Home Assessment Team-Discharge without Delay Programme Update Report
North Lanarkshire Council · 21 February 2023
Back to Adult Care and Social Work Committee — 21 February 2023 and its agenda
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North Lanarkshire Council Report Adult Care and Social Work Committee Does this report require to be approved? ☒ Yes ☐ No Ref DF/MF Date 21/02/23 Home Assessment Team/Discharge without Delay Programme update report From Diane Fraser, Chief Officer of Adult Social Work Services E-mail FlavellM@northlan.gov.uk Telephone 07939284700 Executive Summary The delivery of high-quality support is critical to support individuals who are at risk of admission to a hospital or who have complex discharge needs. The improvement work to progress this is critical to the strategic plan for North Lanarkshire and the Integrated Joint Board as well as central to Home First a national commitment through the Discharge without Delay programme. NHS Lanarkshire was an initial pathfinder site for the national Discharge Without Delay programme, and NL HSCP is a key partner in delivering this work. This report provides an overview of a key development of the work to improve the outcomes for people who can be assessed and supported at home. There are a range of service redesign which is outlined in the report approved by the IJB on 16th February 2022, Winter Planning and Enhanced Supports. It will highlight the Home Assessment Team (HAT) in North Lanarkshire, which includes background, progress to date, plans, recruitment update, successes and risks. The fundamental difference and priority is assessment at home with a focus of complementing established practice and supporting service redesign and streamlining of other key areas of work: First Point of Contact (FPOC), Access Social Work, Home Support and Reablement, Hospital Social Work and locality responses. This includes the longer-term vision of the creation of an enabling hub. Recommendations It is recommended that the Committee: 1. Acknowledge the report. 2. Endorse the strategic direction of HAT and the rollout of HAT across North Lanarkshire. 3. Endorse the plans for the rollout of HAT across North Lanarkshire The Plan for North Lanarkshire Priority Improve the health and wellbeing of our communities Ambition statement (12) Ensure our residents are able to achieve, maintain, and recover their independence through appropriate supports at home and in their communities
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1. Background 1.1 In September 2021 the IJB approved the establishment of a Change Fund to support the remobilisation and redesign of services post Covid, to enable the delivery of the Programme of Work for the North Lanarkshire Health and Social Care Partnership, and to achieve the ambitions set out in the Partnership’s Strategic Commissioning Plan: 1. Do the right thing first time. 2. Provide a range of community services and supports to people to live well in connected communities. 3. Focus on what matters to people. 4. Be at the forefront of technical and sustainable solutions. 5. Promote prevention and early intervention. 6. Ensure North Lanarkshire is the best place to work, volunteer and care. 1.2 At that time, the monies established into a Change Fund totalled £6.076m of non- recurring funding to support new ways of working, create additional capacity and continue to address the impact of Covid-19. 1.3 Priorities for the use of the Change Fund were identified as: • Prevention and early intervention, targeting spending on helping people to live healthier and safer lives and maintaining their independence at home or in the community. This means less spending is required on hospital or specialist care later. • Empower individuals and communities, involving them in service design and delivery. This should result in services that match what people need and want. • Improve efficiency by adopting a whole system approach to improve and deliver services. 1.4 Further investment to support winter planning for health and social care was announced by the Scottish Government in October 2021 in respect of the range of measures to support and protect health and social care services over the winter period and to provide longer term improvement in service capacity. This announcement was supported by new investment funding of £300 million nationally. 1.5 A Winter Planning & Increased Capacity Business Case was developed, and this sets out a total recurring investment of £6.759m in three main categories: 1. Assessment and planning capacity. 2. Direct provision of services and supports. 3. Infrastructure capacity. 1.6 Home Assessment within the first of these categories and is the approach that North Lanarkshire Health and Social Care Partnership is taking to implement what is known nationally as Home First. The Business Case set out a total recurring investment of £6.759m to address the above three categories and to establish/embed Home Assessment across North Lanarkshire. 1.7 In October 2022, in response to the significant pressures across health and social care, in hospitals, the Cabinet Secretary for Health and Social Care advised NHS Boards, Health and Social Care Partnerships and Local Authorities to prioritise Home First initiatives and progress at pace.
