’s been horrendous really, I would have been better if I’d been more open with it [telling people about her falls] but I’ve kept it to myself and thought that people would think I was moaning all the time, but we’ve got by.
I miss the company…it’s very quiet….Being on my own yeah. Some days I don’t see anyone, I’ve never spoken to a soul and it makes you feel really isolated and yet I’ve got a family, they’ve got everything in here that I need but it’s not like visitors, they’ll say ‘what else can I do mum?’.
I think they are very good [carers]….they are enabling me to cope, which I wouldn’t be able to on my own.
Yeah but it’s worked out very well. I was very embarrassed, I thought I would be, I didn’t want it to happen, I didn’t want anyone bathing me, but I needn’t have worried cos they’ve talked to me and everything’s worked out fine.
I have found that a bit, my friends don’t come round like they used to do, cos I have to use the wheelchair for everything and it’s not very convenient.
I would go to these places if I felt I was confident enough and someone would look after me.
I look forward to seeing her [Age UK befriender] and I’m very pleased to see her.
I love Wednesday afternoons, I love fresh air, I love to get out.
CLIENT TIMELINE: AUDREY (See in detail)
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The Case for Change 9. Integration/whole person approach
Physical and Mental health
As previously discussed (see page 16) many of the people who were referred to Intermediate Care Services also had Dementia or other problems with cognition or memory and this is set to increase in the future as people live longer. The need for specialist mental health expertise to be an integral part of intermediate care services in the future has already been highlighted (see page 35).
What needs to change?
Intermediate care services should be equipped to respond to physical, mental health and social needs of people to enable them to stay independent at home and connected with their social networks.
References: (1) Options for integrated commissioning: Beyond Barker. Kings Fund. (June 2015) (2) Loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and meta-analysis of longitudinal observational studies BMJ (2016) (3) Hospital Discharge pathway Study; Interim Report. Sheffield Hallam University (Oct 2015 (4) From dependence to independence: emerging lessons from the Rotherham Social Prescribing Pilot. Sheffield Hallam University (Dec 2013) (5) National Audit of Intermediate Care 2015. NHS Benchmarking. (2015)
There is sufficient evidence that integrated care is the right direction of travel for meeting the changing needs of the population, particularly in the context of increasing numbers of older people and people with long term and complex conditions. Integrated care is associated with improvements in patient experience and higher levels of satisfaction…It has also been shown to lead to improved clinical outcomes and can improve service efficiency.
Kings Fund 2015 (1)
Health and Social Care
The profile of people who use intermediate care services demonstrates that they frequently have both health & social care needs. The review found that even when an individual was assessed as having a predominant health or social care need and was placed in the appropriate health or social care service there needs tended to fluctuate and it was often difficult to then access the other type of support. For example; in the sample of patients reviewed at Positive Steps 22% were transferred back to hospital, often because it was not possible to access a timely clinical review from Positive Steps. 10% of the STEPS referrals reviewed were referred onto CICT for therapy input or rehabilitation following a period of social care re-enablement. People were occasionally transferred from one of the health intermediate care beds into one of the social care bed for a for social care assessment.
Exploring older people’s aspirations to socialise and take up activities should be prioritised by relevant services - the results in this study suggest there is considerable unmet (and unidentified) need in terms of older people doing
what they want to do and going where they would like to go. Improved practical support and better community transport will obviously help combat problems of isolation and loneliness which were prevalent amongst participants in this study and enable older people to stay independent at home and active in their local communities. Our results also highlight the importance and value of having someone to provide support to help overcome any fears and apprehension older and vulnerable people may have about re-engaging socially.
Doncaster Hospital Discharge Pathway Study, Interim findings. October 2015
In addition to this the people reviewed often had a low level of mental health or psychological need (23%). For example low mood, anxiety and loneliness were often an issue. 34% were also identified as being at risk of social isolation. Although intermediate care services are not routinely set up to address these issues, they have a significant impact on a person’s quality of life and can make it more difficult for them to get home from hospital.
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The Case for Change 9. Integration/whole person approach
Progress towards integration
Last year the National Audit of Intermediate Care asked a series of questions to gauge how well integration was progressing. When Doncaster intermediate care services are bench marked in relation to each of these questions it highlights that there is more work to be done to develop integrated intermediate care services in the city. Progress has been made, with MDT reviews taking place in some areas but not consistently and the expansion of the Older People Mental Health Liaison Service to cover all bed based services is a step towards mental health staff becoming part of the establishment. The development of the SPOC (Single Point of Contact) case manager roles who are trained to assess for re-ablement services, can prescribe basic equipment and carry out social care assessments is one example of a trans-disciplinary role. Therapy and rehabilitation assistants in other services are other examples but there are currently several versions of this role in each of the different teams.
