Case Study – Hospital Extended Services
The following example of good innovative practice from Birmingham City Council relates to the collaborative partnership approach undertaken to improve outcomes for vulnerable adults requiring post-Hospital care, whilst at the same time supporting one of the top national priority areas for the Government, i.e. to afford citizens greater access to NHS services and support across 7 days.
The award winning virtual “Hospital Extended Services” Team brings together a number of strands, including participation in multi-disciplinary Discharge Hubs, Early Supported Discharge, the introduction of Enhanced Assessment Beds within the community, 7 Day Hospital Social Work provision and a Post Hospital Discharge Team.
Faced with a 100% plus increase in the number of referrals received by Hospital Social Work staff year-on-year over the past 3 years, which was indicative of the pressure on hospital in-patient services no longer being confined to winter periods, a collaborative approach needed to be taken to ensure a constant throughput of patients and a reduction in the delayed discharges levels.
New ways of working needed to be considered to prevent “burn out” of staff and ensure that the expertise, knowledge and skills-base of Social Workers was recognised and valued as a profession in its own right and not viewed as “the arranger of cleaning/provider of meals”.
Accepting some form of radical change had to be effected to preserve the integrity
of Social Work as a professional resource within Hospitals, instead of looking at possible improvements from the perspective of service providers, the potential to do things differently to secure better outcomes was considered from a service user’s perspective, with any improvements for Social Work staff and statutory partner agencies being considered as “added value”.
As it was recognised that any wholesale transformation would be difficult to achieve immediately, requiring as it would the agreement from a wide range of NHS Trusts, local Clinical Commissioning Groups and the NHS/Local Authority Joint Commissioners, it was perceived that the greatest opportunity for success lay in the potential of “piloting” individual elements of an Extended Service model at different Hospitals (as outlined below), to test “proof of concept”, before seeking approval for “roll-out” across all sites.
Historically, ward staff would automatically refer patients, deemed by a doctor to be “medically fit for discharge”, to Hospital Social Workers, if there was felt to be a need for further support. Such referrals were then timed and, after a defined period of time, were deemed to be “delayed discharges” and reported as such to Senior Managers and the CCG Commissioners, with no account being taken of the fact that some were inappropriate referrals, requiring input from Community Health staff, rather than Social Work intervention.
Establishing a Multi-Disciplinary Discharge Hub, with input from Discharge Nurses, Social Workers and Physio/Occupational Therapists, allowed for greater co-ordination of referrals, with consideration given as to the best profession to become involved. This offered a seamless service for the wards and patients, whilst allowing Social Workers to concentrate purely on cases where their intervention was needed.
Early Supported Discharge
It was recognised that a lengthy hospital stay can lead to a deterioration in an individual’s motivation/mental impairment and ability to independently care for themselves, which may result in some people being inappropriately placed in residential care.
In order to address this situation, consideration was given to “healthier” alternatives, with Early Supported Discharges enabling assessments to take place outside Hospitals and after a maximum 6 week period, during which time the individual was supported at home with a package of Enablement Home Care and Occupational Therapy input, with the subsequent full assessment then determining what, if any, follow-on support was necessary.
Enhanced Assessment Beds
Recognising that, for many individuals, recovery was restricted within the “artificial” Hospital environment, it therefore also had to be accepted that their presentation at that point may not be a true reflection of their long-term need. Yet assessments carried out in such circumstances often led to long-term residential/nursing care being considered or home care packages provided, without taking into account any potential improvement when in a more “homely” environment.
To test the above theory, a small number of Care Home beds were purchased, with support provided for up to 4 weeks by Enablement trained staff to maximise the individual’s personal skills/independence, prior to a full Enhanced Assessment (EA) being undertaken.
The provision of Enablement support would potentially lead to the individual returning to the community in the shortest possible time, depending on progress made, whether that be to their own home or to sheltered accommodation/residential care, if that was the determined outcome based on presenting assessed need.
Based on a successful pilot, the provision of EA beds (EAB) was increased to 200 across the city, as well as 5 sheltered accommodation flats, with Social Workers being co-located on-site to foster partnership working and co-ordinate discharges, ensuring maximum use of resources.
7 Day Extended Service
With the success of the Enhanced Assessment pilot, and significant increase in EAB provision citywide, it was necessary to consider extending Social Work availability over 7 days.
Whilst the need to do so was evident, with no additional funding, the ability to effect hospital discharges in a timely manner 7 days a week relied upon the dedication/goodwill of a “virtual team” of 16 workers dispersed across 8 hospital sites, with their counterparts based within the Care Homes hosting the EABs facilitating throughput, undertaking assessments and accepting new admissions on a similar basis.