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1.8 To address these demands and prepare for winter it was necessary to accelerate the provision of Home Assessment and it was agreed that University Hospital Wishaw would be prioritised given the pressures at this site. This requires close working between Acute and community staff to develop a model to support assessment at home. 1.9 The Home Assessment Team is a multi-disciplinary approach to embed Home First principles and the key difference is staff supporting people to return home from hospital for a period of assessment. The initial implementation stage has evidence of redirecting or reducing the level of support people need following discharge. To develop this at scale it will be necessary to redirect substantial resource to the Home Assessment Team. In addition, there is a need to work closely with all Home Care providers across the sector to create the capacity required to release this resource. 1.10 The objectives are: • A whole system approach on prevention and early intervention through good early conversations and robust assessment and planning which meets quality outcomes for people in encouraging self-management. • A designated workforce in enabling discharge and maximising function in the home environment by increasing the number of timely post-discharge assessments and providing a rapid community response to prevent hospital admission. • A robust discharge pathway for those who require home assessment and rehabilitation following discharge from both hospital front door and wards. • Flexibility to deploy the workforce across the sectors. • Home first conversation to become the norm at every stage of the person’s journey (Why not home? Why not now?). • Clear leadership and presence within discharge arrangements services. • An approach to avoiding admission to be developed with the Integrated Rehabilitation Teams (IRT) and locality teams. • Close links with individuals involved in the Planned Date of Discharge process to identify appropriate patients for the HAT pathway. • Close working relationships with IRT, District Nurses, Acute, Allied Health Professionals, Hospital at Home and Hospital Discharge Support Programme (3rd sector) with access to the equipment store to support hospital admission avoidance and discharge arrangements. 2. Report 2.1 The pressures within the health and social care system have been sustained in the community and acute hospital sites as a consequence a range of improvements have been implemented. Across Lanarkshire there has been a level of success with the introduction of the home first philosophy, planned date of discharge, and development and implementation of a discharge policy. This will be further enhanced by home assessment/ home first teams which are expanding across Lanarkshire. There has been several challenges for NL HSCP, particularly due to capacity and recruitment and will be fully imbedded by March. 2.2 There has been a concerted approach to seeking to embed Discharge without Delay and maximising the concept of Planned Date of Discharge (PDD). This is in addition to hospital transition teams (home first/home assessment teams), and investment in discharge teams in emergency departments.
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2.3 There is a robust organisational structure where DWD improvement projects are monitored and scrutinised through a dedicated DWD lead and DWD steering group. This group then reports to the unscheduled care board for Lanarkshire. 2.4 Progress made against the work plans • Home Assessment Team soft launch in Wishaw in late April taking referrals from University Hospitals Monklands and Wishaw. • Cumbernauld soft launch in August, taking referrals from University Hospitals Monklands and Wishaw. • Cumbernauld and Wishaw Home Assessment Teams operating at reduced capacity whilst recruitment is ongoing. • Governance agreed. • Standard Operating Procedure drafted. • Workshops held in October 2022 to map pathways, review and agree pan- Lanarkshire referral criteria with all key stakeholders in the MDT including transfers of care into reablement, mainstream /longer term home support and rehab services. • HAT staff accommodation secured in university hospitals and community. • Induction programme established. • Data spreadsheet developed and continuing to be revised according to activity and developments. • As of 20th January, 314 patients in total had been referred to and supported by the Home Assessment Team. The growth in the referral rate to the Home Assessment Team has shown a sustained growth, particularly since the beginning of November 2022. Airdrie Bellshill Coatbridge Cumbernauld Motherwell Wishaw Total 35 5 5 86 55 128 314 11% 2% 2% 27% 18% 41% • The chart below outlines the proportion of individuals who have required further service or no service following their time with the Home Assessment Team. A sizable majority of individuals (63%) have required no further support, with 20% requiring ongoing support. Of those requiring ongoing support, 26% required support through the reablement service, 26% required further support through the Integrated Rehabilitation Team (IRT) and 23% required a mainstream home support service,
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• Approximately half of the individuals who have had an assessment completed with the Home Assessment Team, were discharged from the team within 10 days. The table below illustrates the average number of days from initial referral through key milestones such as commencing the home assessment and completion of the home assessment. On average, hospital patients are discharged 1,2 days after a referral to the Home Assessment Team; and following discharge from hospital, it takes, on average, 0.2 days to commence the assessment at home. Average No. of Days Referral - Hospital Discharge 1.2 Referral - HAT Assessment Start 1.4 Referral - HAT Completion 11.5 Hospital Discharge. - HAT Assessment Start 0.2 HAT Assessment Start - HAT Completion 10.3 • The service will continue to develop its performance dashboard to monitor demand and the service’s capacity to respond. Metrics in relation to individuals’ outcomes and the responsiveness of the service will also continue to be monitored and reported. There are also wider measures of success which will be evident beyond the immediate footprint of the team. For example, the success of the service is dependent on its ability to divert and avoid potential demand on other care at home services - by ensuring individuals, through support from HAT, require no further support or a reduced level of ongoing support as a result of effective assessment. Similarly, it is anticipated that the team’s ability to support individuals’ timeous discharge from hospital will, in future and along with the wider Discharge Without Delay programme, deliver improvements to the partnership’s overall performance in relation to delayed discharge. 