www.england.nhs.uk

Hospital to

Home team – Strengthening and

supporting the

partnership between

health and social care

to improve patient

outcomes.

www.england.nhs.uk

Hospital to Home and Community

Health Services

PROMOTE

health and well-being and prevent

avoidable admissions

CREATING cross-sector

solutions

ENSURING safe and timely

transfers of care

In partnership with:

NHS Improvement, Department of Health and Social Care, Local Government Association, Association of Directors of Adult Social

Services, Care Provider Alliance,, NHS Digital, Ministry for Housing Communities and Local Government, Housing partners

www.england.nhs.uk

Aims of the H2H programme

3

Working with partners, provide national leadership to ensure that urgent and emergency care services, community services, primary care and social care, all work together:

• To ensure people receive the right care, in the right place, at the right time;

• So transfers of care are as safe, effective and coordinated as possible.

• With a focus on strengthening the partnerships between health, social care and housing, promote ageing well and staying well;

• Ensuring timely access to community services to reduce avoidable hospital attendances and admissions;

• a collaborative approach to commissioning and future shaping of the local care market.

• Working with service users and people who use services to inform the changes and further developments.

www.england.nhs.uk

Delivery of Urgent and Emergency Care

4

• In order to support the Urgent and Emergency Care System, hospitals, primary

and community care and local councils should also work together to ensure

people are not stuck in hospital while waiting for delayed community health

and social care.

• In March 2018, on average 4,987 people were delayed in an NHS bed every

single day, awaiting either assessment of needs, community health or social

care. Our aim is to get this down to 4,000 before winter pressures begin.

• The human impact of delayed transfers of care is significant. The National

Audit Office report ‘Discharging older patients from hospital’ May 2016 says:

Unnecessary delay in discharge (older people) from hospital is a known

and long-standing issue…longer stays in hospital can lead to worse health

outcomes and can increase long-term care needs…it is also an additional

and avoidable pressure on the financial sustainability of the NHS and local

government.

• We also know that 10 days of bed rest (acute or community) leads to the

equivalent of 10 years ageing in the muscles of people over 80.

(Gill et al, 2004 and Kortebein P, Symons TB, Ferrando A, et al. 2008).

www.england.nhs.uk

National Trends – Delayed transfers of

care

5

• The rise in Delayed Transfers of Care (DTOCs) began around April 2014.

• Compared to February 2017 (the worst performance on record), in November

2017 there were 1,133 fewer people delayed in an NHS bed every day.

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2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18

www.england.nhs.uk

National Level Trends – Acute vs. non-

Acute

6

• The top reasons for delays in Acute and Non-acute NHS beds differs. In November 2017: DELAYS IN NHS ACUTE BEDS

1 Awaiting care package in own home

693 delays per day (222 NHS / 374 SC / 97 Both)

2 Awaiting non-acute care (i.e. NHS community

bed)

720 delays per day (720 NHS / 0 SC / 0 Both)

3 Awaiting assessment 468 delays per day (226 NHS / 177 SC / 58 Both)

4 Awaiting nursing home placement 488 delays per day (263 NHS / 199 SC / 26 Both)

DELAYS IN NHS NON-ACUTE BEDS (Community Beds)

1 Awaiting care package in own home 374 delays per day (77 NHS / 249 SC / 49 Both)

2 Awaiting residential care home placement 300 delays per day (132 NHS / 167 SC / 0 Both)

3 Awaiting nursing home placement 291 delays per day (75 NHS / 152 SC / 64 Both)

4 Patient or family choice 213 delays per day (180 NHS / 33 SC / 0 Both)

www.england.nhs.uk

The Quick Guides • A suite of published Quick Guides can be

found at www.nhs.uk/quickguides.

1. Quick Guide: Improving hospital discharge to

the care sector

2. Quick Guide: Better use of care at home

3. Quick Guide: Clinical input into care homes

4. Quick Guide: Sharing patient information

5. Quick Guide: Technology in care homes

6. Quick Guide: Identifying local care home

placements

7. Quick Guide: Supporting patients’ choices to

avoid long hospital stays

8. Managing care home closures

9. Quick Guide: Discharging to Assess

10. Quick Guide: Health and Housing

www.england.nhs.uk

The following Quick Guides are due to be published shortly:

• Red Bag – the hospital transfer pathway

• Upskilling care home staff

• Integrated discharge teams

• Sharing health and care information

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Forthcoming Quick Guides

www.england.nhs.uk

Introduction – REACH (Realising Every

Asset of Community Health) Programme

1. Community Health Services (CHS) are comprised of a diverse but significant set of

services that are in a unique, agile position within healthcare. They routinely work with the most complex patients within the population, with patient numbers increasing at significant pace.

2. The types of services within the broader group of Community Health Services include preventative care, clinical care in the home setting, rehabilitation and recovery (intermediate care and reablement, bridging health and social care), care homes support, long-term conditions management, and responsive, proactive preventative care such as admission avoidance.

3. CHS have a key role in prevention of admissions, such as rapid response teams, long term condition management, rehabilitation and the work of community nurses and allied health professionals. Through the NHS England REACH Programme we hope to provide solutions (coupled with system wide changes i.e. commissioning of these services) to reduce pressures on urgent and emergency care systems and delayed transfers of care (DToC).

www.england.nhs.uk

Distribution of spend and services within

community health services

Intermediate Care (8%)

Therapies and Rehab (13%)

Step down/up beds (15%)

Local Authority Commissioned services (Health Visiting and School nursing) (16%)

District Nursing (18%)

Others services including: sexual health services, wheelchair services, paediatrics (30%)

www.england.nhs.uk

REACH Programme Overview Overall Objective: Promote health and well-being & prevent hospital admission Activities: A. Lead the establishment of systems and processes to review and utilise the new national

community services dataset to inform REACH (Realising Every Asset of Community Health) programme in line with other data e.g. DToC , National audit of Intermediate Care (NAIC)

B. Commission NAIC for 18/19, and through partnership working increase submissions from more providers to measure impact and scope for further improvement and plan for future data collections C. Identify 4-8 community areas to provide targeted intensive support to implement the REACH programme.

I. Produce core principles/ specifications for selected community health services including proposed outcomes (consider including the interface with the social care offer in this)

II. Support areas to achieve 2 day delivery of intermediate care from referral to receipt of care and 2 hour crisis response

III.Identify opportunities to reduce avoidable hospital attendances rates for urgent care sensitive conditions

IV.Explore opportunities to provide clinical input and support for care providers managing deteriorating residents

V. Falls prevention train the trainer programme for social care workforce and families / informal carers

www.england.nhs.uk

REACH Delivery Team

National level

Regional level

Local Area Targeted

Support for 4-8

areas

Head of Planning

Delivery

Programme Lead

(REACH)

Project Support Officer

(REACH)

Community Health

Services Senior

Implementation Lead –

London

Community Health

Services Senior

implementation Lead –

South

Community Health

Services Senior

implementation Lead –

Midland & East

Community Health

Services Senior

implementation Lead –

North

Project Support Officer

(REACH)

www.england.nhs.uk

Any questions?

The Hospital to Home Programme Management Office can be

contacted at england.ohuc@nhs.net