Continuing Healthcare

Lord Carter visits Royal Surrey County Hospital to see a CHS hospital discharge service

Lord Carter visited a CHS Healthcare hospital discharge service at the Royal Surrey County Hospital to see the model he praised in his landmark review of the NHS.

The Royal Surrey County Hospital is one of 29 discharge services CHS Healthcare operates throughout England. Our service at the Royal Surrey County Hospital is for patients who are fit for discharge but are moving into 24-hour care or need a package of care in order to return to their own home. Lord Carter visited the hospital and saw how the service operates on November 1.

We provide focused support and advice for the patients and their families to help them choose a care home and co-ordinate all arrangements.

In his report, Operational Productivity and Performance in NHS Acute Hospitals: Unwarranted variations, Lord Carter urged hospitals to take “matters into their own hands” by commissioning models such as those run by CHS to reduce the rate of delayed discharges.

Lord Carter commented: “The national strategy should encourage trusts to do more of this to find rapid local solutions to the problem of delayed transfers.”

Dr Richard Newland, chief executive of CHS Healthcare, explained: “Since inclusion in this landmark report, I have been pleased to have the opportunity to meet Lord Carter several times as part of his ongoing work to drive forward and support transformation in the NHS.

“We were delighted to be able to show Lord Carter how our hospital discharge service works in practice; the multiple steps required to achieve a timely discharge when there are often complex needs and how we meet all the challenges.

“We would like to thank our partners at the Royal Surrey County Hospital, particularly chief executive Paula Head who also met Lord Carter. We are proud of our strong and effective partnerships with the NHS organisations who commission our services.”

Susan Adams, regional manager of CHS Healthcare for the south of England, showed Lord Carter how CHS operate a flexible working model, including evening and weekend working, to ensure key performance indicators are met. Patient and/or family is contacted on the same day as referral, care home is chosen within two days and transfer to the care home achieved within five days.

Mrs Adams commented: “This is one of our core services that we have been providing for 20 years. We typically reduce DTOC (delayed transfers of care) by five to ten days, depending upon previous performance and in so doing, save hospitals hundreds of thousands of pounds, as evidenced in Lord Carter’s report.”

CHS Healthcare’s discharge to assess service is featured in the social housing journal Inside Housing

The large, long established discharge to assess service in Birmingham we help to co-ordinate is highlighted in the social housing journal, Inside Housing.

The feature explores how CHS Healthcare works with Anchor Housing as part of a large Discharge to Assess service we run in Birmingham, on behalf of the Birmingham Cross City Clinical Commissioning Group. The beds are known as Enhanced Assessment Beds.

Patients who are fit to be discharged from the city’s acute hospitals but need further support and assessment, are transferred to community based beds.

We manage the beds in eight care and nursing homes within the scheme, co-ordinating all the care and assessments they need to ensure no-one becomes ‘stuck’ in the system.

Once in the discharge to assess placement, the patient is first assessed by an occupational therapist who will decide whether physiotherapy is needed. Around 40 to 60 per cent of patients will have physiotherapy to help them with mobility problems.

We manage the team of physiotherapists to ensure patients receive this support (or reablement) without delay.

Patients are allocated a social worker who will carry out an assessment and co-ordinate next step for the patient: return home/return home with a package of care/choose a permanent care home.

Patients spend four weeks in the discharge to assess bed and the evidence shows the services gives them a better chance of returning to their own home with a package of care than if assessments had taken place while in hospital.

Rachael Hardbattle, CHS Healthcare manager for the Midlands and north of England, who has also overseen large discharge to assess services in Liverpool and Leicester, commented:

“Discharge to assess is the model of best practice for elderly, frail patients when they are ready to leave hospital but not able to go straight back home. To work effectively, it depends on strong relationships with care and nursing homes and close collaboration between professional agencies and social work teams. We have really robust reporting and constantly manage each person’s care, so no-one is ever ‘lost in the system’ waiting for physiotherapy or an assessment to be carried out. Everyone is working to get each patient to the best place – ideally their own home with the support they need, or a good, supported choice of long term care.”

CHS Healthcare highlighted in NHS England guide to improving hospital discharge

CHS Healthcare is featured for good practice in an NHS England guide on how to improve hospital discharge.

Our work is highlighted in the Quick Guide on improving hospital discharge into the care sector, designed to share good practice across the whole of the NHS.

The guide cites our work for Lancashire Teaching Hospitals NHS Foundation Trust, providing the personalised support for families choosing care homes and in so doing, reducing delays to discharge by ten days.

Our work was featured as an example of practical solutions to improve patient experience and involvement in hospital discharge.

Lancashire is one of 21 hospital discharge schemes CHS Healthcare is currently commissioned to provide. These include personalised support for patients who need to choose a care home as they are moving from hospital to 24-hour care and equally, we manage a range of discharge to assess services. We also organise packages of care for people who are returning to their own home after hospital.

Our work is cited for improving the patient and family’s experience of and involvement in the discharge process. Our advisers work flexibly, including evenings and weekends, meeting families, accompanying them on care home visits and helping them to information gather and make a supported, informed choice of care home.