2.3 Recruitment update 2.3.1 Recruitment to HAT ongoing to build capacity and roll out across other NL localities. The pressures within the system regarding workforce are widely acknowledged. These pressures have been impacted by the competitive employment market with staff leaving for better pay and conditions, training and career opportunities. The social care sector is facing significant challenges, as a regulated workforce, the number of people leaving to seek alternative careers is at its highest. Additionally, the cost of living and fuel costs are impacting directly on the workforce.
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2.3.2 A number of recruitment campaigns have been progressed across health and social care to recruit across the team including Home Support, Physiotherapy and Occupational Therapy staff. This is with the intention that the Wishaw and Cumbernauld Team will be fully operational by mid-February. 2.4 Risks and challenges 2.4.1 The implementation of Home Assessment does present with a number of risks. Risk Mitigation The release of a substantial number of Home Support Workers from the mainstream/longer term service will impact on the delivery of long- term home support including disruption of existing care packages and potential increase in unmet need. Working closely with independent home care providers across the sector to create the capacity required to release this resource. People are not supported as required due to the need for effective, efficient and consistent reablement activity. Ringfenced reablement teams to progress to meet needs. Lack of engagement with staff on Older Adult wards. Targeted engagement activities between HAT and ward staff. The lack of downstream flow h may cause a bottleneck at the hospital front door impacting on patient safety. In addition, patients’ outcomes may be poorer due to deconditioning in the hospital setting which ultimately leads to increased dependency on formal supports or transfer to long term care home placement. Engagement activities to support communication and promote earlier discharge from hospital. Planned Date of Discharge (PDD) is not fully embraced. It is critical that a specific date of discharge from hospital is identified at the earliest opportunity with plans made to agree a safe and appropriate transition back home. Engagement/support with refreshed communication across hospital sites and across localities. Also testing a new rota for PDD daily meetings incorporating HAT data. Low referral rate to HAT. HAT utilising NHSL relevant discharge patient information, focussed communications to increase referral, relevant discharge patient information access for NL staff. Recruitment challenges. Planned, phased and strategic recruitment. Low Pharmacy input. Currently under discussion to improve and develop to support HAT.
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Limited access to pool cars. Under discussion. Lack of capacity on acute sites to support HAT. Engagement with University Hospital Monklands and University Hospital Wishaw to review accommodation and provide space for staff. 2.4.2 Other challenges: • Timely movement of people into services, if required, including Reablement, IRT, long-term home support. • Funding for non- cost pays to be agreed and sourced as not included in initial business plan. 2.5 Next steps 2.5.1 As HAT as developed further synergies have been identified with other key programmes of work to improve our prevention and early intervention response. This includes the Frailty Strategy and Home Support Redesign. The interface with other parts of the persons journey is critical, whilst some individuals will not require any statutory support, there will be those who would benefit from further intervention. Therefore, while we ensure FLOW through the acute hospital sites, this is also required within community settings and timely access to reablement, and rehabilitation will be critical. It is our intention for the majority of people to receive reablement to maximise their potential and ensure that they receive the right support. Reablement provision had been significantly impacted during the pandemic and due to capacity and workforce issues it has been challenging to fully recover. As a consequence there will be changes to within the Home Support Service to ensure that Reablement can be fully operational. To do this it will be necessary to prioritise this area of work. This may have a short-term impact on those who will receive longer term Home Support. To mitigate this we will be implementing the new ways of working incrementally and by locality. There will be a range of options available to individuals requiring longer term support following reablement. 2.6 Future actions: • Development of service model to support HAT across North Lanarkshire. • Continue to support an accelerated HAT response with initial priority of Cumbernauld and Wishaw. • Rollout to implement HAT in other remaining localities throughout 2023. • Communication and engagement activities continue including staff briefing sessions. • Finalise Lanarkshire wide referral criteria. • Finalise HAT process and patient/service-user pathways. • Include HAT patients/service users in daily Planned Date of Discharge (PDD) call • HAT rota for daily PDD call. Establish key linkages within the Health & Social Care Whole System Dashboard and track wider impacts of the service on Delayed Discharge performance, and capacity of the home support service.
