Trust deploys an integrated urgent care team to manage patient flow and reduce length of stay, saving 8,466 inpatient bed days and reducing delayed transfers of care

Synopsis

The Integrated Urgent Care Team (iUCT) are a rapid response service designed to support people in crisis due to trauma or ill health to be able to remain living in their home by providing an initial holistic assessment and a 72 hour wrap around service. This establishes on-going support and requirements to ensure people are safe and well, to prevent hospital admission or emergency residential care.

IUCT is a multi-disciplinary service supported by health and social care professionals. The Home First pathway is the Trust’s Discharge to Assess model and supports the discharge assessment of individuals in their own home.

Ambition

The implementation of iUCT and a Home First Pathway was deemed necessary due to a number of factors affecting the flow of patients through the health and care system, thus resulting in increased non-elective admissions and length of stay as acute inpatients. All of which impacts on a person’s ability to rehabilitate effectively following an episode of ill-health or trauma.

The Tameside and Glossop locality also has some significant social issues including continuing high levels of relative deprivation as well as the impact of a reducing resource base. The health of people in Tameside and Glossop is generally worse than the England average.

The team respond to urgent health and social care needs. In most cases IUCT will work with people for a short period of time to ensure that a person’s immediate health and social care needs are met whilst an ongoing support plan is devised and implemented. As well as responding to people who are in crisis within the community, the team also facilitates speedy discharges from hospital via the Home First process {discharge to assess model) which ensures that people are assessed

in their own home environment which reduces the time spent on the ward.

Following the initial assessment the team provides an intermediate care function within the community, whereby the therapists provide clinical input to enable service users/patients to achieve their maximum rehabilitation potential identifying short term goals for a period of no longer than 6 weeks. The Team work closely with the Reablement Service and facilitate discharge or transfer following this intermediate period.

IUCT is a multi-disciplinary, multi-agency service which aims to;

• Provide crisis response within 2 hours of referral.
• Provide reablement to people in their own home within 2 days.
• Reduce demand on acute services (ED attendances and non-elective admissions).
• Reduce length of stay for people by supporting faster discharge using the Home First model.
• Support the reduction of delayed transfers of care by providing the initial wrap-around care for people in their own homes.

Outcome

The service has experienced some key outcomes that support the rehabilitation of patients, patient experience and wider organisational outcomes:

• The service plans discharge at the point of admission always having ’Home First’ as the priority option.
• The service assesses and turns patients around at the Emergency Department /Acute Medical Unit if acute admission is not required by having strong links with medical teams and community integrated services.
• Patients are tracked and reviewed daily to ensure they are captured as soon as they are deemed medically stable for discharge, our community team then wraps around all the health and social care support the patients need in their own home with no need to wait in hospital for assessment.
• All professionals involved in her service understand that patients require acute medical treatment at times but still aim to achieve better outcomes and increase independence by facilitating early discharge to recover and rehabilitate in the persons own home.
• The service uses the Ticket Home’ to put patients in charge of their stay in hospital and ensure person-centred care every time.
• The Home First pathway supports patient in the community by providing a holistic assessment in their own home. The team support, plan and review patients to avoid any unnecessary re-admissions by continuing to use the other services available across the whole Tameside and Glossop system.
• The service supports crisis response within 2 hours of referral and provides reablement support to individuals within their own home within 2 days.

As a result, since the service’s inception in 2017, this innovative way of working has meant that the service has saved:

• A total of 8,466 acute inpatient bed days.
• A monthly average of 9.25 inpatient beds at Tameside General Hospital.
• Equating to a saving of £1.25 million.

Spread

Home First is a pathway which has been shared widely with other Trusts in Greater Manchester. Home First was designed in this way so that discharge to assess could take place at anytime, or day. Any organisation with community services that can respond urgently to assess a patient on discharge in their own home can replicate this model.

Leadership at an executive and senior level has supported the team to be innovative and confident in the development of the model and operationally the team have applied adaptive leadership to do whatever has been required to lead the implementation of Home First across the organisation.

The model is sustainable. Home First is a pathway and not a team which has been promoted and adopted across all clinical areas. It is soundly embedded in all areas and the model is sustained across the organisation.

The services next steps include identifying how it can be expanded to look at increasing acuity and opportunity through our wider community teams and digital health service.

Value

The service have developed a Home First pathway that can be accessed by any team in the hospital under trusted assessor. The service is not reliant on a ‘Home First Team’ or ’Home First Assessor¹. Referrals are accepted by therapists, nurses, social workers or assistant practitioners even by the patient themselves. This increases the resilience of the pathway and allows the wider reach regardless of the day of the week or the time of day.

What is unique is that one team (IUCT) can then wrap around all of the health and social care support that the patient needs through assessment in their own home. The team can provide, care, therapy/rehabilitation, social work assessment, equipment, voluntary sector support, housing support predominantly under a trusted assessor model.

The model whilst transformational is about putting the patients at the centre of the model - for example not fitting patients into services but developing a process that enables services to provide person centred care. Patient feedback about the service is excellent (please see patient story example included) as the service is supporting patients to leave hospital sooner and mobilise independently within and outside of their own home thus increasing independence and the persons social interaction.

The service conservatively reduces patient’s length of stay in hospital by 3 days by completing assessments in the patient’s own home as opposed to hospital. This has significantly impacted upon the Trust’s reduction of delayed transfers of care and the volume of stranded and super-stranded patients in a hospital bed at any one time.

This service has demonstrated that better outcomes, better service and pushing the boundaries through innovation costs less…. A saving of £1.25 million based on reduced length of stay and subsequent bed days and actual beds saved.

Savings would be far more if beds and/or wards could be closed as a result of the service as savings are based on non-cashable direct bed day cost and does not include indirect costs and overheads.

Involvement

Home First is driven throughout Tameside and Glossop’s integrated care organisation with robust leadership and presenting as one team across the health and social care system. The service has worked collaboratively across all professionals by including medical staff, nurses, therapy staff, pharmacists, CP’s, District Nurses and social care colleagues to develop the service and the Home First pathway.

Working relationships across the health and social care system within Tameside and Glossop are excellent and this approach to integrated working has been the team’s recipe for success, sustainability and scalability.

Home First is unique as it is owned at all levels of the organisation and is driven across all divisions not just the discharge team. Every member of staff in clinical areas can articulate what a Home First discharge is which also regularly audited and key information is fed across the organisation.