Change Fund 6-Month Evaluation Report December 2013

Purpose of report

This report provides an update on the progress of the Edinburgh Change Fund to date.

Background

The Scottish Government established a Change Fund for 2011-15 to enable health and social care partners to implement local plans for making better use of their combined resources for older people’s services.

Edinburgh’s share of the national fund was £6.013m in 2011/12, £6.872m in 2012/13 and 2013/14, and £6.013m in 2014/15. National funding ends in March 2015. In addition to the national allocation, the City of Edinburgh Council has committed £1.774m as part of the 2012/13 budget, £1.770m for 2013/14 and £2.648m for 2014/15.

Summary

The Change Fund Evaluation Group undertakes 6 monthly monitoring of all Change Fund investments. This report gives an update for each project/ work stream including:

recurring projects, most of which had funding agreed in 2011 are now well established

a range of one-off projects, totalling approx £1m, which were agreed from slippage in October 2012 and are at various stages of implementation.

Recommendations

It is recommended that the group:

note the progress made in implementing the Change Fund in Edinburgh

Table of Contents

Intermediate Care Service1

Edinburgh Community Stroke Service2

Enhanced Physiotherapy in the Community3

Dietetics4

Community Nursing and Case finding, identification and management of patients5

Domiciliary Care6

Overnight Home Care Service7

Telecare8

Equipment and Adaptations10

Day Services12

Medication Review14

Medication Procedures15

TeleHealth16

Making it CLEAR17

Edinburgh Behaviour Support Service18

Community Connecting20

Carer Support Hospital Discharge Service23

Step Down23

Community Transport24

Innovation Fund25

Communication and Engagement25

One-off Projects27

Intermediate Care Service2013/14 allocation: £742,0672013/14projected spend: £632,830

Intermediate Care is a service that facilitates discharge from hospital with rehabilitation and prevents admission to hospital by providing physiotherapy and occupational therapy assessment and treatment with community therapy assistants and assistant practitioners providing additional support.

18 FTE were funded through the Change Fund, 3 FTE of which are Falls Assistant Practitioners (in post from July 2013).

The Change Fund has enabled the service to achieve the following:

7 day service – launched in Nov 2012. An average of 4 urgent assessments are undertaken every weekend to prevent unnecessary hospital admission.

Hospital discharges - increased from 4 to 10-12 per week (in line with target from 200 per year to 600 per year). Direct discharges are being supported from acute beds as well as targeted rehab beds.

Admission prevention - average of 14 per week so far in 2013/14 (slightly below target of 800 per year, but this is likely to be seasonal) (referrals inc GPs, SAS, falls pathway)

Extended in-reach – early identification and discharge of people who can receive rehabilitation at home

Falls prevention - new referrals are immediately appointed rather than placed on waiting list. Referrals from Scottish Ambulance Service are seen within 24 hrs.

Feedback from service users illustrates how the service aims to improve people’s confidence, mobility and independence:

‘The team really helped me get used to being back at home and I went from being frightened of doing things to being happy to give things ago. My confidence is so much better now and I think I just needed time. I think people forget that older people need more time.’

‘absolutely great, doing exercises every day, showering on own, able to put myself to bed’

‘[the service has made a] very big difference; if I didn’t have the team I think I’d be in hospital or a home by now’.

Edinburgh Community Stroke Service
2013/14allocation: £191,9842013/14 projected spend: £192,487

ECSS is a community based multi-disciplinary stroke service, delivered from 2 community bases: Firrhill and Craighall Centres. Each Centre has 2 stroke specific rehabilitation days per week, and clients are also visited in their own homes, or workplaces as appropriate.

The Change Fund has funded 2 WTE OTs, 2 WTE PT's, 0.5 SLT, 2 WTE support workers.

Key performance information:

Total referrals Oct 12 – March 13: 93 referrals

o53% hospital discharges

o19% Intermediate Care Service

o30% community practitioners

64% of clients are over 65 years. This is a 10% increase from last year.