The NHS England Guide also highlights discharge to assess as being a valuable means of avoiding unnecessary hospital stays and states that assessments of long term care needs should take place out of hospital whenever possible.

CHS Healthcare chief executive Dr Richard Newland commented: “We are really delighted to be included in this NHS England guide on improving hospital discharge into the care sector. Improving hospital discharge is our core service and is something we recognise as being absolutely essential for the whole health system.

“We are very pleased to be featured in this guide, soon after being highlighted in Lord Carter’s landmark report on NHS productivity as an example of good practice we can be widely adopted.

“We have been working in hospital discharge for two decades: we know the sticking points and the challenges; we know how to address problems and what works. Our services very significantly improve the experience of patients and families and at the same time, substantially reduces delays to discharge.”

In each hospital discharge service, usual key performance indicators are: patient and family contacted within 24 hours of referral (including evenings and weekends). Home chosen within two days of referral and transfer from hospital to care home within five days. In discharge to assess services, time from referral to transfer from hospital is typically less than four days.

New hospital discharge services can be set up within just six weeks.

CHS Healthcare hospital discharge service is featured in the Carter report as best practice

CHS Healthcare is cited in Lord Carter’s major report on NHS productivity as an example of best practice in hospital discharge.

The landmark report, Operational Productivity and Performance in NHS Acute Hospitals: Unwarranted variations, estimates every day, 8,500 acute beds are taken by patients who are ready to leave hospital but whose discharge is delayed. This costs the NHS an estimated £900 million each year.

In the report, Lord Carter urges hospitals to take “matters into their own hands” and set up their own systems for improving discharge, such as the work of CHS Healthcare in Dudley.

Lord Carter states: “During our discussions we found examples of where acute trusts have taken matters into their own hands by setting up their own arrangements for step-down care, or have entered into partnership with local authorities or the independent sector.

“The national strategy should encourage trusts to do more of this to find rapid local solutions to the problem of delayed transfers.”

The report highlights two examples of good practice, one being the work of CHS Healthcare in Dudley. The report states:

Some trusts are looking to dedicated support and brokerage to reduce delayed transfers of care. These services work personally with families and beyond the traditional care hours model to support people to move to a care home of their choice, step-down care or back into their own homes. For example CHS Healthcare has worked with the Dudley Group of Hospitals to halve the days spent in hospital by fit to discharge patients saving 995 bed days over four months, at a net benefit of £170,000.

The figures from the Dudley were produced by the hospital trust themselves, in their evaluation of the initial pilot of the CHS Healthcare service.

The pilot in Dudley ran from October 2013 to January 2014, resulting in a saving of 995 bed days, according to the trust’s report. Taking a bed day cost of £220 per day, this produced an overall saving of £220,890 during the pilot. When the costs of commissioning the service from CHS are taken into consideration, there was a net saving for the hospital of £170,490 in just four months.

Bernie Green, urgent care pathways lead for the hospital, who produced the evaluation, commented: “The CHS service offered in principle, similar to our capacity team, is different in the way they operate. CHS work beyond the traditional care hours model and offer individuals more of a personal input by visiting families in their own homes and organising and facilitating care home visits.”

CHS Healthcare continue to provide this service in Dudley, together with 26 other hospital discharge schemes across the country from Durham in the north-east to Southampton and Portsmouth on the south coast. Our typical key performance indicators for patients who need to choose a care home in order to move out of hospital are: 100 per cent contacted on the same day, home chosen within 48 hours of referral and transfer to care home within five days of referral.

We also run major discharge to assess services including in Gloucester, where we run the whole scheme, directly employing nurses and social workers and in Birmingham in a large scale, city-wide scheme.

Dr Richard Newland, chief executive of CHS Healthcare, founded the company 20 years ago while working as a GP and recognising the gap between hospital and community based care.

“We are delighted to receive this endorsement in Lord Carter’s report. It is an extremely impressive, insightful and forward thinking report which sets out very clearly how greater efficiency can be achieved in the NHS.

“We welcome the focus on the hospital discharge process and the key message that although discharge can be complex, hospitals can and should take greater control: it is not out of their hands. We can achieve enormous reductions in delayed discharges with our flexible, 24/7 work with patients and families and co-ordination between acute and community care.”

New series of in-house training launched across the country on new Caretrack reporting function

We are pleased to announce in-house training which is taking place throughout the country in early 2016 to train Caretrack users in a new function. This is an additional ad hoc reporting capacity which allows the user to quickly and easily create their own reports. Harry Bourton, Operations Manager for Caretrack, comments: “We recognise that the demand for reporting in the NHS continues to grow and we want to support our service users to meet this demand efficiently. We developed this new function in response to requests from service users and as always, we are supporting its introduction in a series of training sessions. I look forward to meeting the Caretrack users again on this new training programme during the coming weeks and months.”

Training programme booked so far:
West Sussex CCG: Wednesday 20th Jan
Barnet CCG: 11th February
Enfield CCG: 10th February
NEW Devon CCG: 16th February
Gloucester CCG: 15th March
Eastbourne CCG: 9th March

Directly employed social workers in new flexible discharge to assess model

We are employing social workers in a new, flexible discharge to assess model in Gloucestershire Royal Hospital.

