Living Well in Communities: Scoping and Design V1.0

Living Well in Communities

Scoping and Design

Version 1.0

18 September 2015

Susan Bishop

National Lead Primary Care, Community and Outpatients -QuEST

Head of Improvement Programmes - Joint Improvement Team

June Wylie

Head of Implementation and Improvement- Healthcare Improvement Scotland

Sarah Harley

Health Services Researcher - Healthcare Improvement Scotland

Thomas Monaghan

Improvement Advisor - Healthcare Improvement Scotland

Nathan Devereux

Associate Improvement Advisor - Healthcare Improvement Scotland

1.Executive Summary

2.Context

2.1.Introduction

2.2.Health and Welling Outcomes for Health and Social Care Integration

2.3.Commissioning Request

3.Scoping

3.1.Development Group

3.2.Scanning

3.3.Testing

3.4.Collation, Prioritisation and Dissemination

3.5.Current Activities

4.Summary Outcomes

4.1.Priority Areas

4.2.Theory of Change

4.3.Theory of Execution

5.Summary and Recommendations

Appendices

Appendix I.List of Stakeholders

Appendix II.Mapping Activity

Appendix III.High Resource Individual Data

Appendix IV.End of Life Data

Appendix V.Evidence on Reducing Beds from a Hospital Setting

Appendix VI.Evidence review

Appendix VII.Contributing programmes

Appendix VIII.Frailty and falls

Appendix IX.High Resource Individuals

Appendix X.Anticipatory Care Planning

Appendix XI.Delayed Discharge

Appendix XII.Housing

Appendix XIII.Health and Social Care Integrations Indicators

Appendix XIV.References

1.Executive Summary

Background

The Scottish Government’s vision is that by 2020 everyone is able to live longer, healthier lives at home, or in a homely setting. This vision is supported by the national health and wellbeing outcomes framework, which recognises the contribution that is required from a wide range of public services in Scotland to improve people’s health and wellbeing.

In November 2014, the former Cabinet Secretary for Health, Wellbeing and sport, announced an ambition “..to give back at least 200,000 days to individuals, families and communities..” that would otherwise have been spent in hospital. The ambition is to be achieved by December 2017.

The three national improvement organisations; Joint Improvement Team (JIT), Healthcare Improvement Scotland (HIS) and the Scottish Government’s Quality, Efficiency and Support Team (QuEST) were asked to combine their knowledge and expertise to co-design a range of activities that would contribute toward achieving the ambition.

Scoping

A development group was formed, comprising of practitioners, subject matter experts and representatives from the Scottish Government, NHS boards, local authorities, third and independent sectors, and a public representative. An adapted 90 day three phase innovation process was selected to structure the scanning, focussed testing and dissemination stages.

The development group undertook a series of workshops, meetings and individual conversations to map existing programmes across health, social care and third and independent sectors. A range of evidence and data was collated and reviewed to inform the development group’s thinking and recommendations.

Testing of the areas identified by the workshops, evidence reviews, and data analysis, was carried out through a co-produced deep dive exercise with a partnership.

The development group acknowledged that the volume and diversity of improvement activity already taking place and the complexity of the health and social care landscape, means that the focus areas identified for support through Living Well in Communities will seek to contribute to the shared outcome of enabling people to spend more time living in a community setting, but will not provide an overall solution.

Recommendations

It was therefore agreed that the focus areas will be identified where the data, evidence and stakeholder engagement indicated that the pace and scale of improvement can be increased if additional improvement support is provided. The areas identified as meeting these criteria are as follows:

• Frailty pathways and Falls management and prevention
• Anticipatory care planning
• Improving links between the housing sector, health and social care
• Elements of delayed discharge
• Pathways for high resource users of health and social care services

In addition to the five areas above, Dementia is recognised as an area of work that should be included within the portfolio. As discussions are taking place with Scottish Government Health Directorates about the future scope of this work, it is therefore agreed that dementia should be the focus of a separate scoping process which will report to the Scottish Government in autumn 2015.

