HOME ENHANCED CARE SERVICE

Transcription

1 HOME ENHANCED CARE SERVICE FORMATIVE EVALUATION Paper 2 June June 2011

2 EXECUTIVE SUMMARY This is a formative evaluation of the Home Enhanced Care Service (HECS) at the end of its first (pilot) year, and also considers the impact of closing community hospital beds at the Royal Alexandra Hospital (RAH) in Rhyl. The evaluation is intended as a basis for ongoing engagement with stakeholders to further develop the service. It is also hoped that this evaluation will generate discussion to inform the development of locality services across North Wales and beyond into other areas of Wales. The evaluation of HECS is set within the context of the Triple Aim and the core strategic principles of reducing harm, variation and waste. Nine exploratory questions frame this evaluation: What has been the profile of HECS patients during its first year? How have patients and their carers experienced the care given by HECS? How do we know that HEC care is appropriate and safe? What impact, if any, has HECS (and closing community hospital beds) had on admissions to hospital beds? What impact, if any, has HECS (and closing community hospital beds) had on social services? What has been the role of the third sector in providing HEC care? What has been the cost of HECS care during its first year? Have there been any additional unintended benefits from establishing HECS which add value to other services? What are the next steps for HECS? What has been the profile of HEC patients during its first year? There have been 263 admissions to HEC care during its first year, providing care for 232 individual patients. Over the whole year, the service has received an average of 5 new referrals per week although this average masks an increase in referrals received in the latter months. The ongoing caseload for the service is between 6-13 patients, with the ongoing caseload increasing in the latter months. HECS has predominantly provided care at home for the frail elderly : almost 80% of admissions were 75 years of age or older, with 1 in 5 being 90 years of age and older. Just over half of admissions are people who live alone. The average length of stay in HEC care is 10 days. Almost three quarters of HEC admissions were patients registered with Clarence Medical Centre, Rhyl or Central Surgery, Prestatyn, these two large GP practices accounting for 60% of all those registered with a GP in North Denbighshire. 60% of admissions were step up. Of the step down admissions, almost all were individuals discharged from YGC or Abergele hospital, with over half of step down admissions coming from medical wards, 40% from surgical wards, and 10% from A and E, the Clinical Decision Unit

3 and the Acute Medical Unit. Only 6 step down admissions were patients discharged from community hospitals. Encouraging more step down referrals from community hospitals and the front door of the acute hospital is a potential area for attention and development during the next 12 months. Over half of admissions are returned to the normal care of their GP or a District Nurse following their HEC episode of care, with 9% of admission being patients who were supported to die at home. Clinicians believe that HECS could play a key role in supporting a hospice at home service, working in conjunction with other palliative and terminal care services, to enable more people in the North Denbighshire locality to die at home. As part of this, HECS may also have a role in supporting the development of advanced care planning for those with a long term condition for whom their end of life is anticipated to occur during the following 12 months, but for whom the date of death is unpredictable. 21% of those being cared for by HECS were discharged from HECS due to being admitted to a hospital bed. 10 individuals account for almost half of these admissions, where the individual was stepped up into HEC care, then admitted to a hospital bed, and then re-admitted to HEC care upon discharge from hospital. An initial analysis of the reasons for admission to a hospital bed indicates that these admissions were appropriate due to the nature of the deterioration in the individual s medical condition. 8% of individuals receive ongoing support from another community service upon discharge from HECS, with 5% requiring long term care in the form of CHC/care packages or admission to a nursing/residential home. How have patients and their carers experienced the care given by HECS? All those in receipt of HEC care and their carers are asked to complete a questionnaire, with these being returned to and analysed by BCU Community Health Council. Just over a third of patients and almost half of carers have returned questionnaires, with the feedback being positive with limited suggestions for improvement. A member of the HEC team now also contacts all individuals and their carers by telephone to gain their feedback. This may identify potential areas for improvement that have not yet been raised by those who have formally provided feedback through a completed questionnaire. How do we know that HEC care is appropriate and safe? Through the formal BCU Health Board incident reporting system, any incident reported by staff is discussed and actions taken as necessary. GPs have raised no concerns about the appropriateness or safety of the HEC care given to their patients.

