Rapid Response Services: intermediate tier, multi-disciplinary health and social care service

Transcription

1 Rapid Response Services: intermediate tier, multi-disciplinary health and social care service Provided by: Care Services Efficiency Delivery Programme (CSED - DH) in Partnership with Bristol PCT and Bristol City Council Publication type: Quality and productivity example QIPP Evidence provides users with practical case studies that address the quality and productivity challenge in health and social care. All examples submitted are evaluated by NICE. This evaluation is based on the degree to which the initiative meets the QIPP criteria of savings, quality, evidence and implementability; each criterion is given a score which are then combined to give an overall score. The overall score is used to identify the best examples, which are then shown on NHS Evidence as recommended or highly recommended. Our assessment of the degree to which this particular case study meets the criteria is represented in the evidence summary graphic below. Evidence summary Page 1 of 8

2 Details of initiative Purpose Description (including scope) To establish an intermediate tier, multi-disciplinary health and social care service to respond rapidly to a health or social care crisis. The Rapid Response Service assesses, treats and supports the individual in their own home, avoiding an unnecessary and more costly admission into hospital or residential care. The approach recognises that crises for older people almost always have a health and a social care component. Therefore, the model described involves an integrated approach across health and social care and, in this example, is a partnership between Bristol PCT and Bristol City Council. The initiative addresses the rise in the number of unscheduled admissions to hospital, of which older people are a significant percentage, and which consume a significant amount of NHS funding. It also addresses the admissions of older people to residential care as a result of a crisis and which accounts for a significant percentage of social care expenditure. The Service operates at the intermediate tier between primary and acute care and is a partnership between the PCT and the City Council, with integrated management and multi-professional membership and budget alignment between the two organisations. The service was established in 1998 and is availble to all adults in Bristol, (population 459,000 and larger than the average PCT area) but used primarily by older people. It is staffed by nurses, physiotherapists, occupational therapists, social workers, mental health specialists, pharmacy and reablement workers. The team has a range of clinical skills -for example the ability to offer intravenous therapy in a person's own home - which provide a genuine alternative to a hospital admission for many conditions. Such interventions are supported by clear pathways and protocols between the service and acute services. The team oprerates 7 days a week and from 7.30am to 7.30pm. The out-of-hours service provides the rapid response service outside of the team s normal operating hours. The majority of referrals and activity are within normal operating hours but the arrangements with out-of-hours services ensures that there is a continuity and consistency of service for patients who require a rapid response and can be diverted from an acute admission. The input of the out-of-hours service into the rapid response service is Page 2 of 8

3 relatively small and the cost of this input has not been taken into account in calcuating the overall efficiency of the service. Referrals are made through a single point of entry, and response is guaranteed within a maximum of four hours (but usually less), providing reassurance to referrers and other partners. Over 60% of referrals are from primary care. The service can access step-up beds when required and usually 9 are allocated for this purpose. However, the vast majority of patients are supported in their own homes. Topic Other information Acute / Urgent care The Service focuses on those conditions - primarily ambulatory care sensitive conditions - where there is evidence for safe and successful community treatment (given the right range of services, appropriately trained staff and robust clinical governance arrangements). Targets are set by the PCT commisioners for the conditions that the Team has to divert from hospital and treat in the community. The savings to the PCT can be calculated by comparing the cost of treatment in hospital, using HRG codes, against the cost of providing the community-based service. In 2008/09, the service achieved savings for the PCT of 3.6m, having taken into acount the cost of providing the service. Bristol, in common with other intermediate care services, has not adopted a methodology for calculating the savings to social care by the actvities of the service. CSED, working with the service, has used some very conservative assumptions to suggest that the service also achieves savings for social care. This is based on two elements. First, those people who are referred to the service with a primary social care need and who would otherwise have been admitted to residential care or had more intensive forms of social care suppport had the service not been available. Second, calculations of savings to social care by avoiding older people going into hospital. This is based on the very strong evidence of the negative impact of hospitalisation upon older people, particularly those with any degree of mental frailty, irrespective of the condition that prompted the admission. A significant number of older people do deteriorate in hospital as a result of time spent in bed, falls and infections and, for those who are mentally frail, disorientation and diminished cognitive functioning. Such deteriorations often result in increased social care spend. Thus, in some health and social care systems, over 50% of all admissions into residential and nursing home care come directly from hospital. Using very conservative projections, CSED has calculated that the service achieves minimum net savings for the social care system of 442,000 per annum. Page 3 of 8

