intermediate health & social care needs assessment in ... › wp-content › uploads › ... ·...

08 Fall

Intermediate Health & Social Care Needs Assessment in Doncaster

Data Analysis Report January 2014 Authors: Paul Burton and Karen Tooley Contributors: Dave Hubbard, Hollie Hirst, Jonathan Briggs, Lauren

Edwards Version: Final (20)

Contents.

Section Page.

1 – Executive Summary 3

2 – Introduction 6

3 – Background 7 3.1 – Acknowledgements 7

4 – Context 8 4.1 – Demography 8 4.2 – Prevalence of Long Term Conditions 9 4.3 – Benchmarking 10

5 – The National Audit of Intermediate Care 2014 12 5.1 – NAIC 2014 Key Findings 12

6 – Methodology of Data Analysis 23 6.1 – Scope 23 6.2 – Approach to Data Collection 27

7 – Desk Top Analysis – Findings 31 7.1 – Intermediate Health & Social Care User Profile 31 7.2 – MOSAIC Public Sector Profiler 32 7.3 – Accident and Emergency Attendances 36 7.4 – RAPT (Rapid Assessment Pathway Team) 37 7.5 – Emergency Hospital Admissions 39 7.6 – Avoidable Emergency Admissions 41 7.7 – IDT (Integrated Discharge Team) 43 7.8 – Intermediate Care Service Activity 44

8 – Mapping against Current Service Specification 57

9 – Recommendations 58

10 – Appendices 60 Appendix 1 – MOSAIC Public Profile 60 Appendix 2 – Activity by Service 61 Appendix 3 – Example Dashboard 71

References 73

1. Executive Summary

The Assessment of Doncaster Intermediate Health and Social Care desktop analysis provides an overview of

intermediate care provision in Doncaster in 2013/14. The analysis includes both health and social care,

community and home based intermediate care services, enabling us to outline the broad view of services

available which support the majority of older people who are at risk of being admitted to hospital and

support those being discharged from hospital. The key findings are as follows;

All service providers collect and collate data, but often it is not transferable between providers, data

definitions are variable, collation methods and IT systems are different and information governance builds

barriers rather than supporting translucent joined up approaches.

Service user profile

The majority of service users who have required intermediate care are unsurprisingly over the age of 65

(92%) which is similar to the national average. In 2013/14 intermediate care service users appear to reside in

areas with above average rate of deprivation, whereas there appears to be less demand in areas containing

higher a proportion of older people. The age profile is increasing with as much as 22.39% increase in the

over 85 years estimated by 2019.

The latest data from the Health and Social Care Information Centre demonstrates that Doncaster is in the

worst 20% for a number of indicators and QOF demonstrated high prevalence of Respiratory disease,

Diabetes and Chronic Kidney disease.

The National Intermediate Care Audit 2014 (NAIC)

The NAIC now in its third year provides a bench mark for Doncaster against the national picture and provides

a future framework for Doncaster to create a local tool to monitor success and intermediate care

achievement across a number of providers. In some areas Doncaster mirrors the NAIC for example

integration of health and social care working more closely together. However there is still disparity of

several indicators within the audit which are not comparable for the whole Doncaster locality.

The table below presents data from the NAIC indicating the trends nationally of 3 key indicators.

2012 2013 2014

Integration –

Pooled budgets

21% 32% 38%

Beds commissioned N/A 26.3 beds per 100,00

population

23.7 beds per 100,00

population

Average LOS (days) N/A Home: 28.5

Bed based: 26.9

Re-ablement:32.4

Home: 30.4

Bed Based: 28

Re-ablement: 32.7

Service user flows through the system

In 2013/14 people aged 65+ accounted for almost 41% of emergency admissions, however they accounted

for only 21% of attendances. The Rapid Assessment Project Team (RAPT) in A&E receive on average 50

referrals a month and successfully avoid admission for 66% of its service users, signposting them to a range

of community provision including information, home support and intermediate care services.

Those patients that are admitted to hospital and have health and social care needs are supported by the

Integrated Discharge Team to ensure a timely discharge to the most appropriate location or service. The

team supported 3197 service users, an average of 266 patients per month in 13/14 and the majority were

either supported by a complex assessment worker, were discharged home with homecare or were

discharged to a bed based intermediate care service.

Any delays in discharge from hospital can be extremely expensive and have a negative impact on a national

measure ‘Number of Delayed Transfers of Care (Social Care/NHS)’, where we currently place within the

worst 20% of areas. This has been identified as an improvement area however we currently don’t collate the

reason for delays or longer than average waiting times to ascertain whether any could have been avoided.

The proportion of beds occupied within the bed based services fluctuates month on month; the majority of

2013/14 Positive Step, Rowena, Oldfield and Rose House is operating at full capacity. However there does

appear to be spare capacity across the system with Hawthorn running at approximately 70% capacity.

Service user outcomes

Following discharge from Doncaster intermediate care services, the vast majority (72%) are returned home

with or without support. Few service users would appear to be admitted directly into long term care (6%) or

readmitted back to hospital (12%), the remaining 10% were discharged elsewhere (other).

The proportion of people who subsequently stay at home for up to at least 91 days after discharge from

hospital has been identified as an area for improvement for Doncaster. Overall in 2013/14 Doncaster

intermediate care services reported that they successfully kept 76% of service users at home and living

independently; Doncaster’s performance against this indicator is improving however, it does not meet our

local or national targets (80% - 81%).

Recommendations

Need to adopt a common, agreed local set of key service performance indicators with performance

monitoring agreed within contract specifications

Develop a locality wide dashboard that demonstrates performance for all providers

Identify a common approach to identify service users to aid data analysis

Consider IT technology to aid future data collection

All providers to participate in the NAIC.

2. Introduction

This report forms part of the Assessment of Intermediate Health and Social Care (IHSC) Needs

Project commissioned by Doncaster Clinical Commissioning Group (DCCG) on behalf of the

Doncaster Health and Social Care Community. The Doncaster Health and Wellbeing Board, the

Joint Health and Social Care Transformation Board, Doncaster Clinical Commissioning Group,

Doncaster Metropolitan Borough Council (DMBC) and local providers required an understanding of

the needs of service users prior to admission to Intermediate Care services and also post

discharge.

This report is the culmination of a detailed desk top analysis of data from local providers, DCCG, the

Health and Social Care Information Centre, NHSE England, the Department of Health and NHS

bench marking network and partners to gain an understanding of the current IHSC provision, its

constraints and challenges, gaps and duplication and future recommendations in Doncaster and

includes:

• Benchmarking DMBC / DCCG against a range of relevant national indicators

• Demographic changes projected over the next 5 years

• Analysis of data supplied by local providers for services provided during the financial year

2013/14

A comparison has been made of the Doncaster IHSC position in relation to the national 2014 Audit

of intermediate care.

3. Background

Historically the IHSC services have evolved over time and this includes the data capture,

performance monitoring and reporting, below are a number of known factors which have influenced

the local data collection environment

• No mechanisms to bring together the wealth of data

• New data sharing agreement signed but implementation requires further consideration to

achieve maximum benefits for Doncaster health community.

• Limited integrated performance reporting

• No standard key performance indicators across all providers

• Multiple IT systems in use

• Different organisational data priorities

• No mandatory national input to data collation or performance monitoring

• No routine Doncaster health and social care community approach to whole system

data/service monitoring.

It should be noted that this is the first time that data from all intermediate care service providers has

been requested, collated and analysed in an attempt to gain a complete overview of the capacity

and performance of the IHSC system in Doncaster. This work has required the support and input

from many individuals liaising across multiple providers which has emphasised the issues and

difficulties that arise when seeking to utilise data to understand how the system is working.

3.1. Acknowledgements

We would like to take this opportunity to express our gratitude and to thank all of the individuals

involved in the preparation of this report. We would like to particularly acknowledge the assistance

received from colleagues from partner organisations including Doncaster Clinical Commissioning

Group (DCCG), Doncaster Metropolitan Borough Council (DMBC), Rotherham, Doncaster and

South Humber NHS Foundation Trust (RDaSH) and Doncaster and Bassetlaw Hospitals NHS

Foundation Trust (DBH) who have provided data, their time and support.