These questions may be useful in setting standards around integration in future services and could provide a framework for measuring this.
What needs to change?
Intermediate care should be commissioned and lead in a way that facilitates integration and goes beyond co locating services.
Does the service have? Across all home based Across Home & bed
Doncaster % of services nationally Doncaster % of services nationally
A single point of access for these services? 46% 58%
A single assessment process for these services? 38% 54%
A single patient record, shared by these services? 25% 49%
A single management structure for these services? 33% 51%
Staff working across services? 47% 53%
Trans disciplinary roles within the service? 31% 43%
Joint training and induction programme for health and social care staff in these services? 25% 47%
Weekly MDT meetings attended by health and social care staff? 69% 51%
Mental health specialist included in the establishment of the service? 29% 24%
A single performance management framework for these services? 31% 45%
Not in place Being developed
If not addressed they can cause further deterioration to an individual’s health and wellbeing, increasing the likelihood of readmission or need for longer term care. A recent study also linked loneliness with increased risk of coronary heart disease and stroke (2). Social isolation was also one of the key themes in the hospital discharge study and was an unmet need for many of the patients and carers they spoke to (3).
When identifying optimum care pathways for people the expert panels identified that 35% would have benefited from psychological support or social prescribing as part of their intermediate care response. Social prescribing has been demonstrated to have a positive impact on the health and wellbeing of older people and those with long term conditions (4) and on reducing contacts with health and social care services.
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The Case for Change 10. Workforce
Flexible, multi-disciplinary and multi-agency teams
Collectively the workforce in the core intermediate care services in Doncaster is predominantly made up of rehabilitation assistants and social care support workers (187), Registered Nurses (98) and Therapists (63). This is consistent with the national picture described in last year’s national audit of intermediate care (1) and there are good examples of multidisciplinary working in many services.
However each of the separate teams providing intermediate care has a slightly different establishment of staff often determined by the team being either a health or social care service, where it is located and which organisation provides it. Some teams have therapy, some have 24 hour nursing, and some have social care support staff. No service has all three of these. There is Geriatrician cover in one of the services but not all. GPs provide cover for some of the bed based services but not all. The mental health liaison team covers all of the bed based services but does not follow people up at home.
As discussed the people who require intermediate care services have complex physical, mental health and social care needs and may require access to a range of skills and expertise while with the service, based on their need and not the configuration of services.
Multi-disciplinary and multi-agency teams have been linked to better outcomes for older people (2) and to be beneficial for staff. As part of the review staff from across intermediate care services in Doncaster were bought together to form multi-disciplinary and multi-agency expert panels and review the needs of people referred to intermediate care services. This was observed to be beneficial on a number of levels-it not only fulfilled the requirements of the review but also provided an opportunity to share knowledge, challenge assumptions and develop a collective vision for future services. More opportunities to work across traditional organisational and professional boundaries need to be part of any future service model along with joint training and induction programmes (2).
Older people’s care could be enhanced by greater
use of multidisciplinary and multiagency teams in
both hospitals and the community, bringing
together staff from different backgrounds to
contribute to decisions and break down barriers.
Growing Older Together
46
The Case for Change 10. Workforce
New roles
NHS England suggests that the development of trans disciplinary roles is one way of breaking down traditional distinctions between disciplines and services (3). Some of these new roles have begun to be developed in Doncaster services including the STEPS Case Manager role and trusted assessors in the Integrated Discharge Team. The review identified that in the future there may be a need to develop more flexible roles designed specifically to meet the needs of the local population. Two examples identified by the MDT panels were
1. Falls assessors - clinically trained professionals to assess people at home after a fall.
2. Generic re-ablement or enablement workers - a combination of the STEPS support worker role and CICT rehabilitation assistants who could deliver support plans developed by case managers, therapists, nurses or mental health professionals.
Core competencies
In order to ensure the intermediate care workforce is able to meet the needs of an aging population and work flexibly in new service configurations it would be helpful to develop a shared set of core competencies. The findings from the review indicate the following skills should form part of this (many have been discussed in earlier sections);
• Working as part of a team (page 46)
• Basic falls assessment (page 17)
• Working with people who have Dementia and cognitive impairment (page 35)
• Supporting people in the end of life
• Communication skills as identified by the hospital discharge pathway project (page 42)
• Meeting social needs
• Supporting carers (page 41)
• Continence advice and support (page 41)
• Advocacy and care co-ordination skills.