4 The approach adopted to calculate efficiencies for the health and social care system are outlined in the attached case study. Gate 1: Savings delivered/anticipated Amount of savings delivered / anticipated Type of saving Any costs required to achieve the savings Programme budget Details supporting Gate 1 The health system saving achieved in 2008/09 were 3.6 million, which equates to 832,600 per of population. The savings are cash releasing to the PCT through avoiding paying for hospital admissions. Savings for social care are also expected. The saving declared in this submission are net of any costs and no additional costs of change are noted, but there may be some management time to set up systems. Other The total cost of the crisis response element of the service is 2.8m to which both the PCT and local authority contribute (Approximately 70/30 ratio). The costs are made up of staff cost, accommodation, treatment and step-up, bed-based services where they are required. The net savings to the PCT by treating people in the community are 3.6M and 0.7m for the local authority (see above and case study for further detail). These are the savings achieved in 08/09, the period that the case study refers to, but are typical of what the service has achieved since its creation. Bristol has begun to see a reduction in the number of unscheduled admissions. Commisioners are investing further in the service, at a time of financial pressures, in order to increase capacity in the rapid response service to divert more people from hospital. Bristol's population is slightly higher than the average PCT population and so the expected savings in other PCT areas would be proportionately lower. Gate 2: Quality outcomes Impact on clinical quality Being treated at home is not expected to reduce the clinical quality of the care received. The service has well-established governance arrangements to ensure quality, including joint guidelines across health and social care, incident management, case-study reviews and root cause analysis. Page 4 of 8

5 Three audits are conducted during the course of each year, in areas such as infection control and documentation. Impact on patient safety Impact on patient and carer experience Increasing care at home may improve safety e.g. by reducing falls in unfamiliar hospital or care home settings. Significant improvement in patient and carer experience is likely to increase as hospital or residential care admissions are less likely. Patient evaluations are undertaken to ensure that the service responds to patients needs and wishes. Supporting evidence The service focuses on diverting people who have conditions which best practice shows can be treated safely in the community, if there are the appropriately trained staff. There are agreed pathways between the service and acute care. Patient safety and outcomes are not compromised but there are very positive responses from patients and carers (based on surveys) that a hospital or residential care admission has been avoided and that the person is able to receive treatment and support in their own home. This is particularly important for older people with a degree of mental frailty as receiving treatment in their own home avoids the risks that can be associated with a period in hospital. The treatment and care plan is agreed with the person and their carer. The service includes clinical treatment, rehabilitation and support, linked with re-ablement programmes, and focuses on enabling the person to regain their independence as quickly as possible. Gate 3: Evidence of effectiveness Evidence base for initiative Evidence of deliverable from implementation Where implemented The Bristol service uses an approach advocated by the DH which encourages NHS organisations to adopt practices which enable people with known conditions (ambulatory care sensitive conditions) to be treated in the community and to avoid having to be admitted to hospital. Thus, older people with conditions such as COPD exacerbations, urinary tract infections and cellulitis are being treated successfully at home rather being admitted to hospital. Documented evidence shows treatment at home is equivalent to care in hospital. North Lancs PCT, in partnership with Lancashire County Council, and NHS Nottingham in partnership with Nottingham City Council, have introduced rapid response services adopting a similar approach. Both North Lancs and Nottingham City are achieiving Page 5 of 8