2013 2014 2015 2016 2017 2018 2019

65+ 54400 55600 56500 57500 58200 59200 60400

50000

52500

55000

57500

60000

62500

65000 Doncaster Resident Population Aged 65+ Source : Office of National Statistics

2013 2014 2015 2016 2017 2018 2019

75+ 24900 25400 25800 26100 26400 26900 27900

20000

22000

24000

26000

28000


2013 2014 2015 2016 2017 2018 2019

85+ 6700 7000 7200 7400 7600 7800 8200

5000

6000

7000

8000


4. Context

4.1. Demography According to the Office of National Statistics (1) the adult population of Doncaster aged 18-64 will

reduce by approximately 1.5% between 2013 and 2019. However the elderly population is projected

to increase during this period demonstrated in the charts below and thereby implicating future

capacity and demand on IHSC services:

For persons aged 65+ there will be an increase of 6000 (11.03%)

For Persons aged 75+ there will be an increase of 3000 (12.05%)

For Persons aged 85+ there will be an increase of 1500 (22.39%)

4.2. Prevalence of Long Term Conditions The latest available data from the Health and Social Care Information Centre, Calculating Quality

Reporting Service (CQRS) (2) was used to compare the prevalence of long term conditions reported

by the Quality Outcomes Framework (QOF) 2013 – 14 (3).

According to QOF data Doncaster has a particularly high prevalence of respiratory diseases and

also diabetes and chronic kidney disease.

Coronary Heart Disease

COPD

Stroke / TIA

Cancer

Asthma

Atrial Fibrillation

Diabetes

Chronic Kidney Disease

QOF reported prevalence 2014

4.3. Benchmarking Data from the HSCIC, NHS England (4) and the Department of Health (5) was used to benchmark

Doncaster against relevant indicators for 2013/14.

Proportion of older people (65 and over) who were still at home 91

days after discharge from hospital into reablement/rehabilitation

services (effectiveness of the service)

Permanent admissions of older people (aged 65 and over) to

residential and nursing care homes, per 100,000 population

Proportion of users of social care aged 65+ who reported having

as much social contact as they would like

Proportion of older people (65 and over) offered rehabilitation

following discharge from acute or community hospital

Acute non-elective admissions per 100000 population

Unplanned hospitalisation for chronic ambulatory care sensitive

conditions

Emergency admissions for acute conditions that should not

usually require hospital admission

Emergency readmissions within 30 days of discharge from

hospital

Health related quality of life for people with long term conditions

Health related quality of life for carers

Delayed transfers of care attributable to the NHS per 1000

population 18+

Delayed transfers of care attributable to social care per 1000

population 18+

Delayed transfers of care attributable to both the NHS and social

care per 1000 population 18+

Delayed transfers of care per 1000 population 18+

Resident population aged 65+

Continuing Healthcare cases per 100000 weighted population

Intermediate Care Metrics

According to the above comparative data Doncaster was in the worst 20% of organisations in

2013/14 for the following indicators:

Proportion of older people (65 and over) who were still at home 91 days after discharge

from hospital into reablement /rehabilitation services. (Adult Social Care Outcomes

Framework (ASCOF) 2B)

Permanent admissions of older people (aged 65 and over) to residential and nursing care

homes, per 100,000 population (ASCOF 2A)

Proportion of users of social care aged 65+ who reported having as much social contact

as they would like. (ASCOF (1I)

Emergency hospital admissions for all acute specialties.

Emergency hospital admissions for acute conditions that should not usually require

hospital admission. (CCGOF 3.1)

Delayed Transfers of Care attributable to both the NHS and social care.

Doncaster CCG had the highest per capita rate of cases of Continuing Health Care in

England in 2013/14

5. The National Audit of Intermediate Care 2014 The National Audit of Intermediate Care 2014 (NAIC) (6) is now in its third year of reporting and

provides an overview of intermediate care commissioning and provision in England. The Summary

Report and Reports for Commissioners and Providers can be found on this link

http://www.nhsbenchmarking.nhs.uk/partnership-projects/National-Audit-of-Intermediate-Care/year-

three.php

NHS England has endorsed the 2013 audit and actively encouraged health communities to take

part in NAIC 2014. As in previous years, involvement in the audit was voluntary through a

subscription model and continues to have a high level of engagement.

The number of commissioning groups who went on to provide data for the commissioner level audit

was 75 (including DCCG). Some organisations made joint submissions; the total number of

individual CCGs participating was 89 and Local Authorities, 47. Data was provided by 472 services

registered by 124 providers (60 crisis response, 142 home based intermediate care services, 200

bed based services and 70 re-ablement services).

Doncaster CCG, DMBC and RDaSH took part in the 2014 Audit, DBHFT did not participate. The 3

contributors have submitted data on an individual basis, unfortunately the audit tool does not

currently allow the health community to review and benchmark collaboratively, and i.e. all

commissioner and provider data has not yet been integrated and made available for review.

However, it is the intention of the NAIC team to complete this work in the near future.

5.1. National Audit of Intermediate Care 2014 Key Findings

Below are some key findings from the NAIC 2014. Further reference to key findings can be found in

the Doncaster Intermediate Care Service Activity Section.

5.1.1. Integration

Following national directives CCGs were asked to agree five year strategies, including a two year

operational plan that covers the Better Care Fund through their Health and Wellbeing Board. The

http://www.nhsbenchmarking.nhs.uk/partnership-projects/National-Audit-of-Intermediate-Care/year-three.php

http://www.nhsbenchmarking.nhs.uk/partnership-projects/National-Audit-of-Intermediate-Care/year-three.php

NAIC 2014 has initiated and will be developing indicators to review and monitor ongoing work in this

area.

Multi-agency boards are in place in 69% of health economies (70% in NAIC 2013).

In the Doncaster health and social care community the BCF is viewed as a mechanism to support

the development of integrated services. Key stakeholders include Doncaster health and Council

agencies, acute providers, mental health, voluntary and community service providers, the local

social housing provider, Healthwatch and South Yorkshire Police. The intention is to develop a

number of key metrics to review and monitor the impact of service developments delivered by the

BCF. Within the audit the NAIC team identified that not all data requirements were met, suggesting

that a more rigorous data collection regime for local services is required to monitor and provide a

baseline from which to effect change.

Use of formal Section 75 pooled budget arrangements is on an upward trend from 21% in NAIC

2012 to 32% in NAIC 2013 and 38% this year. Strategic planning is undertaken jointly by health and

local government by 88% of participants (90% last year). Local strategic plans are now in place in

65% of responding organisations (48% NAIC 2013). At the operational level, last year 57% of the

re-ablement services completing the audit stated the service was integral to intermediate care with

staff operating and managed together. This figure has risen to 59% in this year’s audit.

According to the national audit at perhaps the most important level, the service user level, people

raised some concerns about lack of joined up services including too many different carers

organisations, poor communication and co-ordination between services, highlighting the

challenge of making integration work at the frontline of service provision.

5.1.2. Patient Experience of Intermediate Care Services

In addition to the organisational level audit, as part of NAIC 2014, home, bed based and reablement

services took part in the service user level audit and PREM. Participation in the PREM in NAIC

2014 is summarised as follows:

National overall results from the organisations that did respond are as follows;

PREM question: Overall, I felt I was treated with respect and dignity while I was receiving my care

from this service

As illustrated below 95.9%, 89.4% and 94.6% responded “yes-always” for home, bed and re-

ablement services in NAIC 2014, respectively. For home based intermediate care and re-ablement

services these results are close to the bar of 95% suggested by John Young, National Clinical

Director for Integration and Frail Elderly, NHS England.

For bed based services DMBC achieved 83.3% and RDASH achieved 100%. No results were

available for home or re-ablement services.

PREM question: I was as involved in discussions and decisions about my care, support and

treatment as I wanted to be

All service categories were below the 95% target on this metric with 79.6%, 60.7% and 75.6%

answering “Yes-definitely” for home, bed and re-ablement services in NAIC 2014, respectively.

For bed based services DMBC achieved 69.6% and RDASH achieved 57.89%. No results were

available for home or re-ablement services.

PREM question: I feel less anxious / less worried since having this service.

The results for this question were generally positive with only 1.5%, 2.7% and 1.8% of service users

answering “I disagree” to this statement for home, bed and re-ablement services.

For bed based services DMBC achieved 0% and RDASH 4%. No results were available for home or re-

ablement services.

5.1.3. Demand and Capacity – Budgets

In 2013/14, the mean budget for home based intermediate care per 100,000 weighted populations was £1.0

million (see graphic below). The mean investment level for bed based intermediate care is slightly below the

level reported by the NAIC 2013 sample at £1.2 million per 100,000 weighted population, with the re-

ablement result very close to NAIC 2013 reported figure at £0.7 million per 100,000 weighted population.