This is not an exhaustive list and there is more data is available from the review that will be used to help identify the profile of the future workforce.
Trans-disciplinary working means that one discipline may
take on the traditional role of another by agreement, where
the barriers between different disciplines break down and
roles within teams are redesigned to make optimum use of
team skills and knowledge. Assessments may be carried out
by different disciplines working together with insights from
one discipline informing the assessments of another; ‘the
whole will be greater than the sum of the parts’.
MDT Development Guide, NHS England 2015 (3)
References: (1) National Audit of Intermediate Care 2015. NHS Benchmarking. (2015) (2) Growing Older Together. NHS Confederation.(2016) (3) MDT Development Guide. NHS England (2014)
47
The Case for Change 10. Workforce
Specialist assessment and skills
The review also identified the importance of timely access to specialist assessment and advice. The needs of people who use intermediate care indicate that access to the following specialist skills and assessments are particularly important;
• Continence assessment and treatment.
• Comprehensive Geriatric assessment
• Therapy assessment and rehabilitation expertise.
• Sensory assessments
• Psychological support/ counselling services
• Cognitive assessment and interventions
• Behavioural management expertise.
• Clinical assessment and medication reviews.
Close links are also needed with the following;
• Primary care and GP services
• Hospital based diagnostic services
• Home care
• Community and voluntary sector
• Community equipment services.
• Community Nursing
• Urgent care services
The ways in which this can be achieved and the types of roles needed will be explored in greater detail as part of the design work stream in phase 2 of the project.
What needs to change?
Develop a more flexible multi-disciplinary and multi-agency workforce, with a shared set of competencies, joint training and induction programmes.
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Section 5:What does good look like?
In 2015 the NHS Confederation set up a commission to review urgent care for older people. In the report of their findings they state that “our commissioners heard about many areas that provide elements of excellent care, though no one health economy claims to have got all aspects in place.”(1) They did however use the evidence they collected in their review to provide a vision of what excellent urgent care for older people should look like. In the box to the left is the commissions list of how the system could work “to the greater benefit of people.”
Although not specifically about intermediate care and acknowledging that intermediate care also provides a service for younger people with complex health and social care needs, this list brings together lots of the current evidence relevant to intermediate care and is a useful checklist for what good should look like. It also echoes many of the findings of the Doncaster review.
The need for comprehensive change to or ‘transformation’ of community services has also been well documented, with evidence that improved community services not only make a major difference to people’s lives but can also effect change in acute and primary care (2). In 2014 the Kings Fund set up a working group to review the changes needed in community services. Based on their findings they identified some key components for future community service models which are also relevant to intermediate care services in Doncaster. It suggested future models need to:
1. Remove the complexity. “A simple pattern of services should be developed based around primary care and natural geographies and with a multi-disciplinary team, working in new ways with specialist services”
2. Include both mental health and social care
3. Be capable of a very rapid response and able to work with hospitals to speed up discharge.
4. Develop alternative services to provide support as an alternative to admission.
5. Connect with the wider community to help support people at home, combat social isolation and improve prevention.
6. Build the infrastructure, workforce, ways of working and commissioning required to support this.
What does good look like?
It should respect the wishes and goals of the individual and their carer(s).
It should support medical and non-medical care in the most appropriate setting.
It should use the right resources - clinical or social - to support the delivery of care.
It should prevent escalation to any inappropriate services.
It should seek to use the right alternatives to resolve a crisis as early as possible to avoid major disruption to a person’s daily life.
It should provide a clear plan for the individual of what immediate and longer term steps are when acute care is required.
Commission for Improving Urgent Care for Older People. January 2016
In the early stages of the Doncaster review two formal evidence reviews were conducted along with an on-going appraisal of relevant literature, publications and examples of practice from elsewhere.
This work stream concluded that there is no one solution or an ideal model. Intermediate care by virtue of how it has evolved varies from place to place. Its purpose is to connect the system up so it needs to be developed locally and tailored to the needs of the population in that area.
There are clearly some elements that have been demonstrated to be more effective than others (see page 5) and recently the development of crisis or rapid response teams seem to have been particularly important.
References: (1) Growing Older Together. NHS Confederation.(2016) (2) Community Services; how they can transform care. The King’s Fund (2014).
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Section 6:Future vision
1. People can lead independent lives in strong and sustainable communities.
2. People will have choice and control
3. People are healthy and safe, especially when in urgent need or crisis.
Effective intermediate care services are essential to the delivery of outcome 3 and could also make a difference to outcomes 1 and 2 in the future.