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3. Measures of success 3.1 Data collection format agreed and data collection underway including referral numbers, timescales, input services, and outcomes for people. 3.2 Agreed measures so far: 1. Encouraging self-management with a preventative and early intervention approach. 2. Ensure speedy discharge from hospital. 3. Multidisciplinary working across acute and partnership. 4. More people assessed at home. 5. Increased reablement focus. 6. Further developed relationships with 3rd sector. 3.3 KPIs agreed and subject to monitor and review throughout implementation. 4. Supporting documentation 4.1 N/A Diane Fraser Chief Officer of Adult Social Work Services
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5. Impacts ( http://connect/report-template-guidance ) 5.1 Public Sector Equality Duty and Fairer Scotland Duty Does the report contain information that has an impact as a result of the Public Sector Equality Duty and/or Fairer Scotland Duty? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? If Yes, has an assessment been carried out and published on the council’s website? https://www.northlanarkshire.gov.uk/your-community/equalities/equality- and-fairer-scotland-duty-impact-assessments Yes ☐ No ☐ 5.2 Financial impact Does the report contain any financial impacts? Yes ☐ No ☒ If Yes, have all relevant financial impacts have been discussed and agreed with Finance? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? 5.3 HR policy impact Does the report contain any HR policy or procedure impacts? Yes ☐ No ☒ If Yes, have all relevant HR impacts have been discussed and agreed with People Resources? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? 5.4 Legal impact Does the report contain any legal impacts (such as general legal matters, statutory considerations (including employment law considerations), or new legislation)? Yes ☐ No ☒ If Yes, have all relevant legal impacts have been discussed and agreed with Legal and Democratic? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? 5.5 Data protection impact Does the report / project / practice contain or involve the processing of personal data? Yes ☒ No ☐ If Yes, is the processing of this personal data likely to result in a high risk to the data subject? Yes ☐ No ☐ If Yes, has a Data Protection Impact Assessment (DPIA) been carried out and e- mailed to dataprotection@northlan.gov.uk Yes ☐ No ☐ 5.6 Technology / Digital impact Does the report contain information that has an impact on either technology, digital transformation, service redesign / business change processes, data management, or connectivity / broadband / Wi-Fi? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact?
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Where the impact identifies a requirement for significant technology change, has an assessment been carried out (or is scheduled to be carried out) by the Enterprise Architecture Governance Group (EAGG)? Yes ☐ No ☐ 5.7 Environmental / Carbon impact Does the report / project / practice contain information that has an impact on any environmental or carbon matters? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? 5.8 Communications impact Does the report contain any information that has an impact on the council’s communications activities? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? 5.9 Risk impact Is there a risk impact? Yes ☒ No ☐ If Yes, please provide a brief summary of the key risks and potential impacts, highlighting where the risk(s) are assessed and recorded (e.g. Corporate or Service or Project Risk Registers), and how they are managed? Risks have been identified within the body of the report and are managed through the project risk register. 5.10 Armed Forces Covenant Duty Does the report require to take due regard of the Armed Forces Covenant Duty (i.e. does it relate to healthcare, housing, or education services for in-Service or ex- Service personnel, or their families, or widow(er)s)? Yes ☐ No ☒ If Yes, please provide a brief summary of the provision which has been made to ensure there has been appropriate consideration of the particular needs of the Armed Forces community to make sure that they do not face disadvantage compared to other citizens in the provision of public services.