Commissioning Strategy for Re-ablement

and Intermediate Care Services London

Borough of Hackney and City & Hackney

CCG

Consultation document

February 2013

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Purpose of this paper

This paper summarises the joint commissioning strategy for the future redesign of re-ablement

and intermediate care services in City & Hackney. The views of the Older People’s Reference

Group and Health Watch are sought on these proposals.

Background

This strategy follows a review of intermediate care services commissioned by City & Hackney

CCG, London Borough of Hackney and the Homerton Hospital. The commissioning strategy for

re-ablement and intermediate care provides an opportunity for developing new ways of

working, involving greater integration between these key partners and primary care that will

provide more seamless services for patients and service users. It will also provide a blue-print

for greater integration and collaboration between the partners that can extend into other areas

of health and social care in the future.

What are re-ablement and intermediate care services?

They are a range of integrated services to promote faster recovery from illness, prevent

unnecessary acute hospital admission and premature admission to long-term residential care,

support timely discharge from hospital and enable people to regain their independence. 1

Thus, they focus on three critical areas in the care pathway;

Responding to or averting a crisis.

Active rehabilitation following a crisis, either in the community or following a stay in

hospital.

Where long term care is being considered.

Current services

In City & Hackney, the current re-ablement and intermediate care services are;

Rapid or crisis response service, know as First Duty Response Team.

Community-based therapy service, known as Therapy at Home.

Home-care re-ablement service, known as First Response Provider Team.

Bed-based intermediate care service at Median Road Resource Centre.

They are provided by staff employed by the Homerton, formerly the PCT community services,

and by staff employed by the London Borough of Hackney. Some, but not all, of the services have

been funded through a Section 75 agreement between the PCT and the London Borough of

Hackney.

The services have a number of strengths;

They are multi-disciplinary teams which provide a swift and responsive service.

An in-reach service to A&E and observation wards of the Homerton that helps to

prevent people staying unnecessarily in hospital or reducing the time that they need to

be in hospital.

A skilled and professional staff group which delivers high quality service.

Outcomes for patients and service users are generally good.

1 Intermediate Care - Halfway Home, Updated Guidance for the NHS and Local Authorities, 2009

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The consultant geriatrician for intermediate care has developed good links with primary

care and established strong relationships between the different intermediate care

teams.

Comprehensive, multi-disciplinary Geriatric Assessment (CGA) is provided to some

people.

A well-established stroke pathway which leads to good outcomes.

A high satisfaction rate among users of the services.

However, there are also a number of weaknesses, many of which are as a result of the absence

of a clear strategy for intermediate care that reflects the joint priorities of primary care and the

CCG and the London Borough of Hackney.

The availability and the range of intermediate care services are not fully understood by

primary care and other key services. A survey of local clinicians found that referrers are

uncertain as to which service is most appropriate to refer to.

As a result, pathways into intermediate care services are not always clear and it is

sometimes difficult for patients and service users to access the service that is most

appropriate for them.

Referrals to intermediate care services are primarily from the acute sector and assist

discharge processes whilst a relatively small number of referrals are directed to

avoiding admissions from primary care and other community-based services.

Teams are not integrated and function largely as separate entities and not as members

of a coherent, intermediate care service.

The services are provided by the Homerton and by the Council but there is not a lead

provider who is responsible and accountable for the delivery of the whole intermediate

care service and which contributes to the lack of integration between the different

services that make up intermediate care.

The lack of integration leads to people’s journey through different intermediate care

services being sometimes uncoordinated.

Within some services, there is a lack of capacity within the multi-disciplinary team in

terms of the right skill-mix of team members. For example, nurses in intermediate care

are not trained to deliver intravenous therapies in the community.

Relatively low numbers of people who achieve greater independence following a home-

care re-ablement programme.

There is an absence of mental health input to ensure that the holistic needs are properly

met of patients and service users who also have mental health needs.

There is no bed-based capacity which offers nursing care and insufficient medical cover

for bed-based services.

There is no agreed performance framework for judging whether the intermediate care

service is delivering its key objectives.

Whilst Comprehensive Geriatric Assessment is made available to some people, more

could benefit with additional capacity in the multi-disciplinary team.