DMBC’s corporate plan outlines six objectives and intermediate care links in particular to objective 2 “People live safe, active and independent lives”. However redesigning current services based on the findings of the review would also support delivery of objectives 5 and 6 which are about ensuring value for money and working in partnership.
Doncaster CCG’s five year system vision identifies three priority service areas; Care Out of Hospital, Care of the elderly services and co-ordinated care. The ambition is to provide a catalyst for transformational system change by focussing on these three connecting areas. Redesigning and implementing a new model for intermediate care is one of the programmes of work identified to support delivery of this vision and as the case for change has described it links to all three priority areas.
The vision for intermediate care services in Doncaster
It is clear from the case for change that intermediate care services in Doncaster cannot remain as they are and that services will need to be redesigned to meet the needs of people in Doncaster in the future. As discussed the vision nationally is for more integrated services and a shift in emphasis to community based care, closer to home. This is consistent with the evidence presented from the review about what is needed and what could be achievable in Doncaster. The redesign of intermediate care services will help deliver the shared vision for health and social care in Doncaster as well as supporting the individual priorities of both DCCG and DMBC and could play an important role in helping Doncaster’s whole health and social care system meet the challenge of delivering high quality care against the back drop of reducing budgets and increasing demand.
The key changes indicated by the case for change are summarised on the following pages and the future vision for intermediate care is developed further in pages 53-60.
Future Vision
There is a broad consensus on what the future needs to be.
It is a future that empowers patients to take much more control over their own care and treatment.
It is a future that dissolves the classic divide between family doctors and hospitals, between physical and mental health, between health and social care.
One that no longer sees expertise locked in often out dated buildings, with services fragmented, patients seeing multiple professionals for multiple appointments, endlessly repeating their details because they use separate records.
One organised to support people with multiple health conditions, not just single diseases.
A future that sees far more care delivered locally but with some services in specialist centres where that clearly produces better results.
NHS Five Year Forward View. October 2014
Doncaster’s Health and Social Care Partnership’s vision is to deliver a Transformation Programme that will embed the type of person-centred, integrated care described above. The transformation programme is focussed on three outcomes around which the recently refreshed Better Care Fund Plan is based.
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Future Vision Future intermediate care offer in Doncaster
Based on the outcomes of the review and local priorities and national guidance the case for change has identified that in the future intermediate care services in Doncaster will need to have:
1. Four types of service response.
The MDT panels conducted as part of the needs review were asked to identify the optimum care package to meet the person’s needs at that point in time. Analysis of the outputs from the MDT panels identified that in future intermediate care needs to provide four types of service response to support people at times of crisis or when they experience a change in their health and to help them retain their independence:
Rapid/urgent response (47% of the sample required this response)
Intensive/short term community response (47%)
Medium term community response (59%)
Bed based response (13%)
Supported by a number of longer term interventions
Please note the percentages above don’t add up to 100% as people often needed more than one type of response. See next page for more detail
2. A more even balance of step up and step down services -
that ‘react’ when a person is in crisis in the community
and ‘reconnect’ people with their home environment as
soon as possible when they have been admitted to hospital.
3. A smaller bed base in intermediate care services
4. A Single point of access and assessment (see pathway on page 59)
5. Fewer separate services
6. More Integrated services
7. Shared records
8. Mental health as an integral part of the service offer.
9. A flexible workforce with new integrated roles designed
to meet the needs of the people who require intermediate
care in Doncaster.
10. A more person centred approach to planning and
delivering care.
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Future Vision Future intermediate care offer in Doncaster
What is it?
Rapid access to an integrated health & social care assessment in the home environment, directly from the community AND in-reach into A&E, MAU, acute wards and other bed based services to assess health and social care needs and facilitate discharge.
Currently this type of rapid assessment only available once someone has accessed acute services e.g. RAPT, IDT, STEPS via SPOC.
In the future needs to be accessible directly from the community to avoid A&E attendances and admissions.
Key points from the review
• This response would assess and develop a care/ support plan to meet the immediate health and social care needs of a person and facilitate access to appropriate support/ services to deliver that plan.
• It would need to have rapid access to home based re-ablement support and/ or increased home-care.
• Single point for assessment and access to IC services (bed and home based)
• Could also include a crisis falls response
Rapid/urgent response Who needed a rapid/urgent response?
Age - The majority of people who needed a rapid response were over 80 years old. 46% were between 80 and 90 and 22% were over 90.
