Home Ward implementation Confidential

BUSINESS CASE FOR IMPLEMENTATION OF HOME WARD ACROSS LAMBETH AND SOUTHWARK -

PREPARED FOR THE ADMISSION AVOIDANCE PROGRAMME BOARD 13TH June 2013

Submitted by:

Angela Dawe

Director of Operations, Community Services

Guy’s and St Thomas’ NHS Foundation Trust

CONTENTS

Page
1 / Executive summary / 3
2 / Introduction / 8
3 / Background / 11
4 / Strategic objectives, benefits and scope of Home Ward
implementation / 14
5 / Home Ward service design / 18
5.1
5.2
5.3
5.4
5.5
5.6 / Overview and positioning
Location of Home Ward bases
Governance
Management structure, roles and functions
Education and training
IT and communications / 18
23
23
25
30
30
6 / Home Ward implementation – demand, capacity, occupancy / 32
7
7.1
7.2 / Financial case
Costing of Phase 1 implementation
Return on investment / 38
38
40
8 / Implementation plan / 43
9 / Communications plan / 44
10 / Risk analysis / 45
Appendix 1 / Home Ward (GSTT@Home) Activity Analysis (WIP) / 46
Appendix 2 / Home Ward (GSTT@Home) Implementation Plan / 51
Appendix 3 / Home Ward (GSTT@Home) Communications Plan / 55
Appendix 4 / Home Ward (GSTT@Home) Initial Risk Analysis / 63
Appendix 5 / Home Ward Case studies / 67
Appendix 6 / Equality and Equity Impact Assessment Initial Screening / 70
Appendix 7 / Cost estimates for implementation of Home Ward / 79
Appendix 8 / Overall impact of the Home Ward pharmacist / 80
Appendix 9 / References and bibliography / 83

1. EXECUTIVE SUMMARY

The case for Home Ward

This proposal demonstrates a compelling case for implementing Home Ward across Lambeth and Southwark and expanding the range of patients who can access it.

The planned service will:

  • provide safe, high quality, timely and tailored patient care at home that would traditionally be provided in hospital;
  • provide integrated services for complex patients, with a single point of access;
  • contribute to early identification of people likely to require an admission and for whom, with dedicated health and social care, admission could be avoided;
  • provide for high quality and timely discharge, admission/readmission avoidance and case finding of suitable patients identified in hospital;
  • contribute to the development of new ACSC (ambulatory care sensitive conditions) and other patient pathways;
  • contribute to other GSTT (and KCH) work in transforming emergency care;
  • make significant financial savings in return for modest investment.

Fit for the future

The proposed implementation of Home Ward (HW) will make a major contribution to the GSTT ‘Fit for the Future’initiative (May 2013), which places value at the centre of a drive to improve quality and safety whilst reducing costs. The Home Ward service as designed is also integral to the planned transformation of district nursing and the wider Community Health Services.

Patient choice

In addition to the high cost associated with hospital admission, prolonged length of stay - especially in the frail elderlyand those with long term conditions - can lead to a higher risk of acquired infection and other complications, loss of confidence, function and social networks. Increasingly, given the choice, patients and their carers show a preference for receiving care at home, when they have confidence that it will be provided by skilled practitioners offering continuity of care and working collaboratively. Both Home Ward and Enhanced Rapid Response (ERR) are integral to the work of the Older Peoples’ Pathway developed by Southwark and Lambeth Integrated Care (SLIC) by providing rapid support for people in their own homes.

Quality and integration

It is clear from national evaluation of services similar to the planned Home Ward (Munton et al 2011)that their effectiveness is influenced predominantly by the quality of the services and their integration with other health and social services. The Home Ward service planned has been designed for effective integration with acute and primary care services, and with the wider Community and Social Services.