£2.9 million per 100,000 in total.

There is no evidence in the audit of a national trend towards materially higher investment levels in

intermediate care.

Commissioner budgets for intermediate care per 100,000 weighted populations (mean)

5.1.4. Use of Resources – Cost Per Service User

The cost per service user was calculated by dividing the total annual service budget by the

individual numbers of service users admitted/accepted in the period. The mean values for 2013/14

were £1,045, £5,549 and £1,722 per annum for home, bed and re-ablement services respectively.

Cost Per Service User

The cost per service user for bed based intermediate care services is approximately five times more

than for home based services. For re-ablement, the cost per service user is approximately 65%

higher than home based services despite the high proportion of support workers in the re-ablement

skill mix. This may be due to the higher intensity of input evident in re-ablement with the average

input comprises 36 contact hours per service user compared to 13 contacts per service user in

home based intermediate care.

5.1.5. Demand and Capacity – Beds Commissioned

Commissioners reported an average number of beds commissioned per 100,000 weighted

populations of 23.7 (NAIC 2014 sample). The result was 26.3 beds per 100,000 weighted

populations for the NAIC 2013 sample.

Doncaster CCG commissioned 29.74 beds per 100,000 weighted populations (NAIC 2014).

However it is not possible to determine how this is compiled from the national audit tools.

Beds commissioned per 100,000 weighted populations (mean)

5.1.6. Service Accessibility – Opening Hours

The profiles of opening hours for each of the four service categories are similar to the results

reported in NAIC 2013 with no obvious shift towards 24/7 working. As might be expected bed based

intermediate care services are more likely than other service categories to accept admissions 24/7

(43%), with another 43% of the bed based sample operating an extended hour’s model. “Extended

hours” means earlier than 9 am and/or later than 5 pm but not 24/7.

Extended hours is the most common model for crisis response services (69%) with 24% operating a

full or limited 24/7 model and only 7% operating 9 am to 5 pm. Extended hours is also the most

popular model for home based and re-ablement services (54% and 69% respectively), although

32% of home and 26% of re-ablement services still operate 9 am to 5 pm.

5.1.7. Use of Resources - Intensity of Input

For re-ablement, the mean number of contact hours per service user (36 hours) is down 15%

between the NAIC 2013 and 2014 samples, although as noted above, length of stay has not

changed (figure 6.6.2). In contrast, home based services show an increased mean number of

contacts per service user of 13.2 contacts (up 12%), consistent with the increase in length of stay in

this service category.

5.1.8. Workforce - Staffing Levels

Staffing levels have reduced across all service categories in NAIC 2014 sample. For home based

and re-ablement services the number of wtes per 100 service users were 2.5 and 4.6 respectively

compared to 2.8 and 5.5 respectively in NAIC 2013. The higher staffing levels in reablement reflect

the greater intensity of input per service user in re-ablement. The number of clinical wtes per bed

has reduced from 1.5 in NAIC 2013 to 1.3 in NAIC 2014.

These findings were echoed in service user responses to the PREM open narrative question where

a key concern raised was a perceived shortage of staff resulting in rushed visits and unpredictable

and inappropriate visit times.

5.1.9. Workforce – Appropriateness of Skill Mix to Clinical Need

The workforce in crisis response, home based and bed based intermediate care services are

dominated by registered nurses and health care support workers. In contrast, social care support

workers make up 55% of the re-ablement workforce, although this high proportion may reflect the

way participants were asking to complete the audit where services are integrated, by splitting out

the re-ablement and home based intermediate care elements. Crisis response and home based

services have, on average, a higher proportion of OT and physiotherapy input than bed based and

re-ablement services.

As identified in NAIC 2013, mental health workers are rarely included in the establishment of

intermediate care teams. However, the proportion of services confirming that all members of the

team have received training in mental health and dementia care has increased in all service

categories this year. The picture for “quick and ready” access to specialist mental health skills is

more mixed, with the proportion stating “yes” in crisis response and bed based services, lower than

last year.

5.1.10. Workforce – Medical cover

The proportion of home based services relying on the service user’s own GP for medical cover

appears high (72% NAIC 2014, 71% NAIC 2013) when reviewed against the levels of dependency

of service users being cared for by these services. Bed based services also show reliance on

service user’s own GP in 14% of services. The gold standard for effective frailty management is a

process known as “comprehensive geriatric assessment” (CGA) which is known to reduce mortality,

institutionalisation and hospital admission and requires a fully staffed interdisciplinary team - British

Geriatrics Society - Comprehensive Assessment of the Frail Older Patient. BGS, 2010 (7).

Given the uneven nature of the teams suggested by the skill mix data in the audit, it may be that the

full benefits of CGA are not being realised.

5.1.11. Commissioner performance management standards – Whole system performance

For the commissioners that have set whole system performance goals, the common metrics utilised

are set out in the chart below. More than 80% of commissioners that monitor performance now look

at non-elective hospital admissions, delayed transfers of care and admissions to long term care.

The inclusion of these metrics as BCF metrics is likely to increase the utilisation of these key

measures by commissioners.

However, the national audit team identified that;

validation controls need to be implemented on several levels within data collection

data definitions need to be consistent

data collection systems need validating to protect the integrity of the information being recorded

Performance monitoring will need to be enhanced to consider the whole system impact of an

integrated IHSC service and future tools (e.g. dashboards) will be required.

Whole system performance goals

Where commissioners monitor the delivery of service performance of individual intermediate care services, the use of key measures is shown below.

Key measures monitored by commissioners

6. Methodology of Data Analysis

6.1. Scope

There are currently 3 main providers of Intermediate Care services in Doncaster – Doncaster

Metropolitan Borough Council (DMBC), Rotherham, Doncaster & South Humber NHS Foundation

Trust (RDaSH) and Doncaster & Bassetlaw NHS Foundation Trust (DBHT). The services provided

by RDaSH and DBHT are currently commissioned by DCCG. The services provided by DMBC are

currently commissioned by DMBC’s commissioning arm.

This analysis includes data from 11 “core” bed and home based intermediate care services provided

across Doncaster by acute trusts, community service providers and the local authority. Data from 3

other services are also included, although considered as “non-core” for this analysis in terms of

delivery they are an important part of the IH&SC system. The services are provided in a range of

health and social care settings including services users’ home, hospitals, community hospitals and

residential care homes.

The services included in the analysis are as follows;

Provider DBHFT – Intermediate Health Care

High Level Support

Mexborough Montague Rehabilitation Unit. Delivers rehabilitation to patients referred from the acute trust. Patients

receive intensive nursing, OT and Physiotherapy, using a number of

therapy interventions to support home re-ablement.

Capacity; 58 beds - 10 beds are intensive therapy beds for Stroke

patients.

Complex Assessment Pathway (CAP) Beds Patients with complex health and social care needs transferred from acute

ward to CAP bed for CHC assessment to agree package of long term care

support and funding.

Capacity; 24 beds in total –

9 EMI beds (Elderly Mentally Infirm) - Benton (4), Manor View (5).

15 Nursing Beds - Swallow Wood (3), Amethyst (3), Adoline (3) and

Hawthorne Ward (6 nb. in process of transferring to other providers).

Medium Level Support

Low Level Integrated Discharge Team (IDT) – Non core

Support IDT are not a provider of intermediate care services but are a major

source of referral into the system. IDT are an integrated team of health

and social care professionals facilitating complex discharges and transfers

from the acute trust. Working on a transfer to assess model, IDT make

initial assessment in order to liberate an acute bed and to navigate access

to the most appropriate intermediate care service on discharge from the

acute trust.

Capacity; In 2013/14, 3197patients were seen by IDT.

Rapid Assessment Programme Team (RAPT) – Non core RAPT team staff mix and function is similar to that of IDT but patients are

identified whilst in A&E, MAU or the CDU to access appropriate

intermediate care services and prevent unnecessary acute admissions.

Capacity; In 2013/14 693 patients were seen by RAPT.

Provider RDASH – Intermediate Health Care

High Level Support

Magnolia Lodge. This is a ward based rehabilitation of various neurological disorders (apart

from acute strokes) offering a multidisciplinary wide range of treatment

from cognitive to physical therapy. Longer term strokes are admitted on

Magnolia if patients do not meet the criteria for stroke pathway rehab.

