Decision details

The Government have produced revised Hospital Discharge Operation and Urgent Community Response Models with an expectation that they are implemented at pace of the next year. The primary focus of both models is to develop systems that can rapidly mobilise health and social care resources to provide same day hospital discharge for patients that are medically optimised with going home as the default option and equally respond to urgent community care within 2 hours to keep people in their own homes. We are producing a paper that will describe a proposed high level delivery model and will be looking for the JCB to support the described direction of travel

(i)  Joint Commissioning Board is asked to support the overall direction of travel in relation to the proposed Hospital Discharge Operational Model, in particular the shift towards more care being delivered in people’s homes “Home First” – noting the breadth of change required to achieve this.

(ii)  Joint Commissioning Board is asked to support the proposal to allocate the available NHS Hospital Discharge Programme (HDP) funds in 2021/22 in line with the proposed Home First Discharge to Assess model.

(iii)  Joint Commissioning Board is asked to note the annual estimated costs of the proposed Home First Discharge to Assess Model going forward and that there will need to be a decision later in 2021/22, once the financial position regarding NHS Hospital Discharge Planning (HDP) funds beyond March 2022 is known, in relation to how these costs are met within the Southampton Health and Care System. This will be the subject of a separate report.

A primary government assumption at the outset of the COVID-19 crisis was that acute hospital beds would be in high demand and thus the optimisation of flow out of the Page 15 hospital would be a priority. In March 2020 as part of the Government’s response to COVID, legislation was introduced with

immediate effect that changed the timescales and approaches associated with hospital discharge focussing on a “Home First Discharge to Assess (D2A) Operational Model”. These changes have undergone further adaptation since their initial implementation and are now the expected ongoing

Hospital Discharge and Community Support model as set out in the Government’s Policy and Operating model published on 5 July 2021.

The key features of the Hospital Discharge Operational Model are:-

·  An Expected Discharge Date should be established at the earliest point possible in a patient’s journey to allow for pre-emptive planning and information sharing to take place.

·  A “Criteria to Reside” has been developed which describes the clinical scenarios in which a patient would require acute inpatient care. If the patient doesn’t clinically meet these scenarios when assessed then the expectation is that they should be discharged from the bed on the same day.

·  Once a patient is ready for discharge they should be discharged as soon as possible on the same day.

·  A patient’s home (“Home First”) will be the default discharge destination even if intensive support or 24 hour care is required to achieve this.

·  Discharge to Assess” should be the default approach which requires that functional assessment of need and long term care requirements should take place in the community not in a hospital setting.

The expectation is that all patients, regardless of their final eligibility for funding, will follow this process and so the community health and social care system is now managing the assessment and care of self-funders in the same way as all other patients/clients from an earlier stage up to the point

that their needs and eligibility for support is confirmed.

In order to support this new discharge policy, the Government introduced a national Hospital Discharge Fund in March 2020 to cover the additional costs to the community health and social care system of supporting hospital discharge. In May 2021, the Government published its finance

support and funding flows for 2021/22 which covered discharge funding for the first 6 months of this year as follows:

·  For the period 1 April – 30 June, eligible costs will be reimbursed from the NHS HDP for the period up to 6 weeks post discharge

·  For the period 1 July – 30 Sept, eligible costs will be reimbursed from the NHS HDP for the period up to 4 weeks post discharge

The funding position for the second 6 months of the year and beyond has not been confirmed but is expected to mirror the first 6 months with continued eligible costs reimbursed for up to 4 weeks post

discharge.

In response to the new guidance, Southampton stood up a range of provisions and arrangements to deliver the new discharge requirements. This included:

·  The Community Discharge Hub which brought together the teams responsible for discharge across the Council (Complex Care and Hospital Discharge Team), CCG (Continuing Health Care Team) and Solent (Urgent Response and Community Independence Teams) to manage the discharge process, including triaging Onward Care Referrals completed by the hospital each day, initiating and overseeing the D2A process, case managing all patients and clients as they move through the D2A process, liaising and problem solving with the hospital and community services to maintain flow and capturing data that informs the system. A previous business case for maintaining the Community discharge hub was brought to and approved by the Joint Commissioning Board in April 2021.