A ‘City Model’ – complex, flexible, scalable

The planned service is a relatively complex model, encompassing admission avoidance, early discharge and case management, though this is consistent with a ‘City Model’ of virtual ward, and responds to the expectation of ever-growing pressures on A&E, hospital beds, primary and social care. In view of the complexity and scope of the development, the plans propose a new department within Community Services, with four Home Wards encompassing nursing, social work, GP, therapy and pharmacy (some of these roles are part-time) plus an infrastructure which includes:

  • a dedicated service management/clinical leadership role
  • clinical practice development
  • quality assurance, evaluation and research
  • a clinical nurse practitioner in reaching into each hospital
  • business support
  • effective governance

ensuring flexibility and scalability of the service into the future.

A medium-term strategic development

In view of the strategic imperative for GSTT (Guys and St Thomas’ Trust) and KCH (King’s College Hospital) to control costs and relieve acute pressures, the new Home Ward department has been planned as a development that will stabilise and grow over at least a five-year period. The planned service builds capacity and systems which will allow the number of ‘virtual’ beds to increase in response to demand (e.g. during winter) without additional major investment.

Building confidence and profile

Building confidence, profile, and ease of referral, for the new Home Ward service will be key to its success, growth and cost effectiveness. A Communications Plan has been developed to ensure that the service is effectively promoted, understood and provides a mechanism for further feedback. In order to provide the profile needed, both within GSTT/KHP and amongst partners and users, it is proposed that the overall service be named “GSTT@Home”, subject to further testing, with the ‘brand’. This is to enhance the visibility of the new service inthe community and to reflect the integrated nature of the Trust providing the service.

Quality of leadership

Many lessons have been learned from the Pilot Home Ward, and it is clear that the step up to the planned service is significant, and the pace of managed growth for the service challenging. The quality of the service leadership appointment will be a critical success factor, as will recruitment and training of the entire workforce, which will be conducted against clear person specifications and a tailored Home Ward competency framework.

Role of support services

For an innovative, mobile, fast-moving community service, the development of effective IT, electronic recording and telecommunications systems will be key. In view of the importance of workforce, IT and estates services to the success, quality and cost effectiveness of the Home Ward roll-out, it is envisaged that dedicated one-stop liaison arrangements for each support service will need to be established, with a shared accountability for the delivery of the new service to schedule and to quality.

Capacity and demand

Activity analysis work that is currently being completed indicates that Home Ward will be capable of supporting a wider range of conditions and interventions than within the scope of the pilot. Initial projected demand for the established service is about 4380 referrals per year, with a target length of stay of 5-7 days. The plans allow for the following potential development phases:

  • Phase 1.1 – 80 beds (4 wards x 20)
  • Phase 1.2 – 100 beds (4 wards x 25)
  • Phase 2 – 120 beds (4 wards x 30)

Demand estimates based on the limited usage of the Pilot phase indicate that Phase 1.1 and 1.2 bed capacities are realistic.

Financial savings and return on investment

The costings for a service of this scale indicate potential maximum revenue savings for Phase 1 of between £5.5m and £8m per annum, for 80%-100% occupancy, compared to the current PbR tariff. Set against these potential savings are capital costs for set-up of £487k (to be confirmed), which would indicate a rapid payback for the capital investment.

Detailed comparative costs from otherproviders such as Medihome are not available, but an out-of-town tariff suggests that the expanded Home Ward service is likely to offer a more cost effective solution, in addition to the value added which Home Ward offers from more integrated working across the Trust and with Local Authorities, the more complex range of patients provided for, and its wider impact in terms of the planned transformation of Community Services.

Implementation planning

An outline implementation plan has been drawn up which emphasises the challenge of becoming fully operational with Home Ward in time to ease winter pressures in 2013. Plans for fast tracking stages of the development are currently under consideration.

Conditions for success

Based on the evaluation of the Pilot, experience of services elsewhere and stakeholder consultation, the following conditions for a successful HW expansion are identified and incorporated into the service design and implementation planning below:

1)Strong dedicated developmental and operational leadership, with effective business support.

2)Stable recurrentfunding to support a sustainable, rapidly developing, service.

3)HW serving all GP practices in Lambeth and Southwark, who have regular contact with representatives of the service.