Whilst having access to a centrally based Team Manager for advice on complex situations/budget approval, the “virtual” team members volunteered to work weekends/Bank Holidays without the support of a Senior Practitioner and input from administrative staff they would ordinarily receive Monday to Friday.
As such, the most competent and experienced staff engaged in this pilot exercise, as they were required to work autonomously and do so, not for monetary gain, but out of commitment to their professional status and selfless commitment to patients and improved service delivery.
The City Hospital Social Work TeamH are currently piloting the inclusion of Social Workers 7 days a week within an Admission Medical Unit, in an attempt to divert individuals presenting within A & E from having to be admitted as in-patients, where appropriate to do so.
Benefits to Service Users
Enabling an individual to return home as soon as they are determined to be “medically fit” and “safe” to do so, has been shown to greatly aid recovery.
Their presentation is also enhanced, with increased potential to regain lost skills and confidence to prolong independence, when enablement support is provided within the familiar surroundings of their own home.
Undertaking assessments whilst still recovering in Hospital, can lead to an individual’s capacity/ability to independently care for themselves to be misrepresented and could potentially lead to an admission to residential/nursing care being pursued. Avoiding unnecessary placement within residential care, with all of the emotional turmoil this can cause to individuals and family members, with potential loss of a “family home” and attached sentiment, is of enormous benefit to the individual.
Where residential or nursing care is required, this can be a momentous step for all concerned and cannot, nor should not, be explored/arranged “overnight”. As such, the provision of an Interim Bed for up to 4 weeks can provide a “taster” of the Care Home environment and may offer an added assurance to individuals/family members coming to terms with the fact that this is the level of support now required whilst, at the same time, preventing a scarce hospital resource from being “blocked” due to the relevant time needed to effect transfer to the Care environment.
Benefits to Social Work Staff
The innovative approaches adopted have enabled Hospital Social Workers to cope with a 100% plus increase in the number of referrals received year-on-year over the past 3 years.
Managing the receipt of referrals through multi-disciplinary Discharge Hubs has enabled Social Workers to concentrate on complex needs. Instead of spending significant time and effort re-directing requests for Occupational Therapy support and arranging District Nursing care, their knowledge/expertise has more appropriately been focussed on addressing safeguarding/mental capacity issues, supporting individuals and their families to come to terms with the need to explore long-term residential/nursing care and preparing documentation for Continuing Healthcare funding, where this is appropriate.
Benefits to Local Authority/NHS Partners
The introduction of Supported Discharge and Enhanced Assessments within the community has led to an evidenced reduction (11%) in the number of individuals requiring long-term care and, where such placements were required, there has been a significant shift from Nursing to Residential Care, with an associated cost-saving to the Joint Commissioning budget.
There has also been a similar reduction in the number of individuals requiring on-going home care, as their need for additional support has diminished in line with their recovery and confidence gained from the initial enablement support provided.
As with mainstream Social Work provision, the prevailing economic climate, political direction and introduction of the Care Act and other relevant legislation has meant that Hospital Social Work has had to dramatically change in order to be able to meet the vastly increased demands being placed upon it.
Gaining initial support for establishing pilot studies and the subsequent “roll-out” of proven innovative change was not without challenge, given the number of Hospital Trusts/CCGs to engage with. This included 1 “Super Hospital” and 2 Hospitals in neighbouring Authorities, but jointly managed by a Trust operating within the city’s boundaries. However, as the benefits derived were clearly recognised and evidenced, and not exclusive to any single agency, confidence/trust increased, which enabled further new initiatives to be adopted on an incremental and on-going basis.
There is no doubt that the flexible and innovative developments piloted, refined and embedded across the city have been of considerable benefit to not only individuals leaving hospital, but also to their families and carers, and has additionally significantly raised the profile of Social Work as a profession within Hospital settings.
Whilst CCG Commissioners had repeatedly indicated Social Workers should be removed from Hospital settings, in light of the results achieved from the various strands outlined above, they no longer hold such views, as each pilot scheme, which from the outset had to be person-centred focused, proved to be cost-effective and considerably beneficial to patient recovery.
The above combined successes have led to a renewed confidence in the ability of Social Workers to play a more active role in the re-design of service provision and be seen as an equal partner when undertaking collaborative work, albeit one with different skills and values to other professions deployed within the medical model of service delivery.
By ensuring that social work assessments can be undertaken continuously over 7 days,
workers participating in the “Extended Services Team” have enabled early discharge to be effected in ways which have delivered improved positive outcomes for service users and their families, freed-up Hospital beds in a more timely manner and greatly enhanced the reputation of the Local Authority in general and the profile of Hospital Social Workers in particular as allied professionals, with different, but equally valuable, skills and expertise.