Agenda item

A pilot service to support people that have reablement potential to return home from hospital and regain their independence has been in place for the six months April – September 2016, until the new intermediate care contract commenced service delivery on 1 October 20126.

This report informs Members about the success of the service, and how the changes in support to return home are being embedded from 1 October onwards.

Discussion

The Head of Adults’ (25+) Partnership Commissioning and the Better Care Fund and the Director of Planned and Urgent Care at Medway Community Healthcare introduced an update on the pilot scheme that supported patients to return home from hospital and regain their independence. The pilot had taken place for a six month period from April to September 2016.

The pilot had included new ways of working, with a key feature being that reablement of the patient was delivered in the patient’s home rather than in a hospital ward or community bed. This freed up hospital beds, relieving pressure on Medway Foundation Trust.

Following the conclusion of the pilot, a new Intermediate Care contract had commenced on 1 October, with Medway Community Healthcare as the lead provider. Following determination that a patient was safe to be discharged from hospital, they would be seen by an Occupational Therapist within two hours. Following this assessment, a reablement package was put in place for up to six weeks to enable the patient to regain full or as near to full independence as was possible. Many patients did not require the provision of longer term care packages.

The Committee raised a number of points and questions as follows:

Overall Success: A Member of the Committee stated that the figures provided in relation to the pilot demonstrated that it had been a success.

General performance: It was questioned how Delays to Transfer of Care were quantified and it was noted that 940 people had been referred to the Home First pathway, compared to a target of 875. It was also asked whether there were readmissions following the ending of support. The Director of Planned and Urgent Care advised that lessons had been learned from the pilot with regard to facilitation of the enablement package. There were no readmission figures available to provide to the Committee. It was recognised that some patients did not have a suitable home situation to enable them to be discharged there.

Support Criteria: In response to a question about whether there were criteria for determining when intensive support provided should cease, it was advised that this depended on the individual needs of the patient and what they wanted to achieve. It was recognised that being fully independent was not possible in every case.

Service Commissioning: It was confirmed that, following the successful pilot, Medway Community Healthcare had been commissioned to provide the service that had been implemented from October 1.

Ongoing Assessment: In response to Member concerns that patients could deteriorate following their initial assessment and that they may not have appropriate support at home, the Committee was advised that assessments were undertaken by an occupational therapist on a weekly basis. 90% of patients were going home with a social care package and medical support could be provided in the short term. Where patients required long term care and there had been no significant improvement within six weeks, they would be handed over to long term care teams. 77% of patients did not require long term care. In the event of there being specific concerns about a patient, they could be referred to one of a number of partner services. There was a focus on enabling people to return to their own home as this was generally where patients wanted to be.

Care Homes: It was questioned how many people were admitted to care homes following hospital discharge. Concerns were also raised that a care home had recently closed on the Hoo peninsula. It was confirmed that the majority of care home provision was privately provided and figures were not readily available for care home admissions locally. However, a Care Quality Commission profile indicated that there were 61 homes in Medway that did not provide nursing and 13 homes that did provide nursing. Demand for beds was reducing due to reablement work, although there was normally an increase in demand for residential care beds during the winter months.

Decision

The Committee noted the update provided in the report and agreed that an update in relation to the intermediate care pathway should be presented to the Committee in three months time.