ITEM 7 Home Assessment Team Discharge without Delay Programme Update
North Lanarkshire Council · 21 August 2024
Back to IJB Performance, Finance and Audit Committee — 21 August 2024 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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1 REPORT Item No: 7 SUBJECT: Home Assessment Team/Discharge without Delay Programme Update TO: Integration Joint Board Performance, Finance & Audit Committee Lead Officer for Report: Diane Fraser, Chief Officer, Adult Social Work Services NL HSCP Author(s) of Report Margaret Flavell, Senior Manager, Adult Social Work Sharon Simpson, Health and Social Work Manager Ian Nicol, Programme Manager DATE: 21 August 2024 1. PURPOSE OF REPORT This paper is coming to the IJB for: For Approval: ☐ For Endorsement: ☐ To Note: ☒ 2. ROUTE TO THE BOARD This paper has been: Prepared By: ☒ Reviewed By: ☒ Endorsed By: ☒ Ian Nicol, Programme Manager Margaret Flavell, Senior Manager Adult Social Work Diane Fraser, Chief Officer, Adult Social Work 3. RECOMMENDATIONS It is recommended that the IJB PFA Committee: 1. Acknowledge the report. 2. Endorse the strategic direction of HAT and the implementation of HAT across North Lanarkshire.
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2 3. Acknowledge the significant development in HAT practice across North Lanarkshire 4. VARIATIONS TO DIRECTIONS? 5 BACKGROUND/SUMMARY OF KEY ISSUES 5.1 In September 2021 the IJB approved the establishment of a Change Fund to create additional capacity and 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: Do the right thing first time Provide a range of community services and supports to people to live well in connected communities Focus on what matters to people Be at the forefront of technical and sustainable solutions Promote prevention and early intervention Ensure North Lanarkshire is the best place to work, volunteer and care 5.2 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. 5.3 A Winter Planning & Increased Capacity Business Case was developed, and this set out a total recurring investment of £6.759m in three main categories: Assessment and planning capacity Direct provision of services and supports Infrastructure capacity 5.4 Home Assessment sits within the first of these categories and is the approach that North Lanarkshire is taking to implement what is known nationally as Home First. Yes ☐ No ☐ N/A ☒
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3 5.5 It is recognised that being in hospital disconnects people from their family, friends and social network and can result in a sense of isolation, loss of confidence and depression. Older people in particular experience functional decline as early as 72 hours after admission and are more likely to have an episode of delirium or infection. Every unnecessary day in hospital increases the risk of an adverse outcome for the individual, drives up the demand for institutional care and reduces the level of investment that is available for community support. (PubMed - Swinnerton, Price, ‘Recognising, Reducing and Preventing Deconditioning in Older People’. 2023). 5.6 Discharge without Delay (DWD) is a vital component of the Scottish Government’s Unscheduled Care Programme with a Home First approach fundamental to its success. The aim is to prevent delay to discharge where an acute medical issue has been addressed. Reducing delay for people who can be assessed within their own homes rather than a hospital ward is an essential element of reducing the length of hospital stays and thus releasing unnecessarily consumed capacity. This approach requires a shift in mind-set to; “Why not home? Why not now?” and has been proven to result in more positive individual outcomes for people. (SCIE, ‘Hospital Discharge and Preventing Unnecessary Admission, 2022). 5.7 North Lanarkshire’s Home Assessment Team, (HAT), is a multi-disciplinary social work, health and social care resource which applies a whole system approach to planning and preparation for hospital discharge and admission avoidance by facilitating both assessment and intervention within each person’s own home. HAT will support by adjusting the balance of care both at the front door and back door of hospitals. 5.8 To enable timely discharge from hospital and prevent unnecessary admissions, HAT provides: Rapid access to the support that people require to enable them to return home or avoid admission to hospital. Time-limited support to enable an assessment of each person’s immediate and longer-term support needs in their own home, taking into account and optimising use of personal and community networks. A designated workforce focused on 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. Close links with individuals involved in the Planned Date of Discharge process to identify appropriate patients for the HAT pathway.