Capacity; 14 beds


Hazel & Hawthorne Wards As from 1st December 2014 these wards will deliver a reconfigured service. The aim of the inpatient rehabilitation service is to avoid inappropriate and

unnecessary acute hospital admission and provide care closer to home.

The service facilitates both early discharges from the acute hospital (step

down) for up to 28 days and step up care (from the community) for a 7 day

stay, supporting the patient in returning to their own home in a timely

manner.

Hawthorne Ward will be designated as an admissions ward facilitating a

step up approach to intermediate care services Capacity; 18 beds.

Hazel Ward will be designated as a discharge ward preparing patient for

their next move be that home or to another service. Capacity; 20 beds.

Hawthorne ward will cease to deliver the 6 beds for the Complex Assessment Pathway (CAP beds). These 6 beds will now be provided by the existing private care home CAP bed providers.

Low Level Support

Community Integrated Care Team (CICT) CICT offers a comprehensive, therapy led, Health and Social Care

assessment and rehabilitation service. Facilitating efficient and timely

discharge from hospital in instances where a period of assessment,

rehabilitation and recuperation may enable the individual to regain or

improve independence. The services of CICT will be provided on a time-

limited basis that typically will not exceed a period of 6 weeks.

Capacity; In 2013/14 approximately 623 patients were seen by CICT.

Provider DMBC – Social Care

High Level Support

Positive Steps – Home Covert, Bentley. A social care assessment unit (SCAU) providing up to 28 days stay for

social care assessment and intensive re-ablement therapy from in house

therapy services.

Capacity; 22 beds at Home Covert, Bentley. Additional 11 bed unit being

prepared, therefore 33 beds in total.


STEPS (Short Term Enablement Pathway) Patients receive up to 6 weeks of free re-ablement support in own home to

reduce dependence and promote independence. Purely social care

provision. Referral source approximately 60% from acute and 40% from

community.

Capacity; approximately 1450 new assessments / year.

Social Care Assessment Units (SCAU) – Rowena, Oldfield & Rose (AIM beds – Autonomy, Independence and Motivation) Rowena and Oldfield - Up to 28 days stay for dementia patients for social

care assessment or further re-ablement therapy.

Rose House - does not accept dementia patients and provides intensive

re-ablement support.

Capacity; 20 Beds in total. Rowena, 6 beds, Oldfield House, 6 beds,

Rose House, 8 beds.

Nb. Rowena and Oldfield beds will be transferred to Positive Step at

Bentley Covert at end of 2014.

Low Level Support

Home from Hospital Service – Delivered by AGE UK – Non core Jointly commissioned by DMBC and DCCG. The Home from Hospital team provide short-term practical support as well as advice and reassurance to anyone who has received treatment in hospital and is worried about how to then manage at home. Capacity; 165 referrals in 2013/14.

6.2. Approach to Data Collection

To gain a clear understanding of the capacity, demand, performance and gap analysis of current

services, providers were tasked with undertaking a data collection exercise during August and

September 2014 to capture data for each service for the financial year 2013-14.

Initially, a draft data collection proforma was designed, utilising 59 key performance measures taken

from the NAIC 2014 data set and existing IHSC service specifications (where these exist). This

proforma was considered by all providers and an assessment was made as to whether they could

provide data against these measures. It was agreed to incorporate 32 measures into the final data

collection proforma following this consultation.

The table below lists the measures which providers were requested to provide data for with

additional commentary;

ID Measures Data provided

Comments Question Definitions/clarification

1 Total number of referrals Yes All services can provide this information

A referral is defined as a request for an intermediate care service for a service user (including inappropriate requests)

2 Source of referral Yes - partly

Some services can provide this information (less than 50%)

Number of referrals broken down by the service that generates the referral/signpost to intermediate care

3 Reason for referral: No Services cannot easily provide this information

The reason why a service user requires bed or home based intermediate care and support

4 Average time from referral to admission/start of service (days)

Yes - partly

The majority of services can provide this information (over 50%)

Enter the average waiting time from referral to first assessment over the period in days

5 Number of Intermediate Care contacts (if applicable)

No Services cannot easily provide this information

Enter the number of "community contacts" for the service in the period as defined in the Reference Costs Guidance for 2013-14, January 2014, Department of Health

6 Total number of occupied

beds days

Yes - partly


Occupied bed days are calculated as the daily count of beds occupied at midnight totaled over the period required. Excludes service users temporarily absent.

7 Average % bed occupancy over 12 month period


Average % bed occupancy is calculated as occupied bed days (see previous question) divided by available bed days in the period (as a percentage)

8 Average length of stay/ duration of service (in days)

Yes All services can provide this information

Average length of stay is calculated by dividing the total number of days stayed (from the date of admission) by the number of discharges (including deaths) in period

9 Proportion of service users who exceed 42 days (6 week) length of stay/duration of service


Percentage number of service users that are accepted by service and exceed a duration of 42 days

10 Destination on discharge (number of service users)


Number of service users who are discharged broken down by destination type (home, hospital, long term care etc.)

11 Readmission rates to this intermediate care service


Proportion of service users who have previously received this service

12 Proportion of service users re-admitted to hospital

Yes - partly


Number of service users who are discharged into hospital presented as a rate of the total number discharged

13 Proportion of service users admitted into long term care (LTC) direct from intermediate care

Yes - partly


Number of service users who are discharged into long term care presented as a rate of the total number discharged

14 Analysis of reason for admission into LTC


Patient needs.

15 Number of avoidable hospital admissions


Numbers as defined by the national outcomes framework. 2 out of the 4 categories.

16 Number completing re-ablement with no change to on-going homecare need


No definition available

17

Number completing re-ablement/rehabilitation with reduced on-going homecare need

No

Services cannot easily provide this information


18 Number completing re-ablement/rehabilitation with increased on-going homecare need



19 Total number of service users completing re-ablement/rehabilitation


Self-Explanatory

20 Proportion who achieve their individual goals

Yes - partly



21 Change in functionality - Improvement of quality of life throughout intervention



22 Proportion of service users (65 and over) who are still living independently 91 days after discharge post reablement (ASCOF 2B/NI 125)

Yes - partly



23 Proportion of service users whose experience a good or very good service experience

Yes - partly



24 Number of referrals to other preventative/community services



25 Number of referrals to Telecare


Self-Explanatory

26 Evidence of partnership working with family/carers to maximise service users independence



27 Evidence of multi-agency partnership working



28 Evidence of improved communication/coordination between services and agencies



29

Evidence contribution to the development of a range of preventative services

No



30 Proportion of service users who were at risk of being admitted to residential care



31 Proportion of service users who was discharged home with or without support (home with Support)

Yes - partly



32 Service user profile - age groups

Yes - partly


Self-Explanatory

7. Desk Top Analysis - Findings

As mentioned previously this is the first time that data has been collected in an attempt to build a

complete picture of the whole IHSC system this has proven to be challenging. The data collection

exercise achieved limited success; the providers supplied complete data for 5 measures, partial

data for 10 measures, and no data for 17 measures. Consequently it has not been possible to

analyse and directly compare all services and thereby achieve firm conclusions. The following

analysis and results should be viewed cautiously but be a key component to encourage closer

working and debate for potential improvement strategies across the Doncaster IHSC community.

Historically each organisation has independently defined its own set of activity and performance

measures which has been influenced by their own organisational strategy and priorities.

Consequently there is no consistency to data definition, collection, IT systems and reporting across

the health and social care community. This creates difficulties when attempting to review and

assess a whole systems approach to intermediate care.

All the following charts within this section are compilations of core service data received. However,

individual service detail is provided in Appendix 2.

7.1. Intermediate Health and Social Care Service User Profile

7.1.1. Age Profile of Service User

Approximately 92% of IHSC interventions in 2013-14 were to service users aged 65 or over and

over 42% were to service users aged 85 and over.

Users of IHSC - Age Range

Doncaster total Doncaster % National Average % (NAIC 2014)

18 -64 287 7.9 5.4

65 – 84 1799 49.7 46.3

85+ 1534 42.4 48.3

Total 3620 100 100

Age Profile of Service Users Accessing Doncaster Intermediate Care Services

7.2. Mosaic Public Sector Profiler

4180 Doncaster residents were referred to Intermediate Care services in 13/14. 3028 (72%)

DMBC service user postcodes were uploaded to Experian Mosaic Public Sector Profiler to

create a series of Doncaster maps demonstrating the home locations of intermediate care

service users, facilities / private care homes, older peoples score and deprivation (see below).