·  A range of additional D2A capacity (over and above the 10 D2A beds the city already had in place under joint funding arrangements) to achieve the aim of assessing all patients, including self-funders, in a community setting. 38 block contract D2A beds are currently commissioned by the CCG from the independent sector.

·  Additional home care bridging hours to support the Home First principle

·  Additional spot purchased beds for those patients whose needs cannot be met in the D2A block contracted beds, either because of capacity or their complexity

·  Therapy support to the D2A process

·  Additional support to the Community Independence Service

·  Additional CHC staff to support D2A process

·  Additional social work staff to support the D2A process

·  Additional brokerage support

The total costs of this additional provision have been met by the Hospital Discharge Fund. However there was a shortfall of approximately £1M for Southampton (£7.2M for Hampshire, Southampton and Isle of Wight CCG as a whole) between the amounts of funding allocated for the first 6 months

of this year and the costs of this capacity.

Whilst Southampton has succeeded in stepping up the additional capacity at pace to respond to the new guidance and has made significant improvements in the length of stay of patients who were previously significantly delayed in hospital (reducing the length of stay by an average of 14 days for

those needing nursing home care and by an average of 5 days for those needing rehab and reablement in their own homes), the city has also experienced a number of risks and challenges with the new discharge arrangements, in particular:

·  Achieving the 4 week timescale for D2A which the national discharge fund can be used for – approx. 20% of clients are taking longer than 6 weeks to move on from their D2A placement and the average length of stay in a D2A bed is averaging 41 days (5.8 weeks) as achieving the assessments within current resources is proving challenging.

·  Delivering the Government expectations around Home First – which is that 95% of patients go straight home from hospital. In Southampton the figure is 89%. There is a strong overreliance on bedded support and it has been estimated that to achieve the 95% expectation, approx. 7 patients a week would need to move from being admitted to a D2A bed to being discharged straight home with the necessary health and care support around them to enable this. This estimate does not account for any additional growth in discharge numbers/demand.

·  Increased costs of onward care which have been shown to be primarily linked to increased levels of complexity but also potentially the over-reliance on D2A beds which could mean that their capacity for reablement and independence is not being maximised. Patients are leaving hospital at a much earlier stage in their recovery than in previous hospital discharge models thus increasing the likely levels of complexity on discharge. The overall demand on community services has increased substantially particularly in relation to increased costs of residential and nursing home packages, “double up” care (both in terms of  reablement and General homecare), use of equipment and increased therapy. For CHC, numbers of clients were broadly the same between 19/20 and 20/21 but average costs for placements/packages

  have increased by around 28% in 20/21 (26% increase for both home   care and residential; 31% for nursing homes) and for Adult Social Care   average unit costs for placements have increased since 19/20 by 20%   for residential placements, 21% for nursing home placements and   approx. 100% for home care packages.

·  Lack of certainty regarding funding resulting in short term planning

There is therefore a need to both determine a more sustainable model moving forward into the second 6 months of the year and beyond which both complies with the Government’s requirements for D2A and Home First and optimises people’s independence and provides a positive experience, at the same time as better managing onward care costs.

The following alternative options have been considered and discarded:

·  Do nothing is not an option for the reasons outlined in Paragraph 6 above. The current over-reliance on bed based care does not meet the Government’s expectations of Home First, does not offer best outcomes for local residents and is not sustainable in the long term

·  Reverting back to the previous model of discharge pre Covid where D2A was not the norm and people’s long term care needs were assessed whilst still in hospital is also not an option because this would not comply with the Government’s Discharge requirements and increased hospitalisation increases rapidity of deterioration and the potential for higher long term care costs.