46% North (Craighall) / 54% South (Firrhill)

All referrals are screened within 2/3 days

Hospital discharges are seen within a week, all others within 2 weeks

Av length of time in ECSS is 3 months, but some complex cases upto 12 months.

ECSS is often the last rehabilitation service in the stroke pathway and return to independence in self-care, domestic tasks, community mobility and community inclusion is facilitated. Where on-going maintenance support is required referral to many other agencies is made, mainly 3rd sector eg community connecting, CHSS, Edinburgh Leisure. This aims to prevent further stroke episodes and potential hospital readmission.

Outcomes include:

19 (21%) of people sought employment advice:

o5 returned to work

o3 obtained a voluntary post

o1 enrolled in further education

o3 joined a community based project

o7 required advice on welfare rights/employment law & were medically retired.

Feedback from service users is gathered using the CARE measure, examples include:

“Since day one the service I have received has been second to none, staff have been fantastic and have helped me to develop my confidence “

“Really good, didn’t realise I would get so much help as I’ve had.”

“Staff understood what I said”

Enhanced Physiotherapy in the Community
2013/14allocation: £116,2362013/14 projected spend: £110,465

The Change Fund has funded 3 WTE Physiotherapists (1 x Band 6 and 2 x Band 5) and 0.6 WTE Physiotherapy Assistant.

649 new patients have been seen by the service since April 2012, with a total of 3,154 visits delivered. 569 hospital discharges have been supported and 38 people have been readmitted to hospital whilst receiving the EPIC service.

Patient feedback is positive, with

91% of patients feeling EPIC to be beneficial.

100% of referring physiotherapists felt that patients were seen by the service quick enough on discharge from hospital.

Qualitative feedback from referrers suggests that the EPIC service has reduced patients’ length of stay in hospital eg

“We have had many patients that we have referred to EPIC that may not have been able to be discharged without the service due to the longer waiting times / slower ability to respond of standard domi services. These are patients who although are safe to go may not be quite at their previous mobility baseline so if there was a longer wait for community input would have stayed in hospital for rehab.”

“My colleague spoke to one of the EPIC team recently who was happy to accept a referral for a man in a homeless shelter so I think the location may be more flexible than with other services which also helps.”

“We have had some patients who have benefited from prompt assessment of outdoor mobility once home which we may have kept in for longer if the service was not in place.”

Speech and Language Therapy
2013/14allocation: £51,9182013/14 projected spend: £47,962

The Community Speech and Language Therapy service provides highly specialist speech and language therapy to adults with communication and/or swallowing problems associated with acquired neurological conditions in the community.

Additional funding from the Change Fund has enabled the service to increase the SLT staffing capacity (by 1.5 WTE) and has supported the local redesign of the speech and language therapy model delivered to people living with stroke.

Achievements against the key objectives for the project include:

Objective / Performance
To facilitate timely and more responsive access to SLT Early Supported Discharge service by reducing waiting times, facilitating discharge and enabling improved seamless transitions between hospital and community SLT services for people with a Stroke. / Early Supported Discharge Team waiting times
Baseline: 6 weeks
Target: 1 week
Performance: 5-10 days
Develop an integrated and collaborative model of service delivery with SLT resources aligned to Edinburgh Community Stroke Service (ECSS) and work in collaboration to provide MDT early supported discharge and rehabilitation for people with Stroke living in the community. / ECSS referral to SLT
Baseline: 12 weeks (priority dependent)
Target: 1 week
Performance: 1-2 weeks
Develop and streamline an enhanced partnership working model with Intermediate Care Services to deliver a more integrated service for Stroke patients with on-going physiotherapy and occupational therapy needs aligned to SLT intervention delivered by SLT Early Supported discharge Team. / SLT Therapy supported by Intermediate Care workers
Baseline: Nil
Target 100% of all referrals with SLT needs
Performance: 90% achieved

Other achievements highlighted include:

improved communication and knowledge transfer, including the introduction of shadowing and rotational opportunities between hospital and community SLT services

SLT Community Service Lead and SLT Stroke Clinical Lead are now leading a programme of redesign of the Stroke Pathway across NHS Lothian

In-reach pilot - A 6 month feasibility pilot for RIE in-reach. Evaluation report is available. Key findings include heightened awareness of hospital SLT staff regarding range of community services available to support clients. Patients and families report being better informed and having more manageable expectations on discharge.