The profiler has also been used to a produce a brief report (see appendix 1) that categorises the

service users into public sector profile types.

Unfortunately, organisational governance procedures did not make it possible to utilise post

code information from RDASH and DBHFT.

4 3

136

90

9

45 Age 18-64

Positive Step

Rose Assessment

STEPs

120 22 14

61

761 374

164

283

Age 65-84

Positive StepRowena/AIMOldfield/AIMRose Assessment

192

31 13

35

584 233

151

295

Age 85+

Positive Step Rowena/AIMOldfield/AIM Rose AssessmentSTEPs MontaguHawthorne CICT

7.2.1. Position of Doncaster Intermediate Health and Social Care Service Facilities and

Private Residential Homes relative to Service User Home Postcode (where available)

It appears that Doncaster Intermediate Care bed based services are situated diagonally through

the centre of Doncaster, from south/west to north/east. The majority of people who have

received an intermediate care service in 13/14 come from areas surrounding these beds based

services.

7.2.2. Doncaster Intermediate health and Social Care Service Facilities, Private Residential

Homes and Service User Home Postcode relative to average area age (where available)

This map plots Doncaster Intermediate Care services and service users in 13/14 against the

national older people score. There seems to be little correlation with service user location plotted

against the older population areas and position of IHSC service facilities. However with the aging

population further profiling would be required to plan the future provision of services and housing

facilities.

7.2.3. Doncaster Intermediate Health and Social Care service facilities, private residential

homes and service user home postcode relative to areas of deprivation

This map plots Doncaster Intermediate Care services and its service users in 13/14 against

deprivation. It appears that there is a correlation between service user area of residence and above

average rate of deprivation.

7.3. Accident and Emergency Attendance’s

People aged 65+ accounted for almost 41% of emergency admissions in 2013/14. However, this

age group accounted for only 21% of attendances at accident and emergency departments. The

chart below shows the presenting conditions which accounted for more than 500 A&E attendances

for Doncaster residents aged 65+ in 2013-14.

The chart below demonstrates A&E attendances by month for the over 65’s. Seasonal variation appears negligible.

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

2013 1 14 34 34 29 66 57 48 50 50 44

2014 57 77 147 44 38 42 81 65 63

0

20

40

60

80

100

120

140

160No. of People Referred to RAPT

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Not admitted to hospital 62% 79% 83% 70% 65% 65% 58% 56% 61% 58% 74% 71%

Admitted to hospital 38% 21% 17% 30% 35% 35% 42% 44% 39% 42% 26% 29%

0%

20%

40%

60%

80%

100%

Proportion of RAPT clients admitted to hospital (13/14)

7.4. Rapid Assessment Pathway Team (RAPT)

On average 55 people are referred to RAPT on a monthly basis which is an average increase of

28.5% from 2013. RAPT successfully refer approximately 66% of patients away from hospital. The

RAPT service commenced March 2013 and it can be seen in the chart below that patient numbers

continue to grow.

.

From the data received it is not possible to understand why 34% of patients who are referred to

RAPT services were admitted to hospital.

7.5. Emergency Hospital Admissions

In the year ending 31st March 2014 there were 38580 emergency hospital admissions of Doncaster

residents. Service users aged 65+ accounted for 15771 (40.88%) of these. The chart shows

conditions which accounted for 200 or more emergency admissions to service users aged 65+.

These 19 conditions account for almost half of all admissions.

There were 2681 emergency admissions due to falls in 2013-14. Of these 1756 (65.5) were to

service users aged 65+. Of these almost half were to service users aged 85+. From the data

available it was not possible to establish how many patients utilised intermediate care services.

0 500 1000 1500 2000 2500 3000 3500 4000

Congenital malformations, deformations and chromosomal…

Diseases of the ear and mastoid process

Factors influencing health status and contact with health services

Diseases of the eye and adnexa

Mental and behavioural disorders

Diseases of the nervous system

Diseases of the blood and blood-forming organs and certain…

Diseases of the skin and subcutaneous tissue

Endocrine, nutritional and metabolic diseases

Certain infectious and parasitic diseases

Neoplasms

Diseases of the musculoskeletal system and connective tissue

Diseases of the digestive system

Diseases of the genitourinary system

Diseases of the circulatory system

Injury, poisoning and certain other consequences of external causes

Diseases of the respiratory system

Symptoms, signs and abnormal clinical and laboratory findings, not…

The average length of acute hospital stay following an emergency admission is significantly higher

for elderly service users. For service users aged 75-84 the average length of stay is over 9 days

and for service users aged 85+ it is almost 11 days.

1.52 1.22 1.71 1.84 2.49 3.58

4.99

6.45

9.04

10.65

0

2

4

6

8

10

12

00-04 05-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Average Length of Stay for Emergency Admissions in 2013-14

7.6 Avoidable Emergency Admissions

From the Doncaster CCG Local Outcomes Framework (8) – two categories (out of four) described

as “avoidable emergency admissions” relate to IH&SC :

Chronic ambulatory care sensitive conditions

Acute conditions that should not usually require hospital admission

Chronic ambulatory care sensitive conditions – service users aged 65+ accounted for over 40% of

these admissions in 2013-14. COPD accounted for almost 45% of all these admissions for service

users aged 65+.

For acute conditions that should not usually require a hospital admission – service users aged 65+

accounted for almost 60% of these admissions in 2013-14. Influenza / pneumonia and

pyelonephritis accounted almost 72% of these admissions for service users aged 65+.

747

278 217 148 64 54 52 45 33 28

0

200

400

600

800

COPD Heart Failure AtrialFibrillation

Angina Diabetes Anaemia Dementia Asthma Epilepsy Hypertension

Emergency Admissions for Chronic Ambulatory Care Sensitive Conditions for Patients Aged 65+

822

685

312 192 37 36 10 3

0

200

400

600

800

1000

Influenza andpneumonia

Pyelonephritis Gastroenteritis &dehydration

Cellulitis Convulsions &Eclampsia

Perforated Ulcer ENT Dental

Emergency Admissions for Acute Conditions that Should Not Usually Require Hospital Admission for Patients Aged 65+

Nationally, the NAIC 2014 demonstrates that there is insufficient intermediate care capacity for a

prominent presence in A&E (an estimated 30% of acute admissions might be avoidable), and the

average waiting time for a place in a home based intermediate care service is currently six days

(higher than previous years).

Undue waiting in hospital is highly damaging for older people. A wait of more than two days negates

the additional benefit of intermediate care, and seven days is associated with a 10% decline in

muscle strength, hardly an advantage for people with frailty for whom muscle weakness is a

defining characteristic.

Perhaps these unnecessary waits in hospital explain the increasing lengths of intermediate care

stay reported in the audit, and so the whole system deteriorates. Yet, some hope emerges in the

between-locality spread of the intermediate care investment. Some places have achieved an

intermediate care commissioning value of over twice the national average. This implies that larger

volume services are realistic.

7.7 Integrated Discharge Team (IDT)

In 2013/14 an average of 266 people were referred to IDT each month. Patients were supported by

the team for an average 9 days (from first referral to IDT to discharge from the acute trust. – see

chart left, below).

The majority of service users (62.2%) were either discharged into their home with a package of

Homecare (914 is 28.6% of total), admitted to a bed based facility for further assessment (648 is

20.3%, to DMBC Social Care Assessment Units such as Positive Step, also Hazel and Hawthorne

Wards) or are supported by Health and Social Care specialists on the Complex Assessment

Pathway (CAP beds – 424 patients, 13.3%).

Month Total number of referrals 13/14

Average Length of Support

Outcome on discharge from DBHFT

Total number

April 268 9

Complex Assessment 424

May 251 8

Deceased 143

June 252 8

Declined services 51

July 267 10

Discharged 121

August 246 9

Equipment 36

September 247 10

Fast-track 28

October 276 9

Further assessment – SCAU, Hazel / Haw 648

November 249 9

Home with SPOC 114

December 275 11

Homecare – Personal Care plan 914

January 311 7

Hospice 12

February 265 9

Hospital-based rehab 18

March 290 6

Inappropriate referral 141

Total 3197 9

Other Hospital 114

Long term care 200

Respite 11

Therapy completed 103

7.8 Intermediate Care Service Activity

7.8.1. REFERRALS to Intermediate Care Services

In 2013/14, 4220 referrals were made to Doncaster Intermediate Care services. STEPs (34.3%),

Montagu (16.5%) and CICT (14.8%) accounted for 65% of referrals.

