Short term care - Home First and Discharge to Assess

Home First is Derby City Council's short term rapid response and assessment service funded by Better Care Fund with objectives aligned to STP priorities of integration and sustainability of health and care services. The outcomes to be achieved include seven day working, reducing the cost of care packages and admissions to long term residential care, reducing delayed transfers of care (DTOC) from the Acute Trust, as well as a reduced overall budget. Business transformation has established a Home First team able to respond to the demands of strategic objectives and outcomes and meet the needs of customers. The Home First service model also fits well with the new NHS Long Term Plan (January 2019) ambitions to ‘boost out of hospital care’ and commitment to integrated care systems.

Derby City Council's Home First Service

Home First is a 24/7 short term rapid response service for Derby City residents in a crisis situation who do not have existing care arrangements, mainly people being discharged from hospital or in preventing an admission to hospital. Customers being discharged meeting the Discharge to Assess (D2A) criteria or referred from the community are triaged by the Hospital to Home team in the Integrated Discharge Hub to the most appropriate pathway. The Integrated Discharge Hub provides a single point of access to the Home First service.

Home First delivers Pathway 1 and Pathway 2 of the Derbyshire D2A Model. The service operates as an integrated assessment hub in partnership with Derbyshire Community Health Services (DCHS) with 24 beds at Perth House and 10 beds at Arboretum House and a community 'at home' care service. The service also operates an extra care assessment flat and trialling a community night service. DCHS provide therapy and nursing services and NHS intermediate care in the community. Medical and pharmacy services for P2 beds are provided by Macklin Street surgery and Clinical Care Pharmacy respectively.

This short term service is free but those assessed as needing on-going residential or care at home are transferred to the independent care sector.

Home First provides personal care including help with dressing, washing, assisting & moving and assistance with meal preparation. The ethos of the service is to increase confidence and promote independent living and wellbeing to achieve the best possible outcome for each customer.

Discharge to Assess (D2A) – a brief guide

D2A enables timely discharge and for people to be assessed for their ongoing care needs in the most appropriate setting, avoiding long term decisions being made while they are in crisis and need time to recover. A hospital environment is an alien setting and can disable people, limiting their opportunity to manage core activities of daily living independently.

The principles of Discharge to Assess are:

• Assessment in the most appropriate setting
• Applying the principles of Trusted Assessment, reducing duplication of assessments
• Create strength-based person-centred plans of care and promote independence
• Build confidence of person, family & carers
• Sensible solutions of care which reach across organisational boundaries, finding ways to make best use of all resources on the person's journey from hospital to home.

Derbyshire D2A Pathways

• Pathway 1: home for assessment.
• Pathway 2: short term period of bed based rehabilitation and assessment in a residential care setting.
• Pathway 3: bed based nursing care required for more complex cases

Integrated Care in D2A Pathways

D2A Pathway 1 - Home First Community

January-December 2018 Home First community took 957 referrals, an average of 87% of the demand for patients discharged from hospital meeting the D2A criteria. Length of stay in the service was 15 days but by the end of the year was averaging 11days. The ambition is to take 100% of this demand subject to increasing service capacity and the potential offer a community night service which is being piloted.

Customers that are discharged from the service but require on-going care are transferred to the independent sector. It is therefore essential that this sector is developed and has sufficient capacity.

D2A Pathway 2 – Assessment hub at Perth House /Arboretum House

Over the same period there were 759 referrals to the Pathway 2 assessment beds with an average of 64% returning home. Average length of stay in Perth House was 12 days. Average bed occupancy was 75% and based on this the service could potentially take 776 customers, 17 more than the actual in 2018 or an increase of 2%.

Population Projections

The population of people aged 65 years and over between 2017 and 2019 increased by 0.17% from 41,693 to 42,600. Population projections show that that the numbers will increase over the next 15 years.

Projections indicate a 9% increase in total population over the age of 65 years up to 2025 (up 4,000) and an increase of 34% to 2035 (up 14,800) with people generally living longer.

It is estimated that there will be 10,200 people over the ae of 85 years living in Derby by 2035.

The trend is that the number of hospital admissions across all English hospitals is increasing and the number of admitted patients aged above 65 years increased overall by 46% between 2005 and 2015 (The Health Foundation Trends in the number of English NHS hospital admissions, 2006 to 2016).  

Currently, 9% of discharges on average from the Royal Derby Hospital are triaged to a D2A Pathway, for example representing 655 patients over a six month period October 2018-March 2019.    Pathway 1 and 2 capacity will therefore need to be considered in parallel with projections on population, hospital admissions and discharges but given the projected increase in people over the age of 65 years and in hospital admissions in this age group the indications are that the current provision will not meet future demand. 