SLT staff within Acute and rehabilitation sites are providing increased outreach and follow up to selected patients where continuity of care provided by hospital staff would avoid unnecessary wait and referral onwards to community services. The % of patients and impact of this pathway development is currently being evaluated.

Staff morale is high due to increased investment in SLT and opportunities this has enabled in terms of NHS Lothian Wide Stroke Pathway development.

Dietetics
2013/14allocation: £20,6662013/14 projected spend: £18,222

No return was received for this service.

Community Nursing and Case finding, identification and management of patients
2013/14allocation: £187,9172013/14 projected spend: £136,526

The Community Nursing IMPACT (Improving Anticipatory Care and Treatment) team support people with long term conditions in the community. The Change Fund has been used to increase the capacity of the IMPACT team by 3 full time nurses and has provided an additional 1 full time District Nurse Discharge Facilitator to ‘case find’ ie identify patients at greatest risk of admission and readmission to hospital and provide additional support.

The additional investment has supported the reconfiguration of the IMPACT service to provide a city wide, 7 day per week, responsive service. The capacity of the team has increased as follows:

Number of patients on caseload has increased from 289 in January 2013 to 360 in Sept 2013 (20% increase)

Number of referrals has increased from 326 in 2012-13, with a projection of 368 for 2013-14 based on the first 6 months performance.

Increased capacity within the IMPACT team has allowed for significant links to be developed with nursing and medical colleagues in the acute sector within specialist areas of Respiratory, Cardiology and Medicine of the Elderly. The team also link closely with social care services, particularly homecare and Intermediate Care Services. The IMPACT team have been involved in the development of the COMPASS models in South East and North-West Edinburgh and will have a key role in the further development of a hospital at home model.

The IMPACT team have been reviewing SPARRA data to assist with pro-active case finding, all GPs have been contacted and the team have offered to meet with practices to discuss patients with increased SPARRA scores who are at risk of hospital admission.

An evaluation report of patients’ views upon the IMPACT service has recently been conducted. The major findings are that approaching 95% of patients report being more confident and able to manage their symptoms through the use of the service, even where their condition is not improving. In patients’ own views, this has led to less need to escalate their care supports through admission to hospital. In this way, IMPACT is achieving one of its main aims of avoiding hospital admissions for patients with persistent, long term conditions.

The following barriers have been identified by the team, along with remedial actions:

Challenge / Remedial action
GP engagement is an ongoing challenge / New GP contract may help to ensure ongoing GP engagement
Telehealth – use of multi-condition monitoring to support patients and increase capacity has stalled due to provider (02) withdrawing from contract / See telehealth update
COMPASS is an additional work stream that was not in the initial work plan for this service and there has been no additional resource to support this work to date / An enhanced staffing model is being developed by the COMPASS Steering Group

The IMPACT service has demonstrated a contribution to the following high level outcomes:

Outcome / Contribution
Shifting the balance of care and increase the number of patients being cared for in the community / New service supporting patients to self manage using an anticipatory case management approach
Reduce the length of hospital stay & delayed discharge / Working with colleagues across primary secondary & social care to provide alternatives to admission and support early discharge (COMPASS, COPD & Heart Failure) Close links with intermediate care team
Reduce the number of patients admitted as emergency twice or more to acute specialties / Pro-active case finding – SPARRA, engagement with primary care colleagues to identify patients most at risk. Contribute to development of alternatives to hospital admission ( Compass , Hospital at home)

Domiciliary Care
2013/14 allocation: £3,645,0602013/14 projected spend: £3,645,060

Additional Social Care Workers have been recruited to expand the capacity of the Reablement Service. Funding allows for 36 Whole Time Equivalents (WTE). The first additional worker came into post on 5 May 2011. There are currently 36 WTE funded by Change Fund money.