In terms of a genuine step up approach only 9.3% (392) community referrals were made to

Hawthorne ward, whilst bed occupancy on the ward averages 70% per month. From the data

available it has not been possible to identify community step up referrals for CICT or STEPS.

From the national audit, home based intermediate care, the proportion of referrals from acute trusts

in 2013/14 was similar to previous years (29%), consistent with the conclusion that around one third

of home based capacity is used for step down care. Re-ablement services have seen a shift

towards step down care in this year’s sample, with 44% of referrals from acute trusts compared to

35% reported in 2012/13. In contrast, bed based intermediate care units show a reduction in step

down referrals from 68% to 60%.

The complex assessment beds model was established in January 2014 therefore comparable full

year’s data is not available; however activity data for the last quarter is available at appendix 2.10.

1448

697 626

392 363 312 165 97 53 40 27 0

200

400

600

800

1000

1200

1400

1600 Referrals to Intermediate Care - 2013/14

The average number of referrals to Intermediate Care in 2013/14 was 351 per month across all

services with December having the highest number of 390; however, seasonal variations appear

modest.

National audit confirms home based services as the highest volume of the service categories (see

chart below) with an average number of referrals per 100,000 weighted population of 1,014

(2013/14).

Reduced referrals to bed based services (averaging 224 referrals per 100,000 weighted population

for 2013/14) are consistent with the lower average number of beds commissioned by the NAIC 2014

sample (provider data suggests bed occupancy remains constant at 85%).

Re-ablement referrals per 100,000 weighted populations show an average of 583 for 2013/14, and

crisis response, 618.

368 349

324

364

318 312

377

331

390 377 350 360

0

50

100

150

200

250

300

350

400

450

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

Referrals to Intermediate Care - 2013/14

Referrals per 100,000 weighted population

7.8.2 WAITING TIME

STEPs community pathway had the longest average waiting time for DMBC services in 2013/14; 3

times that of Positive Step and Oldfield. However there is no clarity of indicator definition and direct

comparisons are difficult to draw.

6.8

1.7

2.2

2.1

1.5

0.9

0 1 2 3 4 5 6 7 8

STEPs (community)

STEPs (hospital)

Positive Step

Oldfield/AIM

Rowena/AIM

Rose Assessment

Average Waiting Time from Referral to Admission/Assessment (Days)

Nationally, the average time from referral to assessment for crisis response services has increased

from 7.3 hours (NAIC 2013) to 8.9 hours (NAIC 2014). As in NAIC 2013, the median value was 2

hours, nb. Doncaster has no IHSC Crisis Response Service.

The average waiting time from referrals to assessment (in days) has increased for home based

intermediate care (now over 6 days) and re-ablement services (now over 5 days) in 2014, as

illustrated in the chart below.

With a third of home and re-ablement service users waiting in hospital beds, the delays represent a

lost opportunity to reduce length of stay as well as creating a poor care experience for services

users that may impact on the effectiveness of their rehabilitation.

For bed based services, the average time from referral to assessment was the same as last year at

1.3 days and the average time from assessment to commencement of service was 1.4 days giving a

total waiting time of approximately 2.7 days (2.9 days in 2013).

NAIC 2014 – Average waiting time from referral to assessment.

7.8.3. USERS ACCEPTED

CICT accepted 100% of referrals; STEPs accepted 91.7% of referrals and Montagu 92.4%,

however 19% of referrals to Positive Steps were not accepted and it has not been possible to

determine the reason why. No information provided for Hazel and Hawthorne wards.

In 2013/14 Doncaster Intermediate Care services accepted more bed based and re-ablement

clients than the national averages indicated in the NAIC 2014 as per table below.

Doncaster bed based services were more than double the national average with 1076 accepted.

Table below; left.

Re-ablement services were slightly higher than the national average with 1952 accepted. Table

below; right.

Total number of service users accepted (Bed Based Services)

Total number of service users accepted (Re-ablement)

Top Ranking 2531

Top Ranking 9300

Average 390

Average 1780

Doncaster position 1076

Doncaster position 1952

Lowest Ranking 15

Lowest Ranking 79

*NAIC 2014

*NAIC 2014

1328

644 626

255 98 52 27 0

200

400

600

800

1000

1200

1400

STEPs Montagu CICT Positive Step RoseAssessment

Rowena/AIM Oldfield/AIM

Service Users Accepted by Services

7.8.4. BED OCCUPANCY

The proportion of beds occupied within the bed based services fluctuates month on month; from the

graph below it can be seen that for the majority of the year Positive Step, Rowena, Oldfield and

Rose House are operating at full capacity. There appears to be some spare capacity across the

system within the summer months (Jul 13 – Sep 13). Hawthorne has the most spare capacity with

an average occupancy rate of approximately 70% thus has the capacity to increase a step up

approach from community.

92% 72%

54% 59% 71% 64%

78%

43%

83% 62%

72% 86%

0%

20%

40%

60%

80%

100%

120%


Average Percentage Bed Occupancy

Positive Step Rowena/AIM Oldfield/AIM Rose Assessment Montagu Hazel Hawthorne

7.8.5. DURATION OF CARE

It should be noted that Doncaster IHSC services have variable targets for duration of care, from 7

days to 42. The average duration of care in 2013/14 was longest at Rowena and Oldfield (over 6

weeks) and shortest at Hawthorn (1 ½ weeks).

Over 40% of service users at Rowena and Oldfield had a duration of care of over 7 weeks. At the

other end of the scale only 2% of service users treated at Rose had care lasting over 7 weeks.

In the NAIC 2014 sample, average length of stay, as reported in the organisational level audit, has

increased in home and bed based intermediate care services to 30.4 days (up from 28.5 days in

NAIC 2013) and 28.0 days (up from 26.9 days in NAIC 2013) respectively (chart below). The

duration of stay for re-ablement services at 32.7 days is very close to the NAIC 2013 result (32.4

days). The duration of service in crisis response services has decreased from 137 hours (5.7 days)

45.8 45.2

37.7 27.2

25.4 23.3

19.8 14.6

10.3

0 10 20 30 40 50

Rowena/AIM

STEPs

Positive Step

Rose Assessment

HawthorneAverage Duration of Care (Days)

44% 42%

33%

18% 16%

12% 8% 2%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Rowena/AIM Oldfield/AIM STEPs Montagu CICT Positive Step HFH Rose Assessment

Proportion of Patients Whose Care and Support Exceeded 42 Days

National Ref;

Max Target stay 42 Days

In 2012/13 to 90.3 hours (3.8 days) in 2013/14. This may reflect a better understanding of the NAIC

definition of crisis response services amongst audit participants this year.

The costs per service user will be affected by the average length of stay, as a high length of stay will

reduce the throughput of service users and therefore increase the cost per person. In the NAIC

2014 sample, average length of stay, as reported in the organisational level audit, has increased in

home and bed based intermediate care services to 30.4 days (up from 28.5 days in NAIC 2013) and

28.0 days (up from 26.9 days in NAIC 2013) respectively. The duration of stay for re-ablement

services at 32.7 days is very close to the NAIC 2013 result (32.4 days).

NAIC 2014 – Average Length of Stay

7.8.6. DISCHARGE DESTINATION

64.4% of service users discharged from Doncaster Intermediate Care services were discharged

Home With or Without Support in 2013/14. From the data provided by DBHFT for the Mexborough

Rehab Centre it has not been possible to differentiate between with or without support.

No data was received from Hazel, Hawthorne or Magnolia.

1152 710 371 295 202 201 174 58 0

200400600800

100012001400

Destination on Discharge From Intermediate Care

0 200 400 600 800 1000 1200 1400

Admitted to Hospital

Clients Choice

Completed Package

Home with no support

Home with support

Other

Home With/Without Support

Residential/Nursing Home

Destination on Discharge

Positive Step Rowena/AIM Oldfield/AIM Rose Assessment STEPsMontagu CICT HFH NRP (CAP Beds)

Destination on discharge data was collected for crisis response, home and bed based intermediate

care services as part of the NAIC 2014, see chart below. All three service categories show around

two thirds of service users going home or staying at home (63% for home, 65% for bed based

services and 71% for crisis response services) following the intervention by the service.