Other Impacts on Admissions and Discharge to D2A Pathways

Increasing complexity of cases

The increase in complexity of cases being discharged to D2A pathways impacts on the level of staff support required and the length of stay both in bed based and community services where longer and more frequent packages of care calls may be needed resulting in increased care costs.  This includes people with dementia or other mental health diagnosis or chronic illnesses.    Increasing length of stay would further impact on capacity and reduce the number that could be taken by the service.   

Multimorbidity

Multimorbidity as defined in NICE guidelines (NG 56) refers to the presence of 2 or more long-term health conditions including physical and mental health conditions, frailty, chronic pain or sensory impairment and it is estimated that two thirds of people over the age of 65 years will have two or more chronic conditions.   The integrated D2A pathways and enablement ethos of services in Derby align well with the recommended approach to caring for people with higher needs.  Taking into account population projections and the increasing number of older people, there will be a higher proportion presenting with multimorbidity and impacting on services.    

Dementia

The estimated dementia diagnosis rate is good in Derby at 75.8% with a recorded prevalence in the 65 years and over age group of 2,244 diagnosed.

Population projections show that the number of people in Derby diagnosed with dementia will increase by 1,339 or 41.8% over the next 15 years from 3,201 to 4,540 by 2035.  ‌

The direct standardised rate of emergency admissions for people with dementia (aged 65 years and over 2017-18) is significantly worse in Derby.  

Concurrently there is an apparent increase in the number of patients with dementia being discharged to Pathway 3 and based on a service audit of patients admitted to London Road Community Hospital (2019) 38% had a dementia diagnosis and of this group 78% had a known dementia diagnosis prior to admission.  

Based on current evidence and the projected general increase in the number of admissions in future, consideration should be given to supporting people with dementia and their carers in preventing admissions and where possible providing an appropriate pathway on discharge for those who could be managed on Pathway 1 or 2 but due to dementia are currently referred to Pathway 3.   

More information about Dementia can be found on the Mental health webpages 

Summary of potential gaps in services

• P1 capacity to take 100% of the current demand from the Integrated Discharge Hub and the projected increase in demand over the next 15 years.  
• P2 capacity to meet future demand based on the projections that the number of older people, people with multimorbidities and higher needs will increase, impacting on length of stay and the flow through the pathways.    
• Dementia pathway to avoid emergency admissions and/or discharge pathway that is more appropriate in cases where residential care (Pathway 3) could be avoided if a suitable alternative was available.  

NHS Long Term Plan

Further information on the external website NHS - Long Term Plan.

The NHS Long Term plan published in January 2019 set out "how the NHS will move to a new service model in which patients get more options, better support, and properly joined-up care at the right time in the optimal care setting".  

This vision sits well with Derby City's Home First service which already provides an integrated service with NHS partners for patients discharged from hospital, with emphasis on reducing delayed transfers of care and delivering assessment and care in the person's home.

The investment in primary medical and community services proposed may provide opportunities for including the Home First model as part of the expanded community health teams.  

Developing the use of technology will also feature in future NHS plans including maximising the use of assistive technology.   

Derby City Council's Carelink service provides Telecare and other assistive technology that could help avoid the need for residential care and in maintaining independent living at home. For more information visit the Carelink webpage.

Other priorities in the NHS Long Term plan:

• Action the NHS will take to strengthen its contribution to prevention and health inequalities
• NHS priorities for care quality and outcomes improvement
• Tackling current workforce pressures and supporting staff
• Upgrading technology and digitally enabled care across the NHS
• 5 year NHS funding
• Creating 'Triple Integration' Integrated Care systems by April 2021 – to deliver primary & specialist care, physical and mental health services & health & social care.   

With the existing integrated working between Home First, Derbyshire Community Health Services and the Integrated Discharge hub they are well positioned to be able to respond to the priorities set in the NHS Long Term Plan.

The trend is that the number of hospital admissions across all English hospitals is increasing and the number of admitted patients aged above 65 years increased overall by 46% between 2005 and 2015 (The Health Foundation Trends in the number of English NHS hospital admissions, 2006 to 2016). 

Currently, 9% of discharges on average from the Royal Derby Hospital are triaged to a D2A Pathway, for example representing 655 patients over a six month period October 2018-March 2019.    Pathway 1 and 2 capacity will therefore need to be considered in parallel with projections on population, hospital admissions and discharges but given the projected increase in people over the age of 65 years and in hospital admissions in this age group the indications are that the current provision will not meet future demand.