4)An integrated IT and telecommunications system that is fit for purpose in a mobile, rapid, geographically distributed service, including teleconferencing capability for MDTs, and a business continuity plan to overcome any interruption to critical IT information.

5)A scalable model of service delivery providing for a minimum 80 to 100 beds, sustaining occupancy levels that demonstrate cost effectiveness and relief of pressure on in-patient beds.

6)Clear patient pathways for referral and expectations for length of stay in Home Ward, with timescales for discharge regularly monitored.

7)A single point of access, with a streamlined and integrated referral process for Home Ward and ERR, i.e. a single phone number and a single route for e-referral, including ‘out of hours’ cover.

8)Excellent clinical nursing care combining best practice of acute and community nursing, with confidence to treat more patients traditionally cared for in acute settings.

9)Integrated multi-disciplinary and inter-disciplinary working, with clarity about medical responsibility.

10)A consistent service presence in GST and KCH at the rightlevel and background, working with hospital teams, MDTs etc. This will be crucial to the visibility and effective take-up of Home Ward as an alternative to in-patient care.

11)Clear protocols for case managed patients, with Community Matrons included in Home Ward multi-disciplinary team meetings.

12)Well-placed, appropriate office accommodation across the GSTT area, with visible presence in the community (including nursing homes), primary care and hospitals.

13)A ‘ready use’ equipment store, with a small number of key items e.g. portable bladder scanner, home ADL and mobility equipment, IV stands, for short term loan when existing equipment arrangements cannot meet service needs.

14)A distinct, refreshed, dynamic @Home ‘identity’ for Home Ward and ERR, supported by clear and professionally-designed communications/materials, and consistent promotion to patients and referrers.

15)A new career pathway for community nursing, supported by tailored class-leading HW training, to develop senior community practitioners with advanced clinical reasoning, practice and decision-making skills.

Conclusion

There is a compelling strategic, clinical and financial case for the implementation of Home Ward across Lambeth and Southwark. The development will need to be effectively supported by related departments, and in particular by workforce, IT and estates within support services. The Home Ward service planned is an innovative and exciting development that will be central to the planned transformation of Community Services. Wide consultation has taken place in preparing this business case, which has achieved significant engagement across the Trust, KHP (Kings Health Partnership) and primary care, to support the expansion of Home Ward as described in this report.

2.INTRODUCTION

2.1This report sets out the business case and implementation plan for the provision of Home Ward (HW)across Lambeth and Southwark – a service which provides acute clinical care at home that would otherwise be carried out in hospital. It also highlights a number of conditions for successful implementation that will be met, including the relationship of Home Ward to existing acute and community services.

2.2A pilot service has been running since January 2012 in two locations covering 25 GP practices (as at December 2012), serving approximately 30% of the total Lambeth and Southwark population. The pilot is one of the initiatives supported by the Admission Avoidance Programme and funded by reinvested readmissions monies.

2.3The Home Ward pilot has worked in tandem with the Enhanced Rapid Response (ERR) pilot, each service being under separate operational management within the GSTT Community Services. The ERR service is provided across both boroughs, making access for referrers straightforward, whereas HW has been limited to GP practices registered with the Pilot. The projects are overseen by a single operations group reporting to Community SMT and the Admission Avoidance Programme Board, comprising commissioners, GSTT, KCH and Social services members.

2.4The proposal to roll out Home Ward came from commissioners who requested that a business case be developed which is affordable, sustainable and makes a significant contribution to admission avoidance and advanced discharge. Both Home Ward and ERR are integral to the Older People’s Pathway developed by Southwark and Lambeth Integrated Care (SLIC), by providing innovative rapid support for people in their own homes. It was also envisaged that HW would provide a major building block and agent for change in transforming community nursing to meet future healthcare needs.

2.5The HW pilot has been ambitious, combining what are often two distinct services elsewhere – such as hospital at home/ambulatory care services which focus on advanced discharge from hospital, or ‘virtual/community wards which focus on identifying people for case management, through predictive risk scoring with complex needs, usually arising from long term conditions, who are most at risk of hospital admission. Their care is then managed through enhanced and strong multi-disciplinary team working.