14.6% of service users in bed based provision are discharged to an acute hospital and 12.8% to a

care home. Home based intermediate care and crisis response showed similar proportions of

service users discharged to acute care (9.4% and 9.9% respectively) and to care homes (4.1% and

2.9% respectively).

7.8.7. RE-ADMISSION

From the data provided 86 (20%) out of 426 care home patients were readmitted to hospital. A third

of service users (8/24) discharged from Oldfield were readmitted to hospital however it was not

clear whether this was due to the complex clinical / dementia / carer respite need or other factors

whereas Rowena with a similar patient profile only had a 17% (8/46) readmission rate. From

Positive Step 25% (64/259) and Rose House 6% (6/97) were re-admitted.

From the data provided almost half of service uses from Rowena were discharged into long term

care which could explain the lower readmission rate (more clinically complex patient group?).

33%

25%

15% 17%

6% 6% 5% 0%

5%

10%

15%

20%

25%

30%

35%

Oldfield/AIM Positive Step STEPs Rowena/AIM RoseAssessment

HFH CICT

Proportion of Patients Readmitted to Hospital during or after a period of IC service delivery

47%

30%

20%

11% 2% 1% 0%

10%

20%

30%

40%

50%

Rowena/AIM Oldfield/AIM Positive Step Montagu STEPs Hawthorne

Proportion of Patients Transferred Into Long Term Care

7.8.8. LIVING INDEPENDENTLY

The proportion of service users still living independently 3 months after discharge from hospital is

highest for the services with the shortest duration of care and lowest for those with the longest

duration. This is not unexpected as it reflects the case mix of the respective services, i.e. the fittest

patients with the least health and social care needs will be able to stay independent the longest.

No data was available for Hazel and Hawthorne.

Rose House consistently appear to have a high proportion of service users remaining at home 91

days after discharge. On average across these services 76.3% were still at home 91 days after

discharge from hospital. No data available for Hazel and Hawthorne.

88% 78% 76% 75%

64%

50%

0%10%20%30%40%50%60%70%80%90%

100%

RoseAssessment

Positive Step HFH STEPs Rowena/AIM Oldfield/AIM

People Aged 65+ Still Living Independently 91 Days After Discharge

68.0%

72.5%

75.9%

65.7%

71.0%

82.2%

83.1% 82.5% 81.3% 77.6% 86.5%

69.4%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Proportion of people (aged 65 and over) who were still at home 91 days after discharge from hospital

Rowena House

Rose House

Positive Steps

STEPS

STEPs and Rose treated the highest percentage of service users who required support to maintain

independence.

74%

39% 37%

30%

21% 15%

0%

10%

20%

30%

40%

50%

60%

70%

80%

HFH STEPs Rose Assessment Positive Step Rowena/AIM Oldfield/AIM

Patients requiring support to maintain independent living

8. Mapping against Current Service Specification

The objective of a mapping exercise was to ascertain whether the services were being delivered in

line with the service specification and to inform future service specification design and data

collection processes.

A mapping of IH&SC service specifications against the data collected has been attempted for both

DCCG and DMBC commissioned services. However the only specifications provided for the

mapping were;

Intermediate Care 01.04.2014 – 31.03.2016 – DCCG with RDaSH.

Community Nursing 01.04.2014 – 31.03.2016 – DCCG with RDaSH.

Home from Hospital Service 01.04. 2013 – 31.03.2016 – DMBC with AGE UK

The specifications include service objectives and expected outcomes which are aspirational and

represent strategic priorities. The RDASH specifications have no specific, measurable, key

performance indicator’s or performance targets and contain no mechanism for quantifying or

measuring performance to determine success rates. The DMBC specification has a small number of

KPI’s but these are not service specific, for example; “reduction in A&E attendances” or “reduce the

risk of carer breakdown”.

A meaningful mapping exercise has therefore not been possible. The specifications provided do not

cover the full range of core IH&SC services provided and it has not been possible to correlate the

data collected against KPI’s or strategic aspirations.

9. Recommendations

1a. Doncaster Intermediate Care services to adopt and consistently report on a common, agreed

set of local key service performance indicators with realistic targets to improve outcomes or

adopt the national audit for intermediate care indicators, which might include the following:

a. Number of referrals received to Intermediate Care service

b. Number of people who are accepted by the intermediate care service

c. Number of new referrals to assistive technology (including Telecare)

d. Number of new referrals to aids, adaptions and equipment

e. Proportion of people who have aids, adaptations and equipment delivered and

installed before they cease receiving support/care

f. Proportion of older people who are still at home 91 days after discharge from hospital

into Intermediate Care services (ASCOF2B)

g. Proportion of permanent admissions into long term care (residential and nursing)

h. Proportion of people whose duration of support/care exceeds 42 days maximum target

i. Number of service users who are re-admitted to hospital as an emergency within 30

days of discharge from hospital

j. Average duration of support/care received from Intermediate Care service

k. Proportion of people who have achieved their personal goals/ expectations

l. Proportion of people who engage with community life and connect/re-connect with

social networks

m. Evidence that people were happy with the skills and expertise of the person/service

providing the support/care

n. Evidence that people were happy with the quality and timeliness of the service

o. A view of service users Social Care related quality of life

p. Overall satisfaction of people who use intermediate care services

1b. Develop a Doncaster IHSC dashboard in conjunction with commissioning and performance

leads clearly showing performance against all joint KPIs. The requirements and resources

required are as outlined below;

a. Information Sharing Protocol and sign up from all organisations

b. Clear joint performance matrix and data collection plan

c. A dedicated team to collate and analyse the data

d. Reporting mechanism/tool to provide integrated approach to reporting messages

An example of an intermediate care service dashboard which could be developed is provided

in Appendix 3.

2. Amend current and future contracts and service specifications to clearly specify :

a. The content of data to be supplied by such Providers.

b. The format in which the data is to be submitted.

c. The timescales for submitting the data.

d. Target or goal setting

e. Performance management of non -submission or poor performance

f. Data is submitted to Commissioners and partners in accordance with the latest

Information Governance regulations.

3. Adopt a consistent approach to identifying service users across all intermediate care

providers to aid data flow.

4. Consider future IT system configuration for the IHSC community including compatibility of

data collection, data sharing and reporting.

5. All Providers to jointly participate in the National Audit of Intermediate Care to enable

consistent benchmarking.

Your area or file:

Intermediate Care Needs Assessment

Comparison area or file:

Local Authorities - Doncaster (Adults (18+))

This page identif ies the top ten Mosaic Public Sector types in your area ranked on percentage. Follow ing this is a description of the top three types