Home situation - 59% lived alone. 22% lived independently and 36% with support from informal carers and family.
Heart problems - were the most common conditions in the past medical histories for this response (10% more than those who required a bed based response).
Dementia/Cognitive Impairment - 18% of people had an existing diagnosis of Dementia and another 6% had a history of cognitive impairment. On assessment these people had medium to high levels of need around memory and cognition.
End of Life - 7% of people who needed a rapid response required it to facilitate prompt access to end of life care. 22% had pain that was not resolved by simple analgesia. This is also the only response where people had very high needs around pain relief (2%). This could be connected to the end of life referrals. 17% had currently or previously had a diagnosis of cancer.
Local Infection - 10% had a UTI, chest infection or other local infection.
Reduced mobility - prior to this episode 23% were independently mobile and 54% used a walking aid. On referral to intermediate care, just under half needed supervision (40%) or physical assistance (9%) to walk. 6% were unable to mobilise at all. 41% had fallen but only one quarter had sustained a fracture and these were generally not fractured neck of femurs or fractures requiring unplanned surgery .
Wounds - A quarter had a wound or needed some sort of dressing. The majority only needed a simple dressing, but 4% needed something more complex.
Carers - 3% needed a rapid response due to carer breakdown. 12% of the carers identified in this response needed formal carer support, could not continue to care or required a care package themselves. Social reasons led to 5% of the referrals for this group and concerns about social situation or potential safeguarding/ risk issues were identified for 6%.
Home environment - 13% required a home assessment or provision of equipment/ minor adaptations
Over half needed support with domestic activities at the point of referral and 15% were full dependent and just over half needed some support with personal care. Another 21% needed significant support with personal care.
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Future Vision Future intermediate care offer in Doncaster
What is it?
A more intensive, wrap around, intermediate health & social care response that could support a patient at home for a very short period to avoid an acute admission or facilitate discharge from hospital. A combined health, social care and voluntary sector provision that could provide very frequent calls or 24 hour carers/ sitters, for between 24 to 72 hours.
Key points from the review
In the future this response will need to include;
• Carrying out observations & supporting patients to take analgesia regularly for acute pain following a fall.
• Intensive rehabilitation & re-ablement after surgery
• ‘Sitters’ to provide reassurance following a fall or settle back in after an admission.
• Support with ADLs while antibiotics for chest infection or UTI start to work.
• Intensive assessment in home environment over a 24-48 hr. period to inform future
• Care package/ identify needs.
• Support someone to stay at home when their carer is taken ill.
• Capability of this service could be enhanced by integration with telehealth and telecare.
• Will require access to appropriate medics for review and access to an IC bed based service to step people up if needed
Who needed an intensive/short term response?
The profile of people who needed an intensive/ short term response is similar to the rapid response cohort apart from;
Age - Well over three quarters were over 80 years old, slightly more than the rapid response. 49% were between 80 and 90 years old and a further 29% were aged over 90.
Home situation - Slightly less live alone (64%) and slightly more already had a formal care package in place.
Long term conditions - 21% had Diabetes (the highest of all responses)
Mobility - more people needed supervision when mobilising (45%) than in the rapid response but less people were unable to mobilise at all (only 2%)
Falls - This group had a higher risk of falls (74%) and were more likely to have a history of falls (17%) than the other home based responses.
Reasons for coming into contact with services were similar to the rapid response and included falls (37%); local infection (11%) reduced mobility (6%) and social (4%)
Approximately 8% of people also required some prompting or physical assistance with feeding and nutrional monitoring or assessment.
Intensive/short term community response
55
Future Vision Future intermediate care offer in Doncaster
What is it?
This response is similar to that provided by existing community Intermediate Care services who currently provide up to six weeks social care OR health re-enablement as step up or step down support. The review indicated that in the future an integrated health and social care team would be better placed to meet both the health AND social care needs of people who require this type of response and reduce duplication.
Key points from the review
In the future this response will need to include;
• Therapists, nurses and social workers working with a joint team of health & social care re-enablement workers to deliver and review intermediate care support and care plans.
• Access to Geriatricians for advice and expert opinion– with the option of review by the Geriatrician, when a patient requires it.
• Better and more timely access to therapy skills and expertise.
• Falls assessment as an integral part of this service response.
• Length of this response should be time limited but based on need not service specification.
• Access to social prescribing services and workers skilled to assess and respond to low level mental health needs, loneliness and social isolation.
Who needed a medium term response?