4 An audit of a random sample of casenotes to review documentation of care and the care interventions given has been completed, with no major areas of concern highlighted. There does not appear to be a high post HEC admission to hospital rate: 70% of step up HEC admissions were not admitted to hospital within 3 months of their HEC episode of care, of whom almost half had been admitted to an acute bed in the 3 months prior to their HEC care. Almost two thirds of step down HEC admissions were not admitted again to a hospital bed within 3 months of their HEC care. As well as being an indicator of the appropriateness of the care provided, this may also indicate that HECS has a role in reducing the frequent flyer pattern of repeat hospital admissions. What impact, if any, has HECS (and closing community hospital beds) had on admissions to hospital beds? Acute Hospital Beds Timeline graphs were used to plot the monthly number of medical emergency admissions and the monthly number of bed days used (medical and surgical) at YGC by patients of the 4 GP practices who have participated in HEC care since its inception (June 2010). There is evidence that the introduction of HECS coincides with a small reduction in the number of monthly emergency medical admissions for patients from 3 out of the 4 practices, with the single handed practice showing no change. There is also evidence that the closure of the first ward at RAH did not lead to an increase in the number of monthly emergency medical admissions at YGC for 3 out of the 4 practices, with the single handed practice showing greater monthly variation in the number of emergency medical admissions. The picture for emergency and elective bed days used is more varied and thus more difficult to identify any overall trends. However, the evidence indicates that: (a) the closure of the first ward at RAH (August 2009) did not lead to an increase in the monthly number of emergency or elective bed days occupied at YGC by patients from the 4 practices; (b) in relation to emergency bed days occupied, the introduction of HECS coincided with a small reduction in emergency bed days used by one practice (Central Surgery. Prestatyn) but little further overall change by patients in other 3 practices; (c) in terms of elective bed day occupied, the introduction of HECS coincided with a marked reduction in elective bed days occupied by the patients of Clarence Medical Centre, with no overall change in elective bed days occupied by patients from the other 3 practices.

5 Community Hospital Beds The evidence shows that: Following the closure of the first ward at RAH, there was a drop in the number of Rhyl and Prestatyn residents admitted to a community hospital bed from August 2009 to October The introduction of HECS in June 2010 does not coincide with a further reduction in monthly community hospital admissions from October 2010 onwards. Rather, the monthly admission rate after October 2010 increases, although the monthly community hospital admission rate has remained lower than had been true when all the beds at RAH were available. Within this, transfers to community hospital beds from surgical wards at YGC are now at similar levels to those prior to the first ward closing at RAH, whilst transfers to community hospitals from medical wards remaining lower than the level that had been true prior the closure of the first ward at RAH. Direct GP admissions to community hospital beds have remained at a similar level to that prior to the introduction of HECS. On face value, HECS has had little impact on reducing community hospital admissions for Rhyl and Prestatyn residents beyond the reduction that had already been experienced between August 2009 and October However, what is not known and is difficult to determine, is whether the increase in community hospital admissions from October 2010 onwards, would have been even higher without HECS. Given that almost all admissions to the previous wards at RAH had been step down transfers from YGC, and that 60% of HEC admissions have been step up, it is not unreasonable to suggest that HEC step up admissions would have been patients not only being admitted to an acute bed (as suggested by the earlier data) but without HECS, at least some of them would also have been transferred to a community hospital, in line with the previous profile of patients admitted to RAH. What impact, if any, has HECS (and closing community hospital beds) had on social services? Funding for 1.5 WTE social workers for Denbighshire (and 0.5 WTE for Conwy) was made at the outset of the establishment of HECS. Half of HEC admissions have required input from a social worker in Denbighshire, their workload equating to 1 WTE. The remaining 0.5 WTE has supported increased travel time for Denbighshire social workers visiting North Denbighshire residents admitted to community hospitals outside the county. There has been little need for social worker support for Conwy residents. An investment was also made to the Denbighshire Community Equipment Service (CESI) ( 14,000). Just over half of HEC admissions have received support from this service, between them receiving 256 items of equipment (as of March 2011). The investment made has enabled this service to respond rapidly (within 4 hours) to requests for community equipment and has also ensured a full tracking, collection and decontamination service.