An unacceptably large number of people who are admitted to residential or nursing care

directly from hospital without the opportunity of rehabilitation.

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Outcomes for re-ablement and intermediate care services

Intermediate care and re-ablement services are key services for diverting people from hospital,

ensuring swift and safe discharge and enabling people to regain or maximise their

independence. Thus, the service should seek to achieve the following;

Maximisation of independent living

Faster recovery from illness

Reduction in admissions to residential and nursing care, particularly directly from hospital.

Timely discharge from hospital

Effective alternatives to hospital admissions

A skilled intermediate care workforce

Success measured from the view point of patients/service users, carers and staff.

Future Service Design Proposals

To achieve these outcomes, the following proposals are made for the future design of re-

ablement and intermediate care services;

Rebrand the current separate teams as a single intermediate care service with a new

name.

Agree lead provider, the Homerton or the Council, with appropriate governance

arrangements;

o Appoint one Head of Service who will be responsible for; management of all

intermediate care services on behalf of the provider partners; all operational

decisions across all intermediate care services; managing the budget allocated to

the intermediate care service through pooled budget arrangements; the

performance of the service.

Geographical zoning of intermediate care services to align with primary care and other

community services that promote good working relationships, seamless pathways of

care and allow GPs to deliver their role as orchestrators of care for their patients.

The new intermediate care service should include; crisis response service (FRDT),

intermediate care therapy service (T@H), home-care re-ablement service (FRPT), bed-

based service at Median Road.

Close alignment with other key services – community matrons, ACERS, heart-failure

service, community therapy services (ACRT) and palliative care services.

Establish a Single Point of Access (SPA) so that all referrals to intermediate care go

through one access point.

Enhance crisis response capacity by increasing the skill mix of nurses, increase social

work capacity, appointment of mental health specialists.

o As part of wider intermediate care service, team members will also work across

and support other teams in intermediate care.

Integrate intermediate care therapy (T@H) and home-care re-ablement (FRPT) to

deliver a more rigorous, goal-focussed approach and improved outcomes.

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Increase intermediate care bed-capacity which is registered for nursing care and with

increased medical cover capacity.

Use Median Road for bed-based services and as an intermediate care hub for all

intermediate care services and the location of the SPA.

Approach of intermediate care services underpinned by Comprehensive Geriatric

Assessment.

How are services to be paid for and what are the future potential benefits of further investment?

The review of intermediate care included a detailed analysis of current costs, funding

contributions and the related benefits to the health and social care system. In analysing the

costs and benefits to each partner there is recognition of the very strong evidence base of the

inter-dependency between health and social care and that a more integrated approach will

bring benefits to all partners and improve outcomes for local people.

The table below shows that currently, the Council is the larger contributor to intermediate care

services but the greater benefit is to the NHS. It also includes proposals for further investment

that will increase the benefits to all partners through diversion from hospital, reduction in the

demand for more intensive health and social care interventions and maximisation of

independence. A detailed cost benefit analysis is available that supports these calculations.

Council NHS Total

Current Cost of intermediate care £3.00m (77%) £1.00m (23%) £3.9m2 Estimated current net benefit3 £416k (30%) £1.00m (70%) £1.4m Investment recommended £3.7m (65%)4 £1.7m (35%) £5.4m Estimated Total additional benefits

£1.25m (40%) £1.8m (60%) £3.01m

It is proposed that within the first year of a contract, there should be a block contract

arrangement but, thereafter, to agree a CQUIN payment framework with the lead provider.

Summary

Re-ablement and intermediate care services are critically important services to support key

aims of the CCG and the Council and the redesign proposals will support our collective aims of

reducing the demand for hospital-based services and intensive community-based support

services.

The development of a joint intermediate care strategy between the CCG and the London

Borough of Hackney also represents a significant step forward to the achievement of greater

integration of health and social care and seamless services for patients and service users.

The views of the Older People’s Reference Group and Health Watch are welcomed.

2 Includes on-costs 3 Analysis indicates the total benefits from current services are circa £5.4M 4 This includes a portion of what the Council currently spends on interim places at Median Road.