6 efficiencies through their rapid response services. Services develop according to local needs and in North Lancs, they have incorporated their COPD service which captures a significant number of people who otherwise would have been admitted to hospital. In Nottingham, almost 50% of all referrals to the rapid response service have been due to the presence of this service in A&E of a large hospital. Significant numbers of these patients are deemed to have a primary social care need, emphasing the importance of an integrated approach to meeting the needs of vulnerable older people where health and social care needs combine. Degree to which the actual benefits matched assumptions If initiative has been replicated how frequently / widely has it been replicated Supporting evidence for Gate 3 Same as expected See above and other intermediate care services are beginning to have a similar approach, for example, North Lancashire PCT and Lancashire CC, Nottingham City PCT and Nottingham City Council. PCTs are measured nationally on their success in diverting ambulatory care sensitive conditions from acute care. Gate 4: Details of implementation Implementation details The service in Bristol, as in other places, developed through intermediate care services under the NSF for Older People. A key factor in delivering such services quickly is strong leadership from local authorities and PCTs and other partners. They will also recognise the importance of an integrated approach between health and social care organisations if the needs of vulnerable elderly people are to be effectively met. They have ensured that there are effective and appropriate governance arrangments that allow both the commissioning and delivery of services across health and social care. Thus, sound partnerships underpin the development with integrated management of the service and alignment of budgets and resources which have not required the formal mechansims of Section 75 agreements. PCTs and local authorities that wish to use section 75 agreements and pooled budgets - which may be desirable - may take longer to set up their services. However, Bristol shows that such mechanisms are not absolutely necessary. The service is driven by an ethos of constant improvement, Page 6 of 8

7 identifying new pathways that offer a genuine alternative to hospital admission. This demands a constant focus on developing the appropriate skills in community-based services. Examples from Nottingham City and Lancashire show that a more focussed approach to diverting people from hospital and residential care can be created in existing intermediate care services within a relatively short period (less than a year), and where the benefits can also accrue relatively quickly. Time taken to implement Ease of implementation Level of support and commitment Barriers to implementation Risks Examples from Nottingham City and North Lancashire show implementation can be underway within 12 months. Affects the PCT, the local city council, A&E ward admissions at the DGH and care home facilities. The key requirement is a unified approach from health and social care coupled with clear direction from senior managers. GP confidence in the service is critical. This initiative addresses key concerns of the NHS and local authorities to: * Prevent unnecessary hospital admissions. * Prevent unnecessary admissions to residential or nursing care Such admisions place a significant drain on NHS and local authority resources and so there is a great incentive for organisations to work together. Most health and social care systems already have intermediate care with a crisis/rapid response element but the experience of CSED indicates that they do not have the necessary focus and robust performance frameworks for making them both more effective and more efficient. The degree of additional investment required to produce the sort of effective service that Bristol has achieved, will depend upon the level of investment that health and social care organisations have made in intermediate care services. CSED experience suggests that the question is not necessarily more investment but using the resources already invested more effectively and redesigning existing services against best practice. In Bristol, future developments and expansion of the service has required robust business cases to be produced. A key requirement is an integrated approach across health and social care with clear leadership and direction from senior staff (see below). The key areas of risk for health and social care organisations are: * Ensuring clear leadership and sound, joint governance arrangements across health and social care organisations. * Development of integrated services, with integrated manangement, rather than a single organisation approach to preventing hospital admissions or admissions to residential and nursing care. Page 7 of 8

8 * Bringing health and social care resources together to maximise their impact. * Investment in skills of staff and development of clear pathways. * Working with and having the confidence of primary care. These risks are mitigated by the clarity of vision, processes and monitoring arrangements that are put in place by senior leadership and which will drive effective delivery. Health and social care organisations need to recognise the importance of these areas of actvity and the drain that unnecessary admissions are having on their resources. Supporting evidence for Gate 4 No further evidence provided. Further evidence Dependencies In order to operate most effectively, crisis/rapid response and intermediate care services need sound interfaces with other services, for example end-of-life care and management of long term conditions and support to older people with dementia. However, it is possible for health and social care partnerships to redesign current intermediate care services against best practice and then to develop these other important interfaces. The confidence of primary care in the service is essential as, in Bristol, over 60% of referrals are from GPs who recognise that the service provides a genuine alternative to hospital and residential care admission. Contacts and resources Contacts and resources If you require any further information please contactus@evidence.nhs.uk and we will forward your enquiry and contact details to the provider of this case study. Please quote QIPP reference 10/0067 in your . Please see guidance and other case studies on CSED web-site, ID: 10/0067 Published: February 2011 Review due: February 2012 Page 8 of 8