Integrated Care and Assessment for Older People in Fife

The Story So Far

Yvonne McCallionSeptember 2014

Integrated Community Assessment and Support Service (ICASS)

• 4 year Change Fund from 2011/12 initially saw the development of ICASS from 3 component parts:

– Hospital at Home (new)– Intermediate Care Services (existing services)– Homecare Reablement (new)

• Later additions:

– Short Term Assessment and Reablement (STAR) beds – Discharge Hub

Integrated Community Assessment and Support Service (ICASS) cont.

• Designed to bring together key component parts of service provision across Health and Social Care

• By enabling an increased level of input in the community the model would deliver improved health and social care for older people by:

– Integrating services– Reducing emergency hospital admission numbers– Reducing length of stay 

• Effective links between key services due to multidisciplinary / multiagency nature of the teams

Hospital at Home (H@H)

• New Consultant led service supported by nurses and GP’s linked to wider community services e.g. District Nursing

• Care and medical intervention (normally delivered in a hospital setting) to patients in their homes

• Developing across Fife since April 2012 - fully operational in 2 Community Health Partnerships (CHP’s) and being rolled out in 3rd CHP

• Current occupancy level of 70% - equivalent to an average cost per bed day of £170 in Hospital at Home compared to an average cost per acute bed day of £267 – decreasing cost as occupancy increases

The H@H Team

• Consultant Geriatrician

• GP with Special Interest sessions

• Specialist Nurse Practitioners

• Healthcare Support Workers

• Pharmacy / AHP

• Admin support

Hospital @ Home Service Parameters

• Age > 75 years (ish!)

• GP referrals • Step down from acute after Consultant review • Refer to Single Point of Access

• H@H will accept for clinical assessment at home

• 9 am – 5 pm, Mon – Fri admissions from GP’s

• 7 days / week care

• H@H are now taking step down from VHK 7 days a week

Referral Criteria / Guidance

Problems Included Problems Excluded

Delirium (chest infection, UTI)

Dehydration

Reduced mobility (chest infection, UTI or muscular)

Chronic disease exacerbations (COPD, AF, PD, CCF)

Cellulitis / Leg ulcers

Diabetic foot infection

Falls (no #s)

Pain management

Palliative care (acute)

Stroke

Cardiac chest pain

Lower leg fracture

GI bleed

Head injury (loss of consciousness)

need for high level care ie. Sepsis

Acute abdomen

Hospital at Home – Activity

• Implementation in April 2012 to August 2014 - over 2200 admissions• Average length of stay of 8.8 days compared an average 15.2 days

following an emergency admission to acute• Capacity of 60 patients per day across Fife

Hospital at Home – Challenges

• Challenges relate to the uniqueness of the model:

– Development of software support systems for clinical staff . Communication with GP’s

– Development of highly specialised nursing teams

– Medication management

– Medical workforce issues

– Out of hours service provision

– Case finding within the acute hospital – mostly GP referrals

National Definition of Hospital at Home

December 2013

• An episode of specialist care delivered at home as an alternative to acute hospital care and where the care is overseen by a consultant / equivalent specialist.  An equivalent specialist would include Associate Specialist, GP with an interest in this type of care, Consultant Nurse or AHP or Specialist Practitioner who must be case load holding practitioners

• The locus of care is usually at home but could be in a care home if the individual is usually resident there – or is ‘stepped up’ there by the team

• ‘Stepped up’ care in this context is when a more intensive response is required, but the individual does not require admission to hospital and could go to a temporary place of residence to get that care, for example a care home

Intermediate Care Services

• Comprises Community Hospitals and Intermediate Care Teams  • Community hospitals admit from the community and transfer in from the

acute hospital for either stroke or general rehabilitation

• Intermediate care teams in each LMG area - vary in composition depending on availability of community resources in each area but in general Intermediate Care Teams as part of ICASS consist of:

– Integrated Response Teams– Care At Home Teams– Community Rehabilitation Teams– Community Physiotherapy

Intermediate Care Services (cont.)

• Supports patients to maintain (prevent hospital admission) or regain (support discharge) as much of their previous independence as possible following a deterioration in functional ability

• Provides a range of enabling, rehabilitative and treatment services in community and residential settings

• Provides a bridge between acute and primary care services

• Team comprises AHP’s and Rehabilitation Care Assistants

Intermediate Care Services (cont.)