Rank Mosaic Public Sector Types Your area/file % Comp. % Pen. % Index

1 N59 Pocket Pensions 146 12.87 7,816 3.31 1.87 389

2 F24 Bungalow Haven 129 11.38 13,459 5.70 0.96 200

3 O62 Low Income Workers 65 5.73 13,584 5.75 0.48 100

4 K48 Dow n-to-Earth Ow ners 64 5.64 11,934 5.06 0.54 112

5 M53 Budget Generations 64 5.64 17,638 7.47 0.36 76

6 N57 Seasoned Survivors 55 4.85 6,658 2.82 0.83 172

7 L51 Make Do & Move On 53 4.67 12,908 5.47 0.41 85

8 F23 Solo Retirees 41 3.62 4,506 1.91 0.91 189

9 H30 Affordable Fringe 37 3.26 14,350 6.08 0.26 54

10 H31 First-Rung Futures 36 3.17 5,733 2.43 0.63 131

N59 Pocket Pensions

a

Key Features Channel Preference Index

Retired and mostly living alone Face to Face 88

1 or 2 bedroom small homes Post 98

Rented from social landlords Landline 124

Low incomes Email 94

Prefer contact by landline phone Mobile 71

Visit bank branch Online 85

F24 Bungalow Haven


Elderly couples and singles Face to Face 79

Ow n their bungalow outright Post 106

Neighbourhoods of elderly people Landline 94

May research online Email 105

Like buying in store Mobile 67

Pre-pay mobiles, low spend Online 88

O62 Low Income Workers


Older households Face to Face 109

Renting low cost semi and terraces Post 113

Social landlords Landline 94

Longer length of residence Email 98

Areas w ith low levels of employment Mobile 100

2 or 3 bedrooms Online 90

10. Appendices

Appendix 1 - Public Profiling

Appendix 2 - Service Specific Data Analysis

Appendix 2.1 – Hazel Ward. 30.3 Referrals on average every month

14.6 days is the average length of stay over the year

30 30 28 34 28 38 25 35 20 34 35 26 0

5

10

15

20

25

30

35

40


Referrals - HAZEL

14.6 14.6 14.8 15.0 14.3 12.8 14.1 12.0 13.5 17.5 15.0 16.6 0

2

4

6

8

10

12

14

16

18

20


Average Duration of Care (Days) - HAZEL

Appendix 2.2 – Hawthorne Ward 32.7 Referrals on average every month


50.6% are aged 65-84 and 46.6% are aged 85 & over

28 37 27 37 32 33 35 17 38 40 37 31 0

5

10

15

20

25

30

35

40

45


Referrals - HAWTHORNE

12.8 11.5 7.5 8.9 10.6 10.0 11.1 11.5 9.6 8.2 10.2 12.1 0

2

4

6

8

10

12

14


Average Duration of Care (Days) - HAWTHORNE

0 9 164 151 0

20

40

60

80

100

120

140

160

180

0-17 18-64 65-84 85+

AGE Profile - HAWTHORNE

Appendix 2.3 - STEPs

120.7 Referrals on average every month

110.7 Service Users Accepted on average every month


72.1% Discharged Home With/Without Support

132 151 119 141 100 95 135 116 130 111 109 109 0

50

100

150

200


Referrals - STEPS

123 143 116 138 98 94 100 81 115 105 106 109 0

50

100

150

200


Service Users Accepted - STEPS

39.1 42.9 43.9 43 41.8 34.4 31.4 28.3 29.5 43.1 35.7 39 0

10

20

30

40

50


Average Duration of Care (Days) - STEPS

223

921

30

104

0 100 200 300 400 500 600 700 800 900 1000




Other

Destination on Discharge Apr-Mar 13/14 - STEPS

Appendix 2.4 – Mexborough Montague Rehab Unit





59 46 40 62 49 54 54 56 79 71 52 75 0

20

40

60

80

100


Referrals - MONTAGU

55 40 38 59 45 49 51 55 73 64 45 70 0

20

40

60

80


Service Users Accepted - MONTAGU

26.6 28.4 34.1 26 27.4 27.7 30.4 29.5 20.6 24.2 24.4 26.7 0

10

20

30

40


Average Duration of Care (Days) - MONTAGU

531

66

72

19

0 100 200 300 400 500 600


Other



Destination on Discharge Apr-Mar 13/14 - MONTAGU

Appendix 2.5 – CICT





73 47 60 45 56 40 59 52 53 46 45 50 0

20

40

60

80


Referrals - CICT

73 47 60 45 56 40 59 52 53 46 45 50 0

20

40

60

80


Service Users Accepted - CICT

19 24 19 20 20 27 22 22 25 25 29 27 0

5

10

15

20

25

30

35


Average Duration of Care (Days) - CICT

34

476

100

1

0 50 100 150 200 250 300 350 400 450 500


Home With/without Support

Other

Residential/Nursing HomeDestination on Discharge Apr-Mar 13/14 - CICT

Appendix 2.6 - Positive Step

26 Referrals on average every month




25 24 21 20 30 16 34 23 34 28 23 34 0

10

20

30

40


Referrals - POSITIVE STEPS

23 21 19 16 24 13 32 16 28 23 17 23 0

10

20

30

40


Service Users Accepted - POSTITIVE STEPS

28 27.4 29 21.4 23.2 21 25.6 23.1 26.5 27.5 28.2 24 0

10

20

30

40


Average Duration of Care (Days) - POSITIVE STEPS

64

116

64

15

0 20 40 60 80 100 120 140




Other

Destination on Discharge Apr-Mar 13/14 - POSITIVE STEPS

Appendix 2.7 – SCAU, Rose House





9 11 8 13 14 16 17 29 31 17 0

10

20

30

40


Referrals - ROSE ASSESSMENT

10 6 11 8 4 10 9 7 10 7 10 6 0

2

4

6

8

10

12


Service Users Accepted - ROSE ASSESSMENT

16 19.3 26.3 25.1 16 15.8 21.8 23.5 18.4 14.5 19.5 21.6 0

5

10

15

20

25

30


Average Duration of Care (Days) - ROSE ASSESSMENT

6

89

0

2

0 10 20 30 40 50 60 70 80 90 100




Other

Destination on Discharge Apr-Mar 13/14 - ROSE ASSESSMENT

Appendix 2.8 – SCAU, Rowena (AIM)




54.3% Discharged to Residential/Nursing Home

5 4 3 2 6 5 5 4 5 6 4 4 0

2

4

6

8


Referrals - ROWENA/AIM

5 4 2 2 5 5 5 4 5 7 4 4 0

2

4

6

8


Service Users Accepted - ROWENA/AIM

45.8 64 53 36.5 31.5 32.3 39.6 43.8 23.7 29.8 60.5 88.5 0

20

40

60

80

100


Average Duration of Care (Days) - ROWENA/AIM

8

11

25

2

0 5 10 15 20 25 30




Other

Destination on Discharge Apr-Mar 13/14 - ROWENA/AIM

Appendix 2.9 – SCAU, Oldfield




37.5% Discharged to Residential/Nursing Home

2 3 4 1 2 4 4 1 2 1 0 3 0

1

2

3

4

5


Referrals - OLDFIELD/AIM

2 3 4 1 2 4 4 1 2 1 0 3 0

1

2

3

4

5


Service Users Accepted - OLDFIELD/AIM

25 29.3 38 18 50.5 65 53.3 137 39.5 58 29 0

50

100

150


Average Duration of Care (Days) - OLDFIELD/AIM

8

6

9

1

0 1 2 3 4 5 6 7 8 9 10




Other

Destination on Discharge Apr-Mar 13/14 - OLDFIELD/AIM

Appendix 2.10 – Complex Assessment Pathway Beds

12 Referrals on average every month


Average Length of Stay 30.7 Days over the 3 month period

10 14 12 0

5

10

15

Jan-14 Feb-14 Mar-14

NRP CAP Beds Referrals

10 14 10 0

5

10

15


NRP CAP Beds Service Users Accepted

25 31 36.2 0

10

20

30

40


NRP CAP Beds Average Duration of Care (Days)

88.9% of Discharges were Home With/Without Support

10% Readmitted to hospital on average

1 1 2 6 8 0

5

10


NRP CAP Beds Discharge Destination

Admitted to Hospital Home With/Without Support

0% 17% 13% 0%

5%

10%

15%

20%


NRP CAP Beds Readmissions to Hospital

Appendix 3 - Example Dashboard

Short Term Enablement Programme (STEPs) – Dashboard Screen Shot

Owner: Doncaster Metropolitan Borough Council/ STEPs/ Kath Lindley (Team Manager) Creator: Tony Sanderson (Project Manager)

References.

1. National Office of Statistics - 2013/14

http://ons.gov.uk/ons/taxonomy/index.html?nscl=Population

2. Health and Social Care Information Centre - Calculating Quality Reporting Service (CQRS) – 2013/14

http://systems.hscic.gov.uk/cqrs

http://www.england.nhs.uk/wp-content/uploads/2013/01/la-pack-e08000017.pdf

3. Quality Outcomes framework (QOF) - 2013/14

http://www.hscic.gov.uk/qof

http://www.hscic.gov.uk/ccgois

4. NHS England – 2013/14

http://www.england.nhs.uk/ourwork/qual-clin-lead/

http://www.england.nhs.uk/ccg-ois/

5. Department of Health – 2013/14

https://www.gov.uk/government/organisations/department-of-health/about/statistics

6. NHS Benchmarking Network - National Audit of Intermediate Care – Summary Report. November 2014.

http://www.nhsbenchmarking.nhs.uk/partnership-projects/National-Audit-of-Intermediate-Care/year-

three.php

7. British Geriatrics Society – Comprehensive Assessment of the Frail Older Patient – BGS. 2010.

http://www.bgs.org.uk/index.php/resources-6/bgscampaigns/fit-for-frailty

8. Doncaster CCG outcomes Framework - 2013/14

http://www.england.nhs.uk/wp-content/uploads/2013/01/la-pack-e08000017.pdf

http://systems.hscic.gov.uk/cqrs

http://www.hscic.gov.uk/ccgois

intermediate health & social care needs assessment in ... › wp-content › uploads › ... ·...

Documents