COVID-19 good practice case study: Discharge to assess in Warwickshire

The health and care system in Warwickshire has maintained, and strengthened, its ‘discharge to assess’ model through the COVID-19 period by remaining aligned to its core principle of maintaining a person centred Home First approach.

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The experience of joint working in a Warwickshire County Council led Better Care Fund project with the local NHS partners’, which remedied poor performance around delayed transfers of care (DTOC), meant that it had a strong foundation from which to respond to COVID-19.

The health and social care partnership had invested significant time and effort over the past two years in understanding the actual flow of their system and how they could make things better, and improve their support to people, including reducing DTOC. Having built these strong relationships, as the pandemic hit, the system was able to have potentially difficult conversations without fear or trepidation. The relationship with their provider market was crucial too, understanding the market, its pressures and the opportunities was a key enabler to their partnership preparedness and response.

"…having looked at our DTOCs and managed the different areas of challenge, it enabled us to build relationships based on trust and constructive challenge... we did it from a data perspective, so first we made sure that all the sign off was correct and reflected reality... this then enabled us to go through and address the problems without questioning the data / sign off… don’t get me wrong it was a challenge, we had meetings were it was clear people in the room weren’t happy, but then we were able to talk about it and get to the crux of our challenges rather than it being superficial… this was the great ground work for our COVID response…”
"…actually it’s not about an integrated hierarchy, it’s not about integrated staff teams, it’s just about integrated delivery…”"
"… in an open way, we pre-set, pre-laid our apologies… but that showed the maturity of our partnership, that we knew that our response wasn’t going to be perfect and that sometimes organisational requirements would supersede those of the system… thankfully the apologies weren’t needed in the end…"

Pathway 1: supported discharges

During the COVID-19 response, via their hospital social care teams, the council continued to directly support discharges from the acute trusts under the health pathway of the discharge guidance.

The council’s occupational therapy led reablement service was further adapted from winter to include transitional support, a shorter term offer to people, including those not meeting the Care Act threshold.

The partnership was clear that it wanted to support people leaving hospital quickly, and for their destination to be home, whether via the Community Emergency and Response Team (CERT), reablement or homecare people needed to be back at home. The council had recently introduced PowerBI and has been able to use it to bring insight and support decision making. During the response more Homecare was delivered to maintain people in their own homes Through joint working most people were able to exit hospital at the earliest opportunity via CERT, Reablement or Homecare with peoples’ longer term needs being assessed once they were back home.

"…there’s a lot to be said about relationships, it probably seems a bit ‘old school’, but I believe with good relationships and good data you can rule the world..."

Pathway 2: Bedded rehabilitation

Warwickshire has achieved prompt pathway 1 discharges into the community using a Home First strengths based approach not delayed by the need to assess for Care Act eligibility.

Pathway 2 discharges were supported by good availability of beds across the system which are commissioned in the main by the Council. This includes capacity in Extra Care Housing supported by Reablement.

The one commissioner managing the challenges faced by the market on Pathway 2 was really beneficial to flow and unblocking challenges. During the response to COVID-19 Warwickshire managed to continue their downward trajectory of Care Home admissions, cementing and substantiating their person centred Home First approach.

“…this has brought us closer than we were before, and we were close already...”
“…if you haven’t got good trust, appreciation of others, honest conversations with a level of transparency, if you’re at war with the NHS COVID is likely to have made things worse…”

Critical success factors

Warwickshire is evaluating its COVID-19 experience to learn the lessons and strengthen the successful integrated working that has seen people supported to return to their homes.

A number of critical success factors have enabled the system to work effectively and remain aligned to the core principle of maintaining a person centred approach:

  • Sustained focus and leadership: developing discharge pathways which embed a person centred approach and a Home First / Discharge to Assess mindset has been a shared priority for over two years
  • Market management: The council has worked to develop a buoyant home care market that works and recognises the different geographies and needs.
  • In-house reablement: Maintaining and developing an expert in house, council, reablement service that embeds a Home First approach.
  • Partnership working: The opportunities afforded by an integrated acute/community provider, South Warwickshire Foundation Trust, and strong partnership working between the Trust and the council have been significant.
  • Social work: Maintaining strong social work presence in the hospital has been a key enabler in supporting a proactive Home First approach.
  • Integration enables Home First: The Integrated Care System alongside Primary Care Networks are seen as a key enabler to deliver a further embedded Home First culture.

Together this has meant that implications of COVID-19 and associated guidance hasn’t changed the fundamentals, rather it has enabled the principles of a Home First approach to be further embedded.

"…we are nothing special, but together we do a good job… we continue to trust each other, so when we give jobs to people to do, we leave them, give them the autonomy… when it doesn’t work well, we use our openness to learn from that rather than blame each other… so I think that has been our foundation to making things work in Warwickshire running up to COVID…” 
"…the world that we live in is based on trust and appreciation of others and therefore you won’t be able to do any of this work if you haven’t got a good relationship… that means honest conversations, a level of transparency that everyone’s happy with, trust and ultimately a focus on people…”
"…it’s an open and honest conversation, letting people get on with their work… people not trying to control the whole system...”

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