The programmes that were identified by the development group as contributing to the overall aim but that will remain separate to the portfolio are detailed in the full report.

For the focus areas identified,improvement support will be divided in to two separate but complimentary elements:

• Time-limited improvement support to increase the pace and scale of change across a portfolio of programmes that are already contributing to enabling people to live well in communities

• Tailored and responsive improvement support for partnerships undertaking analysis of their current priorities, to determine gaps in meeting needs of people and places, with a view to supporting whole system review and redesign of pathways

This portfolio of work, named “Living Well in Communities”, will offer to help build conditions for improvement where they don’t already exist and support programmes within the portfolio moving through an improvement journey. Partnerships will be identified for each focus area, and improvement support provided to help diagnose, test and implement interventions and re-design pathways.

Living Well in Communities: Scoping and Design v1.0 / 1

2.Context

2.1.Introduction

The Scottish Government's vision is that by 2020 everyone is able to live longer, healthier lives at home, or in a homely setting. It promotes prevention, anticipation and supported self-management and a focus on ensuring that people who need to go to hospital get back into their home or community environment as soon as appropriate, with minimal risk of re-admission.

The Programme for Government (2014) includes the aim, as set out in a Ministerial commitment in November 2014, “to give back at least 200,000 days to individuals, families and communities by 2017 that would otherwise have been spent in hospital”[1].

2.2.Health and Welling Outcomes for Health and Social CareIntegration

Health and social care integration is underway with all arrangements to be in place by April 2016. The national health and wellbeing outcomes for Scotland have the overarching aim that health and social care services should focus on the needs of the individual to promote their health and wellbeing, and in particular, to enable people to live healthier lives in their community.

The Health and Wellbeing outcomes framework recognises the contribution that is required from all services in Scotland to improve people’s health and wellbeing. It promotes a system whereby health boards and local authorities, along with partners in the housing sector, the third sector and communities take a bottom up approach to designing and delivering better coordinated care. A coherent and integrated approach across national improvement support mirrors the integrated approach to achieving better outcomes that people expect to see in their communities and localities.

There is also a need to make best use of resource in delivering high quality care and support services through continuous improvement of outcomes, using improvement methods with the objective of ensuring that services are consistently well designed, and reliably delivered by the right people, to the right people, at the right time.

2.3.Commissioning Request

The Person-centred and Quality Unit within Scottish Government has responsibility for policy development and support for policy implementation in relation to the aim “to give back at least 200,000 days to individuals, families and communities by 2017 that would otherwise have been spent in hospital”.

Three national quality improvement bodies; Healthcare Improvement Scotland, The Joint Improvement Team, and the Quality and Efficiency Support Team, were directed by the policy lead to use their combined resources and expertise to determine the scope of what needs to be done to achieve the aim and to design delivery support.

3.Scoping

3.1.Development Group

The three improvement bodies brought together a co-chaired scoping and design team to co-ordinate and drive the work. The team formed a dynamic development group of practitioners, subject matter experts and representatives from Government Directorates, NHS, Local Authority, Third and Independent sectors and a public–patient representative to oversee and inform the scoping and design.

The scoping and design team reports through the co-chairs to the Directors of the improvement bodies and on to the policy leads in Scottish Government.

A development group was convened for the design phase of the programme, which brought knowledge and expertise together across health and social care services. Part of the responsibility of the development group was to oversee stakeholder engagement, which included reviewing a stakeholder map and agreeing engagement activities at each meeting. Stakeholders were scored against a matrix of influence and interest to determine the most appropriate form of engagement (SeeAppendix IList of Stakeholders on page 15).

3.2.Scanning

3.2.1.Mapping existing improvement and delivery programmes and initiatives

The development group undertook a series of workshops, meetingsand individual conversations to map existing programmes across health, social care, Third and Independent sectors. Stakeholders were invited to add to the mapping exercise through face to faceand telephone meetings. Visual management was used to chart and consult on the output of the workshops and engagement activities (See Appendix IIMapping Activity on page 16).