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4 Close working relationships with Rehab Team, 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. 6 PROGRESS AGAINST WORK PLAN 6.1 HAT Roll-out Phase 1: Wishaw and Cumbernauld fully implemented Phase 2: Motherwell and Airdrie fully implemented Phase 3: Coatbridge and Bellshill: Coatbridge commenced December 2023 although not fully staffed yet with work ongoing to progress. Bellshill not yet fully operational, but utilising Motherwell-based HAT Home Support staff to support discharges via HAT. 6.2 Service Model Standard Operating Procedure agreed. Workshops held 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. 6.3 Data and measurement Data spreadsheet developed to record activity and enable monitoring of performance and outcomes. This continues to be revised according to activity and developments. 6.4 Recruitment Recruitment to HAT ongoing to build capacity and roll out across all NL localities. The pressures within the system regarding workforce are widely acknowledged and adjustments continue to be made to skill-mix. Several recruitment campaigns have been progressed across health and social care to recruit across the team including Home Support, Physiotherapy and Occupational Therapy staff. Several Home Support Workers have expressed an interest in transferring to HAT. This will be facilitated as soon as their posts have been backfilled. It is the intention for existing staff to be able to work flexibly across sectors as required to meet demands. 6.5 Leadership and Operational Management Interim operational management of HAT has been delegated to two Locality Social Work Managers, aligned to the 2 hospital sites of University Hospitals
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5 Monklands and Wishaw, and an NHS Service Manager, working closely with the discharge arrangements and the hospital social work teams. This will be rolled out across the six localities. They are reviewing the operational structure of the HAT and holding regular meetings with Team Leads including Allied Health Professionals and IRT to take forward any outstanding work to establish HAT. Strategic management is also undergoing a review to ensure integration into the new GIRFE/Enabling Approach arrangements. 6.6 Risks and challenges 6.6.1 The implementation and embedding Home Assessment practice presents with several 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 in-house home support and the independent home care providers across the sector to create the capacity required to release this resource. People are not supported as required due to ineffective, inefficient and inconsistent reablement activity Ring-fenced reablement teams established to meet need Regular weekly Reablement meetings between Home Support and Rehab Teams across 6 localities to target reablement activity and achieve practice consistency Lack of trust in HAT process Targeted engagement activities between HAT, ward and community staff to develop trust and confidence in assessment at home 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 Promote earlier discharge from hospital and assessment at home Planned Date of Discharge (PDD) is not fully embraced Refreshed PDD process Low referral rate to HAT HAT presence in hospital settings to develop further trust and confidence
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6 Recruitment challenges Planned, phased and strategic recruitment Low Pharmacy input Ongoing pharmacy input and medication training across relevant staff Limited access to pool cars Further purchase of pool cars Lack of capacity on Acute sites to support HAT Accommodation and space identified for HAT staff 6.6.2 Other challenges: Timely movement of people into services, if required, including Reablement, IRT, long-term home support. Funding for non paye costs to be agreed and sourced as not included in the initial business plan. 6.7 Embedding the approach 6.7.1 As HAT has developed, further synergies have been identified with other key programmes of work to improve our prevention and early intervention response. This includes Getting It Right for Everyone (GIRFE), the Frailty Strategy, Home Support Refresh, the Back to Basics Enabling approach and the Operation FLOW Optimal Discharge Planning Target Operating Model. 