Age - People who needed this type of response were slightly younger than other responses. 39% were under 80 and only 16% over 90.
Home situation - 59% lived alone prior to the episode reviewed and over three quarters without any type of formal care package or support.
Long term conditions (LTCs) - 70% required regular monitoring of their LTCs (10% more than the other home based responses). 8% of those who needed monitoring also needed regular interventions linked to their LTCs. 42% had heart problems, 19% had Diabetes. A quarter had a pre-existing respiratory condition and for 16% breathing problems were affecting their mobility at the point of referral. More likely to have arthritis than other responses (24%)
Dementia/ Cognitive Impairment - 12% had an existing diagnosis of Dementia and 4% were known to have Cognitive Impairment prior to this episode. However the level of need around cognition and memory was lower than other responses. (14% had medium need, only 3% had high)
Mental Health - Low level mental health issues including low mood, lack of confidence and anxiety were present for 29% of this group.
Mobility - More independent with mobility and transfers prior to this episode than the other responses, but reduced mobility and difficulties transferring were the main needs when they were refereed to intermediate care.
Falls - 66% were are a falls risk and for 24% falls was the reason for this episode of care. Just under half of these had sustained a fracture as a result of the fall (10%) and many of these had then required unplanned surgery.
Planned surgery - Around a third of those who needed this type of response were admitted for planned surgery and required some form of rehabilitation, re-ablement or temporary support at home following this.
Wound care - 30% had a wound, requiring a simple dressing; this was usually as a result of surgery.
Activities of daily living - The majority of people who required this response needed some support with personal care and domestic activities of daily living but this at a lower level than the other responses.
Medium term response
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Future Vision Future intermediate care offer in Doncaster
What is it?A different type of bed base which could be smaller if supported by more intensive, flexible support in the community. This service would be for the most complex patients, providing assessment and re-enablement where it is not possible to provide this at home. A significant proportion of this bed base needs to be equipped to safely assess and meet needs of patients with Dementia, Delirium and cognitive impairment.
Key points from the review
In the future this response will need to include:
• Ideally this would be an integrated health and social care bed base. With the flexibility to meet both health & social care needs.
• Providing short and medium term interventions.
• Mental health expertise would need to be as an integral part of the staffing 24/7
• Offering short term assessment and medium term interventions.
• Access would be via the same single point of access and assessment by the community IC service so people are admitted only when it is not possible for them to support someone at home.
• In-reach by community IC service into the bed base to facilitate discharge and support patients in their own homes ASAP.
Bed based response Who needed a bed based response?
Age - Tended to be slightly older than other responses 54% were over 85.36% were over 90.
Home situation - 73 % lived alone (almost 10% higher than other responses). Only 8% were living independently prior to this episode. 52% had some form of care package or regular health intervention, again more than other responses. 38% were managing with regular support from friends and family.
Long term conditions (LTCs) - 84 % required monitoring of chronic illness or LTCs. 24% required regular interventions as a result of LTCs and 3% more frequent interventions.
Dementia/Cognitive Impairment - Those who needed a bed based response were more likely to have a diagnosis of Dementia or cognitive impairment prior to this episode than other responses (22% - Dementia 15% Cognitive Impairment) and on assessment over 50% had needs around memory, cognition and confusion. For 32% this was a high or very high level of need. 16% had come into services due to a local infection and for some this was the cause of the confusion and delirium so a bed based service was needed while this resolved. Communication was often difficult for this group of patients as a result of their confusion.
Mental Health, behavioural symptoms and risk - 14% had a mental health diagnosis prior to admission and 25% had current support needs related to their mental health or behavioural symptoms, which is much higher than other responses. A quarter had significant risk issues or there were safeguarding concerns (25%).
Mobility - more likely to have needed a walking aid prior to this episode and on referral just under half needed supervision, another 28% needed physical assistance, while 9% were not mobile at all.
Falls - 76% were a falls risk and for 40% a fall was the reason for this episode of care, with half of those having had a fracture as a result of the fall (20%). There was also a slightly higher incidence of Osteoporosis in this group than others.
Nutrition - 27% of the sample needed nutritional monitoring or referral to a dietician and the same percentage also needed support, prompting or physical assistance with feeding and drinking.
Continence - 38% had continence needs, double the number in home based responses.
Informal Carers - 80% had an informal carer and were identified over half needed formal carers support and 11% were unable to cope or needed their own support package.