6 Domiciliary personal care is provided by health care support workers employed by BCU Health Board, with this support available 24/7 if required. Some individuals may also already been in receipt of local authority funded domiciliary personal care. High level data for 2010/11 suggests that there was an increase in the number of care placements for those over 65 living in Denbighshire. It is unclear whether this increase has in any way been influenced by the closure of the wards at RAH or the introduction of HECS. The reasons for this increase are likely to be multi-factorial, and a joint exploration and audit of this increase across health and social services may identify areas for improvement not only for HECS but across all community services, particularly regarding short term care placements. What has been the role of the third sector in providing HEC care? There was little additional use made of third sector organisations in supporting HEC care, over and above that already provided through existing Service Level Agreements. In light of this, a review of the means of accessing third sector support was undertaken. A voluntary sector co-ordinator is now working for an initial pilot period with the HEC Team to identify those who would benefit from immediate and ongoing support from the third sector. This new arrangement will be reviewed after 3 months to assess its effectiveness in generating added value for HEC care. What has been the cost of HECS care during its first year? The full year investment made to establish HECS was 734,300. This equates to a cost per admission of 2792 and a cost per admission day of 279. Although funded as a discrete service, HECS has not in reality been stand alone, with HEC staff supporting other community teams as and when capacity has allowed. An estimate was thus made of the proportion of HECS investment that has directly supported HEC care and the proportion that, to date, has enabled support to be provided to other community services. On this basis, the proportionate cost of HECS care has been 622, 450, with a cost per admission of 2367 and a cost per admission day of 237. The cost per admission to the RAH wards was in the range of 2895 and 3474 with an average cost per admission day of between 103 and 124. The cost per HECS admission ( 2792 or 2367) is thus lower the cost per admission to the previous wards at RAH, although the cost per HEC admission day is higher ( 279 or 237) than had been true per admission day at RAH. It is worth noting that as the workload of HECS increases, the cost per HEC admission and significantly, the cost per admission day will reduce. There may be an argument that the intense nature of the care provided by HECS has meant that individuals have had access to care more rapidly than could sometimes have been accommodated on inpatient wards, thereby

7 necessitating longer hospital stays. Thus, whilst HECS may appear to cost more per admission day than traditional inpatient care, this may mask the fact that HECS is providing more intense care over fewer days. Moreover, the cost comparisons undertaken were based solely on the pay and non pay costs of the previous RAH wards. Were the facilities and overhead costs to be added to these direct ward costs, the average cost per HEC admission would compare even more favourably with the cost per inpatient admission to RAH and the cost per HEC admission day would be more comparable with that for the cost per admission day at RAH. The high level financial comparison does not include the potential impact that HECS may have had, however small, on reducing pressures on acute bed usage. Although it is acknowledged that this is always difficult to quantify as a cash releasing saving, the evidence suggests that HECS may have the potential to release acute bed capacity. Finally, for a similar level of investment to HECS, many more people are managed by the intermediate care service in Denbighshire (RARS) and that in Conwy (CICS) than for HECS, making the cost per admission to HECS higher than the cost of care given by these intermediate care services. However, the caseloads of the services are different and thus it is difficult to compare like with like : the caseload of HECS is characterised by individuals with medical needs and by the provision of 24/7 care if required; the caseload of other intermediate care services focus more on the provision of re-ablement and rehabilitation services for those who do not have a distinct medical need. Have there been any additional unplanned benefits from establishing HECS which add value to other services? HECS has facilitated positive engagement with GPs regarding service change and it is anticipated that this will further support the development of other health and social care services within the North Denbighshire locality. GPs have reported improved working relationships with other members of the health and social care team. Although difficult to prove, it is likely that this has created a HEC effect in generating additional benefit to non HEC patients in their practices. A confidence and trust has also been generated in the ability of a multiagency, multi-disciplinary team to design, develop, implement and monitor a major service change which has proven to have positive benefits for patients, their carers and staff. This provides a solid foundation for future service developments within both the immediate and wider localities. Through HECS team members providing support to other community services (and vice versa), mutual additional capacity and flexibility at peak times for all community teams has been generated. Equally, the availability of health care support workers out of hours has presented an opportunity to further develop mutually beneficial closer working relationships between these workers, the GP out of hours service and the Marie Curie service.

