Agenda item

This paper aims to provide the Health and Wellbeing Select Committee with an outline overview of the Home First service model, which was implemented within Bath and North East Somerset in March 2017.

The Senior Commissioning Manager and the Commissioning Project Manager introduced this item by giving a presentation to the Select Committee. A copy of the presentation can be found on their Minute Book and as an online appendix to these minutes, a summary of the presentation is set out below.

Time is the currency

·  Time is the currency of health and social care

·  It is used to measure a range of aspects from waiting times, A&E Performance Times, DTOC’s to the length of social care visits.

·  However time is also the most important currency for our patient's. We know that the average patient admitted to hospital is within their last 1000 days.

The Last 1000 Days

·  If you had 1000 days remaining, how many would you choose to spend in hospital?

·  This thought has led to development of a social movement within the NHS called the Last 1000 days. This is about recognising that time is the most important thing for our patients and thus patient’s time must be important to those who care for them.

·  The Select Committee were shown video of a poem by a nurse called Molly Case, which was commissioned by NHS England that outlines the importance of this movement.

Home First

·  Home First (also known as discharge to assess) is based upon the principle that it is aimed, where safe, for all patients to be discharged home as soon as they no longer require care that can only be provided in an acute hospital bed.

·  Here Rehabilitation, Reablement and outstanding health and social care assessments can be undertaken at the right time and in the most appropriate environment for the patient to increase independence & fully assess their long term needs.

·  It ensures patients aren’t making decisions about their long term care needs whilst in crisis

·  If patients are unable to safely return home then temporary options need to exist to allow assessments to be undertaken in an environment which will best meet their needs.

Benefits

·  It reduces the risks associated with prolonged hospital stays such as increased risk of infection and functional decline.

·  It ensures patients independence & functioning is optimised, allowing for a true assessment of their long term care needs.

·  It improves patient flow through the hospital, ensuring patients are discharged in a timely manner, decreasing delayed transfers of care and improving A&E performance.

Home First Pathways

·  Whilst the rationale for Home First is clear, responsive pathways need to exist to support this principle.

·  Within B&NES it has been agreed with other system partners in Wiltshire and Somerset, that we will utilise a number pathway options for the RUH facing system. This ranges from patients needing no additional support to go home, to those who need support in long term care settings.

·  Within B&NES Pathway 1, home with additional support, has had the most significant work to date.

Home First Pathway 1

·  Within B&NES the Home First Service (Pathway 1) is delivered by the Integrated Reablement Team. The Reablement team are currently commissioned to provide Home First discharge slots for 20 patients per week between Mon and Fri.

·  Additionally they provide care, support and assessment to all Home First patients on their caseload across 7 days, for a maximum of 6 weeks.

·  It was agreed that this service provision should consist of the following:-

o  A 24 hour turnaround from ward referral to discharge.

o  An initial assessment by a Registered Physiotherapist of Occupational Therapist within 2 hours of discharge to identify immediate care and equipment needs.

o  Care support of up to 4 visits per day, delivered by the Reablement Team or Reablement Strategic Domiciliary Care Partners.

o  Equipment provision to support the patients care and mobility needs.

o  On-going rehabilitation and reablement to increase independent functioning.

o  On-going assessment to fully assess long term care needs.

o  Onward referral to appropriate services once long term needs are apparent.

Home First Pathway – Performance & Plan

·  Since May 2017, 126 patients have been discharged into the B&NES Home First Service, an average of 14 per week. Whilst it is recognised that this is below the commissioned activity expectations; work is currently being led by the Home First Operational Group to deliver improvements.

·  Planned improvement work includes the development of a single point of access ensuring a streamlined referral process, agreement of 10 triage questions to identify all eligible patients and the development of a Home First performance dashboard to assess performance.

·  Additionally, the service is planned to be expanded to deliver 7 day referrals and discharges to ensure the service is responsive to patients discharge need.

Home First Pathway 2

·  This Pathway is for patients that are unable to go home and need further support to get them home; temporary bedded options need to exist to support such patients.

·  Currently within B&NES this is provided solely by community hospitals. It is noted that this is distinct from comparator areas, which have a diversity in their bed base which goes beyond community hospitals and includes rehabilitation and assessment beds within residential and nursing homes.

·  Plan within B&NES to procure 5 beds within a nursing home which will deliver bed based rehabilitation and assessments for up to 6 weeks. Additionally the beds aim to support the social care model of reablement, which aims to optimise independent functioning by increasing a patient’s ability to undertake activities of daily living such as washing and dressing.

Home First Pathway 3

·  Pathway 3 is for patients whose long term needs are known and will be entering long term care facilities directly. Work is being undertaken to ascertain how nursing and residential homes could be best supported in the management of such patients and ensure such support can be accessed in a timely manner.

·  This is likely to include in reach Reablement support to reduce functional decline and benchmarking against the NHS Care Home Vanguard site guidance to develop further actions.

·  Additionally it is noted that Pathways 2 & 3 developments are to be discussed at a system-wide discharge workshop on the 24th July.

Councillor Lin Patterson said that it sounded like a wonderful service. She asked if a nursing home had been allocated to provide the 5 beds mentioned within Pathway 2.

The Senior Commissioning Manager replied that they were about to embark on this process by asking for an expression of interest.

Councillor Geoff Ward commented that this was an interesting element of health care and felt that loneliness can also be a factor in some cases as their own home can at times feels like a prison for elderly people. He asked how this scenario was handled.

The Commissioning Project Manager replied that Age UK have been involved in some soft support discussions.

The Senior Commissioning Manager added that some Virgin Care / Community Services are available in this respect. She added technology can also play a part in this scenario with the use of apps such as Skype.

Councillor Lizzie Gladwyn said that she had some concerns as the system relies a great deal on communication, especially relating to the assessments that are carried out at home. She asked what contingency plans were in place.

The Commissioning Project Manager replied that this is why a single point of access is so important. He added that the ward should ensure that medication needs are addressed before discharge. He said that re-admission would be a last resort and informed Councillors that weekly operational meetings take place.

Councillor John Bull agreed with the comments made with reference to loneliness. He asked what steps were taken to ensure patients are safe when returning to home.

The Senior Commissioning Manager replied that patients are assessed initially in hospital before discharge and then at home to view their ability to use stairs, cook, make hot drinks and dress themselves.

Councillor Lin Patterson asked who oversees the assessment in hospital.

The Senior Commissioning Manager replied that this could be carried out by a number of ward staff including Doctor, Nurse, Occupational Therapist and Physiotherapist.

The Commissioning Project Manager added that this is where the development of the 10 triage questions will become important.

Alex Francis, Healthwatch asked if there had been any delay in provision of care or equipment to patients returning to their home.

The Senior Commissioning Manager replied that she was not aware of any delays in care provision, but that there was work to do on how quickly equipment can be provided as it was possible to go home with some but other items do need to be ordered.

She added that most patients assessed so far are not requiring any additional care.

Alex Francis asked what the expected level of demand for the service was.

The Senior Commissioning Manager replied that the service will have to demonstrate its benefits before an expansion can be considered. She added that review will take place after it has been active for 12 months.

The Select Committee RESOLVED to note the report and presentation provided regarding the Home First service model.