Pressure on the NHS from delayed transfers of care, coupled with pressure on local authorities to deliver timely assessments of people ready for discharge, is creating a bottleneck in the system. Latest figures on delayed transfers of care from NHS Digital indicate that there were 177,100 total delayed days in April 2017, of which 115,600 were in acute care. 55% of all delays were attributable to the NHS, 37.9% to social care and the remaining 7.1% to both NHS and social care.
There’s clearly a need to address this and find solutions to the issues which, in general, aren’t easing.
Discharge to Assess
As new models of care are developing across the sector, and Better Care Funding is being used to help drive integration and new ways of working, one model has emerged as a potential solution to help delayed transfers of care.
D2A has been set up as a way to ease the pressures and help people back into the community for assessment.
NHS England’s Quick Guide: Discharge to Assess defines it as, ‘Where people who are clinically optimised [medically-fit to leave hospital] and do not require an acute hospital bed, but may still require care services, are provided with short-term, funded support to be discharged to their own home (where appropriate) or another community setting. Assessment for longer-term care and support needs is then undertaken in the most appropriate setting and at the right time for the person.’
However, it requires the NHS, local authorities and care providers to work together to create a suitable pathway, to support people out of acute settings. Beyond that, it requires partnership, conversations between all stakeholders and the right attitude to find solutions that make a difference to people’s lives in a time of immense pressure.
Pilots are popping up across England to develop D2A pathways and evaluate their effectiveness for patients, the NHS and local authorities. As with any new initiative, different areas are taking different approaches.
In Portsmouth, Agincare, in partnership with Portsmouth City Council and Queen Alexandra Hospital, has developed its model around the flexibility of its live-in care workforce.
The Portsmouth D2A pilot set out to offer clients and patients real choice to return or remain at home safely with the right support. Set up in May 2016 to run for 18 months, its aim was to reduce the number of people permanently admitted to long-term care, reduce length of hospital stays and excess bed days, reduce delayed transfers of care, increase the number of people transferred home from hospitals and reduce the number of people admitted to hospital. It was originally conceived as a reablement pathway, but now also provides discharge pathways for end of life care, patients with dementia and community-based hospital admission prevention.
Its underlying principle is to offer patients greater reassurance, supporting the transition from an acute setting to home with anything up to round-the-clock support of a live-in care companion.
The 18-month block contract guaranteed rolling discharge capacity of five live-in care workers per week, providing a maximum two-week intervention for each potential discharge patient. During the contract, this increased to eight workers with additional spot purchasing available. The live-in care workers trained alongside the NHS and adult social care, and a frontline manager supported the collaboration.
The live-in care workers offer practical support, enabling assessment at home within 48 hours, and offering anything up to 24-hour support and continued assessment for a short period as determined by the commissioner. The scheme is also able to respond to emergencies to prevent admission and support people prior to admission.
Over the period of the contract, the pilot evolved, with referrals doubling after six months and expanding to meet changing priorities and demand.
The pilot achieved evidence and outcome-based commissioning that flexes with demand. The service helps to fill gaps in capacity and deliver a more comprehensive service for a limited time. Health and social care teams adapted their commissioning to include the service as part of a range of solutions to enable hospital discharge and prevent readmission.
Over 12 months, adult social care saved £52,000 p/a by reducing avoidable residential placements.
For the NHS, savings totalled £378,000 by reducing delayed transfers of care by an average of 18 days in hospital. Also, only 6.5% of patients involved in the pilot were readmitted to hospital, against a national average of 12.2%, as calculated by the Nuffield Trust.
Tracking patients after 12 months of delivery, 69% receive domiciliary care or no care at all.
Beyond this, the pilot increased trust and understanding between systems, helping to remove some of the pressure and enabling them to function outside of crisis mode. It also enabled Portsmouth City Council to adapt and evolve its ideas and pathways with a trusted provider partner without the risk of compromise from a lack of capacity, continuity or quality.
The scheme has been extended to two years, with Portsmouth City Council announcing its intention to re-commission the service for a further three years. Agincare and Portsmouth City Council have been nominated for a national award for the model. Agincare is rolling it out to new local authorities and NHS partners to meet local demands, strategic plans or sustainability and transformation partnerships.
The model has the potential to deliver single or multiple pathways for long-term service development, or to ease shorter-term winter pressures. It creates a single point of contact for reablement and rehabilitation teams. Plus, the live-in care workforce is able to work nationally and can be permanently based in any location.
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