8 Moreover, during the course of the next 12 months, plans will be explored to develop a 24/7 district nursing for the central area. Currently, district nurses are on call after 10pm until 8am, with previous plans to introduce 24/7 working district nursing being cost prohibitive, mainly due to the costs of ensuring that a second person is available to attend home visits out of hours. The availability of the HEC support worker, who is already on duty, to attend home visits with a district nurse may thus facilitate the introduction of a 24/7 district nursing service for the benefit all patients in the central area. This may also realise some cost savings. HEC patients will also benefit from the support of both a trained nurse and a support worker out of hours. What are the next steps for HECS? Key areas for development of the service in North Denbighshire during the next 12 month period are: A focus on increasing the step down support HECS can provide for all hospital transfers, but particularly for patients transferred to a community hospital from an acute bed. Working with local GPs, the opportunity for HECS to more often act as a suitable alternative for a community hospital admission should be explored, thereby reducing the number of North Denbighshire residents cared for in a community hospital bed outside the immediate locality. Equally, HECS could play a greater role in stepping down more patients from community hospital beds, thereby reducing their overall length of stay and returning them more quickly to their locality. Equally, the potential for HECS to support more step down from the front door of YGC (A and E, Clinical Decision Unit and the Acute Medical Unit) should be explored. HECS has a role in supporting the development of a hospice at home service within North Denbighshire to support more people to die at home, when this is their choice. This could include the development of advanced care planning in primary care for those with long term conditions who are in the last year of life and for whom the date of dying is unpredictable. The management of more medically complex patients by HECS would also build on the work undertaken to date. The start of a pilot for a community based IV service in North Denbighshire may support this. A formal audit of those whose episode of HEC care ended in a hospital admission (and who are not re-admitted to HECS as a step down into HEC care) may identify service changes or improvements that could prevent such admissions to hospital. There is also the challenge of further embedding HECS within mainstream community services in such a way as to retain its unique focus and ability to respond rapidly and intensively to those with medical needs, whilst also at the same time working in a seamless manner with other community teams. This will help ensure that the most cost effective use is made of HECS and all community teams working in the North Denbighshire locality. In addition, two further complementary areas worthy of exploration:

9 There is merit in discussing with local GPs, the GP out of hours service and the Local Medical Committee, the potential for new HEC referrals to be accepted out of hours (particularly at weekends) on behalf of the participating practices. The clinical governance implications of this will require careful attention and may be difficult to resolve. There is also merit in exploring jointly across health and social care the reasons for the increase in care placements during 2010/11 for those over 65. This may identify changes that HECS and other community health and social care services could make to reduce the demand for such placements amongst elderly residents in North Denbighshire. It may also be timely to review the catchment population for HECS and consider how those patients living in Flintshire, registered with a Prestatyn GP, may receive HEC care. Currently, only those individuals living in Denbighshire or Conwy registered with one of the 9 North Denbighshire practices have been able to benefit from HECS. In relation to the portability of HECS, some GP practices in other localities have already expressed an interest in adopting HECS in their areas. It is suggested that in considering HECS for other localities, the establishment of a discrete multi-disciplinary/multi-agency HEC Team is not a prerequisite, but rather the remit of existing health and social care teams within the locality could be reviewed, extended and enhanced to support the provision of HEC care. Such a remodelled community resource could then adopt an explicit role to support GPs in providing enhanced medical care for their patients at home, with the agreed Local Enhanced Service used for HECS also adopted by GP practices in other localities for this purpose. As a final note, the experience of those working in HECS supports the recognised benefits that a single point of referral, with access to all locality health and social care community teams, would bring to the provision of seamless patient care. Access to one point of contact to enable discussion about the most appropriate care pathway for individuals would help referrers to more quickly and easily access the most suitable community support for the individuals in their care, rather than being signposted and referred onto a number of community services. A single point of referral in North Denbighshire could also be further complemented by a common working base shared by health and social care staff. It is suggested that further formal evaluations of HECS are undertaken in 6 and 12 months time to monitor the impact of the proposed service changes.