In view of the level of interest partnerships have in older people services, including frailty pathways, it was agreed that a programme of work on Frailty should commence as soon as possible. It was therefore agreed that this area of work would be included in the Living Well in Communities portfolio.

3.2.2.Evidence scan

A review of the evidence base was undertaken, which included literature known to the core team, the development group, and the range of policy delivery and improvement programme leads. A high level literature scan was also commissioned from HIS’s Evidence and Knowledge team. The key points from this search are included below.

• A review of evidence of interventions that can lead to care closer to home:
• Early and supported discharge for older people
• Care at home and hospital at home interventions
• Assertive case management for long-term conditions and high service users
• Targeting people at high risk
• Self management
• Technology enabled care
• The Scottish Association of Medical Directors commissioned an evidence review to assess the impact of health and social care integration and anticipatory care planning on reducing admissions and bed days for the frail elderly.
• Ko Awatea 20,000 days campaign. The core team drew on the experience of the 20,000 days and beyond campaign at Ko Awatea, New Zealand. Conversations were set up with those responsible for designing and implementing the campaign to learn from their approach in engaging the community and measuring the impact of the programme.
• Literature search on conditions and focus areas. Analysis of national data andintelligence identified a small number of long term conditions and multi-morbidity as a potential focus.
• Housing strategy. The Joint Delivery Plan for Housing in Scotland sets out a range of actions required to enable the housing sector to make the strongest possible contribution to the health and wellbeing outcomes, by working with Partnerships both in strategic planning (at Partnership and locality level) and in delivery of services.
• Systems thinking and design, improvement and implementation methodologies. The evidence scan included large scale change theories and methodologies, transformational change, Deming’s System of Profound Knowledge, use of Breakthrough Collaborative Improvement Programmes, Lean, design and innovation methodologies, and implementation research.
• Health inequalities. The link between socio-economic deprivation, increased use of health and social care services, and poorer health and wellbeing outcomes.

3.2.3.Data dive

A range of dataand intelligence was collated from available sources by a unique collaboration of analysts from Information Services Division in National Services Scotland, the Joint Improvement Team and the Health and Social Care Integration Division in Scottish Government. The analysts worked together to provide the development group with a range of presentations and interpretations and rapidly responded to the need for iterations. This included data on cohorts of patients defined as high hospital and community prescribing resource users, generated from the Integrated Resource Framework database; an output of the Health and Social Care Data Integration and Intelligence Project.

3.3.Testing

The opportunity was taken by the design team to work with a health and social care partnership to undertake a ‘deep dive’ focusing on the concept of ‘person and place’. This is in line with the Scottish Government’s integration agenda, which is “about designing services around a person’s circumstances and their personal outcomes, ensuring that they experience the right care and support whatever their needs, at any point in their care journey”[2].

A ‘deep dive’[3] is a technique to “rapidly immerse a group into a situation for problem solving or idea creation”. It is a proven method for innovation in process improvement and often focuses on four distinct areas: process, organisation, culture and leadership.

This deep dive was co-producedwith the partnership, and led by the Health and Social Care Partnership Integration Chief Officer. The workshop was attended by a range of staff representing Midlothian local authority and NHS Lothian. The group included the Clinical Director and Head of Healthcare and Strategic Planning for the health and social care partnership, and, the Integration Manager, Head of Adult and Older People Services and Falls coordinator for the local authority. Data analysts in Scottish Government and National Services Scotland’s Local Intelligence Support Team provided an initial series of data presentationsthen worked rapidly and responsively with the team to generate new data at their request. The process of undertaking a deep dive and feedback from the local and national teams has reinforced the benefits of using this approach to identify priority areas of focus for future pathway redesign.

3.4.Collation, Prioritisation and Dissemination

The accumulated knowledge was analysed and a summary of the quantitative data used to inform the design of Living Well in Communities is given below.