Providing services in Gloucester since April 2014, our well-regarded team have already established a flexible model for nurse assessments. We employ experienced nurses who carry out assessments during evenings and weekends.

By working flexibly, the nurses ensure no time is lost and meet families at times they find most convenient. For example, between December 2014 and May 2015, our nurses completed 221 assessments for patients moving from hospital into a care home. They took an average of just 1.8 days from referral to assessment being completed (this can take up to ten days in some areas).

From January 2016, we will be extending the same flexible model to the social work assessment. We will co-ordinate the whole of the discharge to assess process, employing and managing the social workers and nurses to ensure assessments are co-ordinated without delays.

The team will be spot purchasing beds across Gloucestershire and commissioning physiotherapy and occupational therapy.

Discharge to assess is based on the principle that once a patient is fit for discharge from hospital, they move into a community based bed in order for further assessments to take place. The model is effective in reducing lengthy delays in acute beds and ensuring the patient receives the assessments and support they need in the community, before a decision about their long term care is made.

Susan Adams, CHS Healthcare Manager for the south of England, said: “We are really delighted to launch this model which enables us to manage all the different parts of the ‘jigsaw’ of the discharge to assess process.”

“Having this full oversight, by employing social workers ourselves, gives us control of the whole workflow. We can avoid the delays that have traditionally arisen when one part of the health and social care sector is waiting for another part of the sector to carry out an assessment. We have proven the flexible working model works for the nurse assessments. By working during evenings and weekends, valuable time is not lost and equally, it works for families – many people have daytime work commitments and want to see the nurse during evenings or weekends.”


The jigsaw principle: guidelines for developing a full and accurate needs portrayal

by Art Calder, Head of Clinical Services, CHS Healthcare

When assessors are being trained for roles with the Ombudsman, they are encouraged to perceive cases like a jigsaw: are there any pieces missing? If pieces A and B fit together, but B and C do not, what do they need to reconsider? This is a helpful concept when we consider the process of building the needs portrayal document (NPD); the foundation for retrospective claims for continuing healthcare funding.

Creating the NPD is undoubtedly the greatest challenge within retrospective claims management. Gathering evidence is a procedural challenge – obtaining records from care homes and services takes persistence and organisation. But the NPD requires the case manager to turn hundreds of pages of contemporaneous evidence into a single document. This requires a high level of skill, judgement and experience.

The NPD incorporates all the available evidence and considers individual needs in each of the domains we use in continuing healthcare: behaviour, cognition, psychological and emotional needs, communication, mobility, nutrition, continence, skin, breathing, drug therapies and medication, consciousness. The case manager developing the NPD is not judging whether that person should be eligible for continuing healthcare; their role is to establish an accurate picture of the person, their needs and capabilities.

When we meet families and go through the NPD, discussions are often about emphasis – we are seeking to portray needs on a typical day, not a particularly bad or good day. The care records may show what medication was needed during a spell of especially poor health, or might record communication on a day when it was notably good.

Discussions with the claimant should be a collaborative way of establishing what the true, typical needs would have been. In my own discussions with families, reading over a needs portrayal, often a relative will comment: “Yes, that would be Mum all over.” When I hear that sort of phrase, it gives me confidence in the portrayal.

We always seek to triangulate data. The majority of evidence for a needs portrayal comes from care home records, but we always seek to cross-reference care home records with other evidence, principally records from visiting professionals, such as GPs, occupational therapists, physiotherapists and hospital records.

Of course, we are evaluating care home records which go back more than a decade to 2004. It is often challenging to find the person within notes that can be very stark and factual. “Bill sat in a chair. Bill had dinner,” notes might tell us. Sometimes, residential care homes provide richer care records, giving us a more rounded picture of the whole person while nursing home records focus on medical details. Today’s care home records are more comprehensive, reflecting not only changes in the way we record care but also the fact that people are living longer with increasingly complex health needs. Records reflect this complexity, although a detailed record might provide more medical information but little about the person as a whole.

It is essential that the person producing the NPD is a clinician experienced in continuing healthcare. They must have the experience of delivering that care to understand what sometimes scant notes mean and how to accurately portray typical needs.

They must also have been comprehensively trained in the process of developing a NPD; to understand how the pieces fit together and the principles of triangulation. This is a specialist role and many CCG continuing healthcare departments are struggling to find the human resource and experience required.

A clinical background is only a very basic foundation for the role. Essential too is a keen eye for detail, honed analytical skills, deep insight to the principles and practice of Continuing Healthcare and in a culture of ongoing sea changes, a wider comprehension of the health and social care legislative world. In other words, we need to be both a Jack and a Master of all trades and there are few people with the necessarily broad skill set and experience.

The Ombudsman training comparison is highly pertinent: the needs portrayal must first stand up to scrutiny of solicitors, panel and ultimately, the Ombudsman, if a complaints process is enacted. Producing the needs portrayal is a testing but critical challenge.

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