6.7.2 The interface with other parts of a person’s 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 to enable people to maximise their potential and ensure that they receive the support that is right for them. 6.7.3 Reablement provision was significantly impacted during the pandemic due to capacity and workforce issues. Subsequently, there have been changes within the Home Support Service and Integrated Rehab Teams (IRT) to ensure that Reablement can be fully remobilised. This entails a separation of assessment and planning functions, including Reablement, HAT and IRT, and a long-term “Living Well” Service. 6.7.4 Weekly meetings have been established between relevant staff in HAT, Home Support, Reablement and Rehab Teams to facilitate effective communication regarding individual service users and reablement activity and subsequent goal setting supported by a standard operating procedure. 6.7.5 Each locality is developing a multi-disciplinary enabling approach to ensure an effective and timely response that taps into community resources, where
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7 appropriate, through our recently appointed third sector community connectors. 6.8 Next Steps Embed HAT across North Lanarkshire whereby Home First becomes the norm in Acute and Community and align with the Target Operating Model to optimise discharge. Conclude recruitment and complete roll-out across localities. Communication and engagement activities continue including staff briefing sessions. Ensure Lanarkshire-wide referral criteria are widely known. HAT process and patient/service-user pathways used in everyday practice. HAT patients/service users to be discussed on Planned Date of Discharge (PDD) call. Full remobilisation of Reablement. Improved interface with the Equipment Store and Assistive Tech Team and subsequent service delivery. Ensure HAT is embedded in whole system approach aligned to GIRFE principles and Back to Basics Enabling Approach. Undertake a test-of-change in Airdrie/Wishaw which will aim to: Identify the range of preventative and early intervention services. Build on the prototypes developed through the Partnerships involvement in the national GIRFE Pathfinder Programme. Improve access through changes to first point of contact. Put in place robust screening and allocation through an MDT and enabling approach. Reduce waiting times through embedding the team around the person, working to a single, shared plan and eradicating unnecessary referrals. 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. 7 DATA ON ACTIVITY AND IMPACT 7.1 Since its inception in April 2022 to 2nd July 2024, 2,119 patients in total had been referred to and supported by the Home Assessment Team. 7.2 As illustrated by the Chart 1 below, there has been a natural, gradual build and expansion of the team as staff have been recruited and trained. This is reflected in the gradual build-up in the volume of referrals. Whilst all localities are not yet fully operational, an average of 120 new individuals are currently supported by the service every month. Those people who are referred to HAT are also being discharged quicker from hospital to be fully assessed in their home environment, with 82% of individuals referred to HAT and discharged from hospital on the same day.
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8 Chart 1 7.3 As HAT has become established the team has been able to accept more complex cases and fully support the multi-disciplinary team working that is required to support a “Home First” approach for individuals. We can see below in Chart 2 that over time, as more complex cases were being accepted in financial year 2023/24, that the proportion of people recorded as completing the service with no further service required decreased; however, we know from our monitoring of delayed discharges that the HAT approach is improving flow. Chart 2 Of the those requiring a further service, the service with the highest number was the Community Alarms Service (16% of total completing). This was followed by Home Support Reablement (13%), then Integrated Rehab Team (IRT) - Physio and Mainstream Home Support (both 11%) and IRT – Occupational Therapy (10%).