2.6The GSTT Home Ward model supports early discharge by augmenting secondary care, and can be provided at home within two hours of referral, if required. It also increases the capacity of admission avoidance in the community, through the speedy response of a nurse-led multi-disciplinary team working in conjunction with GPs, Community Matrons, District Nurses and the Rapid Response service. Through case management, Home Ward works with GPs and Community Matrons to respond to clinical needs or monitoring of people living in the community with complex needs and who are at risk of hospital readmission.

2.7The present report builds on a number of previous analyses and evaluations of HW and related developments, notably:

  • an external evaluation of the Home Ward pilot and the Enhanced Rapid Response schemes from Virginia Morley Associates September 2012 including user feedback;
  • the original business case for the Home Ward Pilot as part of the transformation of community services;
  • the new older people’s pathway developed by Southwark and Lambeth Integrated Care (SLIC);
  • scoping work on the future of Home Ward in November 2012;
  • work on the Intermediate Care Pathway;
  • the current operational policy and medical model options papers;
  • patient and referrer feedback

2.8This report incorporates the findings of a stakeholder consultation and service observation during development of the business case. This work elicited positive feedback and recommendations for further improvement which have been incorporated in the plan. Those who had referred patients to Home Ward - GPs, hospital Consultants, District Nurses etc - expressed appreciation of the service and were keen that it should continue and expand. They were eager for it to be available across both boroughs. It is envisaged that further consultation will be undertaken to refine details of the HW implementation plan.

2.9The present report also draws on a review of other NHS and commercial models of acute home-based provision including Medihome, Hospital at Home Ltd, Orla, other NHS models and contact with virtual ward related services in three other trusts in addition to Virtual Wards visited in the original Pilot start-up and awareness of PACE (Post Acute Care Enablement Service) provided by Bromley Health Care (a social enterprise).

  • Wandsworth& St. George's Healthcare NHS Trust;
  • University College London Hospitals Trust -including Community Nursing Service – Camden;
  • Barking, Havering and Redbridge NHS Hospitals Trust.

2.10We are grateful for the openness and support of colleagues within GSTT, King’s College Hospital (KCH), Primary Care, Social Services and across Kings Health Partnership in formulating the present plans.

3.BACKGROUND

3.1Lambeth and Southwark commissioners established an overarching admission avoidance programme in 2011-12, focussed on developing schemes to prevent hospital admissions and readmissions and to enhance discharge. The programme has been governed by a joint commissioner, provider and social care programme board (the Admission Avoidance Programme Board).

3.2Contract terms were agreed between commissioners, GSTT and Kings College Hospital (KCH) to withhold funding for acute emergency readmissions in line with the national guidance. A total of £5.3m was agreed in 2011-12, which was used to support the Admission Avoidance programme at a cost of £4.4m. This included the following initiatives:

  • the Home Ward pilot, the focus of this business case;
  • Enhanced Rapid Response;
  • enhanced social work support;
  • respiratory hospital at home;
  • review of stroke readmissions;
  • home equipment rapid access;
  • handyperson service;
  • discharge coordinator (Kings College Hospital);
  • night owls (Southwark).

3.3For 2012-13, national guidance in relation to emergency readmissions changed, but it was agreed at the start of 2012-13 to roll forward 2011-12 funding assumptions and agreements in relation to emergency readmissions, thus providing financial certainty for the year. The most significant investment in the programme was for the Home Ward pilot (£1.4m) and Enhanced Rapid Response (£2.1m) both of which were commissioned from GSTT community services. Both schemes focus on avoiding admissions and readmissions with a significant element agreed to relate to the work of Southwark and Lambeth Integrated Care (SLIC). The initiatives and funding for 2011-12 therefore supported both the acute/commissioner contribution to SLIC plus also the wider whole system admissions avoidance programme.