• Intermediate care teams in 2 out of 3 LMG areas have introduced 6 day working

• Initial data indicates that more patients have been discharged home at the weekend as a result of 6 day working

• Improved capacity and flow within core hours

• Scope for additional activity with transfer of unfilled Rehabilitation Care Assistant posts

Intermediate Care Services – Activity

• In 2013-2014, these teams received on average 633 new referrals each month across Fife - 10% increase over 2012-2013

• 16,478 referrals to Intermediate Care Services in previous 2 years

CHP Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Total

D&WF 269 222 168 196 205 237 240 285 220 250 233 246 2,771

G&NEF 226 239 228 260 264 236 270 262 168 219 203 196 2,771

K&LM 199 213 182 209 182 202 180 160 228 222 198

Total 694 674 578 665 651 675 690 707 616 691 634

Homecare Reablement

• Aims:– To transform the traditional provision of home care service– To provide person-centred support to more clients with the same

resource– A more proactive approach to delaying service users’ needs for

institutionalised care

• Originally established as a distinct service

• Intended roll-out to all home care service users

• Major undertaking to up-skill all home care staff to a reablement approach

• Budgetary constraints versus demand for Homecare

Short Term Assessment and Rehabilitation Beds

• September 2012 - Short Term Assessment and Rehabilitation (STAR) bed model developed to support reablement approach

• Early evaluation has highlighted positive outcomes

• Improved prospects for older people at risk of long term care following a hospital stay or a crisis in the community

• Opportunity for intensive reablement for those with reduced independent living abilities

• Operating in local authority and independent sector beds

Short Term Assessment and Rehabilitation Beds (cont.)

• Effective in building resilience and confidence to allow people to return home and remain as independent as possible

• Recognition of the positive outcomes led to investment from the Change Fund to pilot the model within independent sector care homes

• Current in depth evaluation of the model and outcomes, however early indications show vast majority of service users returning to live within their own homes

• Evaluation supported by the Joint Improvement Team

• Budgetary constraints

Discharge Hub

• Discharge hub established in the acute hospital – roll out August to December 2013

• Built on the success of a test of change featuring an Intermediate Care Team in reach to assess model

• Aim to facilitate early and effective discharge planning, reduce length of stay in the acute setting and reduce inappropriate transfers to community hospitals

• Criteria - clinically fit for discharge, Predicted Date of Discharge within 48 hours, patient requires support on discharge

• Staffed by Patient Flow Co-ordinators, Home Care Managers and administrative staff

Discharge Hub (cont.)

• Aim to assess patients within 4 hours

• Discharge pathway and plan agreed with patient and relatives / carers

• Ward staff supported to plan discharge

• Referrals average 80 per week

– 55% of referrals received before midday– 77% of patients are discharged within a week– 43% are discharged within 48hours of PDD

• Success with discharging patients to await assessment at home

• Reducing assessment capacity within Discharge Hub

Discharge Hub – Activity

What Now?

• ICASS evaluation complete – awaiting sign off – series of recommendations including audit of case load

• STAR bed evaluation supported by JIT

• Recommendations from July ICASS development session – existing services and Day Hospitals links

• Integrated Care Fund – which Change Fund projects should we continue to fund? What are our new priorities? Expansion of H@H – adults with complex needs, care homes out of hours

• Development of Joint Strategic Commissioning Plans

What Now? (cont.)

• Agreement to transfer funding for Rehab Care Assistant vacancies in Intermediate Care Teams

• Hospital @ Home case finding from acute – component of Nurse Consultant Older People role

• Discharge Hub – move to management of EDISON and centralised community bed management

• Review processes within the Discharge Hub to ensure meets demands of service

What Now? (cont.)

• 500K

• Test of change

• Reablement approach

• Initial assessment by Discharge Hub

• Full assessment at home by Intermediate Care Teams

What Now? (cont.)

• Reablement approach by external providers

• Review and monitoring by Intermediate Care Teams

• Transfer to mainstream homecare where required at lowest level of need

• Opportunity to recycle available packages of care

• Demand, Capacity, Activity and Queue work to understand and model high volumes Health and Social Care pathways