• The number of emergency bed days used in Scotland has seen a gradual reduction from 4.11m in 2008/09 to 3.83m in 2013/14, however the number of emergency admissions has risen from 521,406 in 2008/09 to 542,805 in 2013/14
• People aged 75 years and over are 4 times more likely to experience an unplanned admission per 1,000 of the population compared to those aged 45-54
• 60% of all deaths in Scotland are attributable to long term conditions and account for 80% of all GP consultations
• On average, 70-75% of beds occupied through delayed discharge are by those aged 75 years and over
• Falls account for approximately 390,000 emergency bed days a year
• 2% of the population were responsible for 50% of the hospital and community prescribing resource (2012/13). This 2% of the population were responsible for 77% of all inpatient bed days (Appendix III. High Resource Individual Data on page 17)
• The average length of stay for people in the final six months of life differs by up to 10 days depending on where they live (Appendix IVEnd of Life Data on page 18)

3.5.Current Activities

The outcomes of the scanning and testing of the current system were used to map existing activities that contribute towards achieving the overall aim of Living Well in Communities.

Figure 2 below contains a map of current nationalprogrammeswhich relate to the aim of Living Well in Communities. In addition there will be a range of existing improvement initiatives within NHS Boards and Health and Social Care Partnerships which contribute to this aim.Appendix VIIContributing programmes on page 23contains a description of each existing national programme.

Figure 2 - Map of existing activities that will contribute towards the aim of Living Well in Communities.

4.Summary Outcomes

4.1.Priority Areas

The development group acknowledged the volume and diversity of improvement activity already taking place across the health and social care landscape and that there is already significant work in place that will contribute to the ambition of “giving back at least 200,000 days to individuals, families and communities by Dec 2017 that would otherwise have been spent in hospital”.

In light of the broad range of improvement activities and initiatives which are currently being taken forward locally and nationally, the design group agreed to focus on areas where the data, evidence and stakeholder engagement indicated that thepace and scale of improvement could be increased if additional improvement support was provided.

In doing this, it is recognised that the overall aim will be delivered by a combination of the impact from the existing programmes of work at both a national and local level and those that are being initiated and strengthened through the Living Well in Communities portfolio.

The identified priority areas are listed in Table 1below with more information on each priority area available in Appendix VIIIto Appendix XII on pages 25to 34.

Table 1 - Drivers recommended as priority areas for Living Well in Communities.

Priority area / Aim / More detail
Frailty and Falls / To support partnerships to identifyproblems with current pathways for frail older people, and test and implement innovative solutions to re-design whole system pathways that will enable frail older people to remain living in the community. / Page 25
High Resource Individuals / To develop and understand the current pathways and social resource use of those individuals with high resource needs, and identify areas for system wide improvement that will improve the care and experience for people, and their carers. / Page 28
Anticipatory Care Planning / To achieve person-centred care and personal outcomes for people with long-term conditions, by supporting partnerships to implement the use of Anticipatory Care Planning and increase access to Key Information Summary. / Page 30
Delayed Discharge / To reduce the number of bed days occupied through delayed discharge, by supporting partnerships in identifying underlying causes and sustainably embedding the Delayed Discharged Expert Group recommended interventions, together with testing and implementing innovative solutions to redesign whole system responses across all sectors. / Page 32
Housing / To support the implementation of the Joint Improvement Team’s Housing programme, and test a range of approaches to test innovative approaches to housing solutions that will contribute toward improving discharge pathways. / Page 34

Dementia is recognised as a national priority for Scotland and was identified by the core group as an area for inclusion within the portfolio of work. Discussions are currently taking place with Scottish Government Health Directorates in relation to the future scope and scale of improvement support for people living with dementia and it has therefore been agreed that dementia should be the focus of a separate scoping process which will report to the Scottish Government inautumn 2015. There is a strong interface between the Focus on Dementia Programme, Living Well in Communities and the Older People in Acute Care Programme, which will be taken into account when planning improvement support activities and measures.