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MentalHealthServices
Community & voluntary
sector
WellbeingService
HomecarePackage
Intermediate Caredetermined by individual need
CommunityNursing
GP Services
Acute care/h
osp
ital b
ased
sup
port
ADAVANCE CA
RE
P
LA
NN
ING
/C
AR
E
C O O R D I N A T I N G
Bed basedResponse
Medium term Response
Intensive/short term
Response
Rapid/urgent
Response
Future Vision Future intermediate care offer in Doncaster
Intermediate care in the future - React and Reconnect
The relationship between intermediate care services and the wider, health and social care system.
58
Future Vision Future intermediate care offer in Doncaster
An Integrated Intermediate Care pathway with a single point of access.
Needs assessment or acute treatment that cannot be provided in
the community?
Requires assessment or IC services to
facilitate discharge?
Needs longer term support at home?
EXIT - no services required
Can they be supported safely at home?
Require other IC services?
Longer term community support• Health services • Social care• CVS• Carer Support• Supported housing• Advice services
Admission to acute hospital
Residential/Nursing Home Care
Rapid Response/Assessment
Intermediate Care Beds
Single Point of Access
INTEGRATED INTERMEDIATE CARE SERVICE
Other Service
Critical/unplanned event for person
Planned event for person
Short Term/Intensive response
Medium Term response
Agree IC/Support Plan
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Can they be supported safely at
home?
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Future Vision Future intermediate care offer in Doncaster
Rapid/urgent response
Medium term community response Bed based response
Existing services can be mapped onto the four types of service response as below. Core intermediate care services are in bold, other services that provide elements of intermediate care are in italics. The biggest gap is in the intensive short term response. Although lots of teams provide an element of rapid response and assessment this is currently in A&E or to facilitate discharge from hospital and needs to be more joined up and extended. The medium term home based response is already well established in the form of CICT and STEPS but as we have seen could be provided by one single, integrated team in the future. The bed base could also be smaller and simpler than it is at present.
RAPT in A&E and MAU
IDT from the acute hospital wards
Home from Hospital (AGE UK)
STEPS Case Managers- doing SPOC assessments
CICT- falls assessment
Hazel- bed based assessment service
Mental Health Liaison in A&E and hospital wards.
ECP service.
General
Hawthorn
MMH Rehab
Positive Steps
Specialist
Magnolia
Windermere
MMH stroke rehab
CAP beds
CICT
STEPS
Falls service
Home from Hospital (AGE UK)
Community Therapy service
Community Nursing service
Community Mental Health Service
Social Prescribing Service and Wellbeing team.
Single Point of Access
RDaSH’s SPA and DMBC’s SPOC, RAPT, IDT, ACT
Intensive/short term community response
CICT end of life care.
Early Supported Discharge- COPD and Stroke
HEART team (telecare)
Night visiting service
60
Future Vision Next Steps
The case for change marks the end of phase one of this project and the completion of the review of intermediate health and social care services.
Phase two will focus on redesigning these services based on these findings. Four interconnecting work streams have been identified for phase 2.
1. Designing the service model
2. Financial modelling
3. Commissioning and contracting
4. Communication and engagement.
Phase 3 will then focus on implementation of a new model.
More detail about each of the phase 2 work streams is below, along a proposed timeline.
1. Designing the service model
It is important to note that the vision articulated on pages 53-60 is not a service model. Elements of all of the types of responses described are already provided but not consistently, with the right capacity and often at the wrong point in the pathway (see page 60). In the future services need to be configured to facilitate delivery of these different responses in a co-ordinated way so that the experience of those using the service is seamless. There are a variety of ways in which this could be achieved. For example;
• Current services could be reconfigured to work together differently and deliver a more co-ordinated pathway.
• All the responses could be provided by one large service.
• There could be several locality based services providing the three home based responses with a central point of access and one central bed base.
The next phase of work will involve working with stakeholders to design the service model and the following design principles have been agreed to ensure the findings of the review guide the next phase of work.
Design principles for future intermediate care services
1. Respond to needs and personal goals of the person and their family/carers NOT diagnosis.
2. Work collaboratively and flexibly to meet physical, mental health and social care needs.
3. Be simple to access and experienced as one seamless service.
4. Offer responsive, time limited evidence based interventions.
5. Consider all options to safely support someone in their home environment first before transferring them to a bed based service.
6. Have a single system for record keeping, sharing information and a single assessment process.
7. Focus on enablement, maximising independence, promoting self-care and maintaining social networks.
8. Ensure care is co-ordinated while a person is with the service and arrangements are in place for on-going care co-ordination and navigation where required on discharge from the service.