The Reablement Service is a short term service that helps people regain skills to live as independently as possible. Surveys of people who have recently finished receiving a service. Some of the feedback is given below:

“I have been very happy with the care I have received and am glad that I have improved sufficiently to carry on without this support.”

“As time has passed I have become stronger and [am] now able to do things for myself, but all the time they were here, my carers were most thoughtful and helpful, and encouraged me to make steady progress. Home care Reablement service is a splendid help, especially to someone on their own. Thank you.”

Money from the Change Fund was also used to continue the Reablement Service capacity developed as part of the Phased Implementation of New Model of Care for Orthopaedic and Stroke Rehabilitation Pathways.

Additional money has also been made available through the Change Fund to expand Care at Home provision.

During 2012/13 total provision for older people across all domiciliary care services increased from 32,625 hours per week at the beginning of April 2012 to 37,068 hours per week at the end of March 2013. This is an increase of 13.6%. This can be seen in the graph below.

During 2013 total provision for older people across all domiciliary care services increased from 37,068 hours per week at the end of March 2013 to 38,628 hours per week at the end of September 2013. This is an increase of 4.2%. This can be seen in the graph below.

Overnight Home Care Service
2013/14allocation: £300,0002013/14 projected spend: £300,000

Money from the Change Fund is being used to expand the service. Prior to the additional funding three teams operated in the city. The extra funding allows the recruitment of staff for a further three teams to operate overnight. The fourth and fifth teams commenced operation in November 2011 and February 2012 respectively. The sixth team started work in September 2013.

The Overnight Home Care Service often plays a pivotal role in facilitating the support of people at home. The visits overnight may be short in duration but they do secure the sustainability of the entire package by ensuring that people receive appropriate care in their own home 24 hours a day, thereby avoiding an admission to long term nursing or residential care.

The number of visits made by the service per night has increased from 65 visits in October 2011 to 131 visits in September 2013. The number of services users supported has also increased, but more slowly. This suggests that the number of people requiring more than one visit is increasing reflecting the expectation that people with higher levels of need are supported in the community.

Telecare
2013/14 allocation: £285,2282013/14projected spend: £285,228

Additional funding for telecare services and equipment was made to support people with health and social care needs in the community. The money is being used to fund:

6 FTE Call handlers

1 FTE Equipment Technician

3 FTE Mobile Support Workers

1 FTE Assessment Officer

1 FTE Project Officer

These posts are ensuring calls are managed appropriately, the service continues to offer same day installation for hospital discharges or prevent hospital admissions, offers complex assessments and reviews where required, offers clients a timely response to emergency calls and continues to offer support and supervision to staff groups.

This workstreamhas been working closely with Home Care and Reablement services, with the aim of releasing Home Care hours through the use of telecare technology, enabling Homecare to reprovision these hours to support further clients. The funding is also being used to:

Maintain and enhance the existing service, (with regards to provision of equipment, response and installations) to support people to live at home and increase independence and safety.

Facilitate an annual 10% increase in complex packages for people aged 75+.

The service is continuing to workwith the Scottish Ambulance Service to develop a rapid installation process to decrease unnecessary hospital admissions. It is helping tosupport the delayed discharge team and the Step-Down project and also linking in with Step-Down to provide technology for trialling prior to discharge in to community. A Telecare Dementia Resource Manual has been developed as part of the wider Dementia Strategy to help support people with dementia and their carers. The workstream is developing links to provide technology to support Falls Management. The serviceis offering development training to other people/teams which again will raise awareness with the aim to increase the number of people supported in the community.