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9 Service at Completion Home Support - Reablement 13% Locality SW Referral 1% Home Support - Mainstream 11% Integrated Day Service 0% Integrated Rehab Team - Physio 11% LSS 0% Integrated Rehab Team - OT 10% District Nurse 6% Rehabilitation - Other 1% NL Leisure 0% Community Alarms 16% Third Sector 3% 7.4 The contribution of the Home Assessment Team also appears to be having an indirect impact on the Partnership’s overall performance in relation to patients’ discharge being delayed in hospital. The below (Chart 3 & Chart 4) illustrate the significant reduction in the number of bed days delayed per week in both acute sites and off-site wards, particularly towards the end of 2023 and into early 2024. Chart 3
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10 Chart 4 8 CONCLUSIONS 8.1 This report provides an update on the establishment of HAT in North Lanarkshire, which includes background, progress to date, plans, recruitment update, successes, risks and next steps. 8.2 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 establish the Home Assessment Team (HAT) is critical to the delivery of the Plan for North Lanarkshire and the University Health and Social Care North Lanarkshire Strategic Commissioning Plan. 8.3 HAT provides assessment at home with a focus of complementing established practice and supporting service redesign and streamlining of other key areas of work including the longer-term vision of the development and implementation of an enabling hub approach across the North Lanarkshire Health and Social Care Partnership. 9 IMPLICATIONS 9.1 NATIONAL OUTCOMES Link(s) to National Health and Wellbeing Outcomes People can look after and improve their own health and wellbeing and live in good health for longer ☒ People, including those with disabilities or long-term conditions, or who are frail, are able to live, as far as reasonably practicable, independently and at home or in a homely setting in their community ☒
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11 People who use Health and Social Care Services have positive experiences of those services, and have dignity respected ☒ Health and Social Care Services are centred on helping to maintain or improve the quality of life of people who use those services ☒ Health and Social Care Services contribute to reducing health inequalities ☒ People who use Health and Social Care Services are safe from harm ☒ People who work in Health and Social Care Services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide ☒ Resources are used effectively and efficiently in the provision of Health and Social Care Services ☒ 9.2 ASSOCIATED MEASURE(S) Data spreadsheet developed to record activity and enable monitoring of performance and outcomes. This continues to be revised according to activity and developments. 9.3 FINANCIAL The funding for HAT provided via the Winter Planning & Increased Capacity Business Case has been incorporated into baseline budgets and as such is part of routine financial management arrangements. A funding gap has been identified for non-PAYE (Pay as You Earn) costs therefore this cost impact requires to be resolved through the current financial sustainability arrangements. This paper has been reviewed by Finance: Yes No N/A 9.4 RISK ASSESSMENT/RISK MANAGEMENT Relevant Risk Register Details Current Risk Level Risk Owner Home Support Programme Board High Margaret Flavell As outlined in Risk under section 6.6.61 9.5 ENGAGEMENT & PARTICIPATION Please tick the engagement and participation objectives that link(s) with this piece of work and provide further details on the engagement and participation that was undertaken. Objectives Further details ☒ Involve stakeholders in the development work aimed at achieving the national Extensive engagement with service-users and staff has taken
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12 outcomes place in relation to the Redesign of Home Support and getting it Right for Everyone (GIRFE) ☒ Provide stakeholders with information on how to get involved See above ☒ Ensure a diverse range of engagement and participation and opportunities are in place to suit different needs See above ☒ Measure how well we involve community stakeholders in the planning, design and delivery of our services Ongoing and linked to partnership engagement and participation work and GIRFE testing ☒ Provide regular feedback on how stakeholder engagement and participation is shaping and influencing service development and delivery Regular contact/engagement with families, workers and partners, the production of service-user and staff newsletters ☒ Provide support to enable stakeholder representatives to participate meaningfully and confidently at meetings See above ☒ Develop participation guidelines to ensure a common understanding and set of expectations for both stakeholders and partnership staff See above ☒ Support engagement planning and participation in localities, taking account of other engagement activity and local plans across the Community Planning Partnership See above 9.6 INEQUALITIES & FAIRER SCOTLAND DUTY EQIA completed & Fairer Scotland Impact Assessment Form completed and attached to report: Yes No N/A EQIA added to website: Yes No N/A 10 BACKGROUND PAPERS None
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13 11 APPENDICES N/A Diane Fraser Chief Officer / Head of Service (Adult Social Work Services) CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact the following: Margaret Flavell, flavellm@northlan.gov.uk Sharon Simpson, sharon.simpson@lanarkshire.scot.nhs.uk
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14 Direction from North Lanarkshire Integration Joint Board (IJB) 1 Reference Number 2024/0821-07 2 Report Title Home Assessment Team Discharge without Delay Programme Update 3 Date direction issued by IJB 4 Date from which direction takes effect 5 Direction to: 6 Does this direction supersede, revise or revoke a previous direction – if yes, include reference number(s) 7 Functions covered by direction 8 Full text of direction 9 Budget allocated by Integration Joint Board to carry out direction 10 Performance Management / Governance arrangements 11 Date direction will be reviewed