9. Take a multi-disciplinary approach with an appropriately skilled workforce, access to specialist skills and assessment and the flexibility to meet a range of physical, mental health and social care needs.
10. Be commissioned and lead in a way that promotes and facilitates integrated working and empowers staff.
11. Sit in the community, alongside primary care services and in-reach into acute services to facilitate discharge from A&E and hospital admissions.
12. Be monitored and evaluated on an on-going basis as a single service with a shared set of quality indicators.
13. Demonstrate value for money and sustainability
Based on the findings of the review and key principles from Growing Older Together. NHS Confederation.(2016) with reference to DCCGs principles for care out of hospital and DMBCs
Domiciliary Care position statement
61
Future Vision Next Steps
2. Financial modelling
Some assumptions regarding cost have been made based on local and national evidence which suggest it would be possible to reconfigure the existing resource to achieve the future vision. These assumptions are;
• Reducing the number of separate teams and simplifying services will result in efficiency savings,
• Bed Based Intermediate care services are more expensive than home based services.
• There are longer term savings to be made by reducing demand in other parts of the system. For example emergency admissions and care home placements.
As stated previously more detailed financial modelling is required to test these assumptions and assess the financial implications of the transition period including the likely need to double run existing step down, bed based services while establishing home based alternatives. This work stream will run in parallel to the design of the service model. See timeline on page 63.
3. Commissioning and contracting.
The approach to commissioning and contracting will also in part be dependent on the service model agreed. It is however essential that the commissioning model selected is an integrated health and social care one to facilitate the development of a simpler, integrated service offer. This is also a national priority at present, which means there are a number of new options emerging for integrated commissioning (1) and more opportunities to do something different. It will be important that the commissioners of current intermediate care services to work together in the coming months to appraise these options and agree the best approach for Doncaster.
4. Communication, Consultation and Engagement
One of the strengths of the methodology used in the intermediate health and social care needs review has been the number of people who have been involved from across current services and different disciplines. It is essential that this engagement is maintained into phase 2 and there are opportunities for a range of people to contribute to the design of the future model. There will also need to be a clear plan for communicating the findings of the review and sharing the case for change with all key stakeholders.
It is anticipated that there will be an opportunity to do some further work with the participants of the hospital discharge pathway study, who have all used intermediate care services in Doncaster during the review period, and to involve them in the design of future services. Some specific engagement with people from BME communities is also planned as well as wider patient and public consultation.
62
Future Vision Next Steps
Intermediate Health and Social Care Review - Time Line for Phase 2 Intermediate Health and Social Care Redesign
Phase 2 April 2016 May 2016 June 2016 July 2016 August 16 September 2016 October 2016
1. Produce Case for Change
2. Communication & engagement with key stakeholders including:
• IH&SC Transformation Governance
• Health & Wellbeing Board
• Overview & Scrutiny Board
• Member Practices
• Partner Organisations
• Patient groups
3. Develop joint working arrangements for design phase and agree scope of phase 2.
4. Design future integrated service model
5. Identify and agree appropriate commissioning model/ mechanisms for future services.
6. Develop financial model.
7. Understand options for transition and/or procurement.
8. Draft service specifications
9. Develop selected commissioning model
10. Develop appropriate governance structure to support early testing and implementation
11. Develop financial model and payment mechanisms.
12. Plan implementation and agree timeline for phase 3
13. Test, refine and implement new model
Agree at project board
Agree at project board
Recommendations made by project board to be
approved by the Health and Well Being Board and
DCCG Governing Body.
Phase 3
63
Integrated Discharge Team
Magnolia Ward
Medical Assessment Unit
Montague Mexborough Rehab Centre
New Horizons
Older Peoples Mental health
Positive Steps
Public Health
Rapid Access & Prevention Team
Rotherham, Doncaster and South Humber NHS Foundation Trust
Short Term Enablement Programme
Stroke Teams
South Yorkshire Housing Authority
Social Prescribing Service
Wellbeing Team
Windermere Ward
Future Vision Acknowledgements
Thank you to all the individuals and teams who have participated in the review and supported this piece of work
Accident & Emergency
Age UK
Care of the Elderly Service
Community Integrated Care Team
Community Mental Health Team
Community Nursing Team
Community Voluntary Service
Doncaster and Bassettlaw Hospitals NHS Foundation Trust
Doncaster Metropolitan Borough Council
Doncaster Clinical Commissioning Group
Emergency Care Practitioners
Falls Service
General Practitioners
Hawthorn Ward
Hazel Ward
Health Watch Doncaster
Hospital Discharge Study Team -Sheffield University
64
