The hospital avoidance response team – HART – service is delivered by members of the Lincolnshire Independent Living Partnership and takes referrals from secondary care discharge hubs, A&E in-reach teams, the ambulance service, primary care and community health providers. This example of a local initiative forms part of our managing transfers of care resource.
In the past, Lincolnshire was a challenged area with high levels of delays and a lots of siloed working. The system has worked hard in recent years to bring together organisations, to think innovatively and to emphasise home first principles. Lincolnshire was used as a case study in the previous HICM Best Practice guide, and since the original case study, they have been given additional funding to support winter pressures and extend service capacity, which has been integral to the Lincolnshire system. The service is now operating within its third year having been recommissioned from its original pilot for a further two years, demonstrating the need for this service at all times of year. Since its inception in its first pilot, the service has accepted 3322 referrals (June 2019) of people needing support to either avoid hospital admission or to be discharged from hospital.
The project was initially funded by clinical commissioning groups, but it has since increased capacity with additional funding from the county council via the Better Care Fund. Age UK work closely with the STP to understand issues in the area.
Eligibility to HART extends to people over the age of 18 who live in Lincolnshire and for whom support would either prevent an avoidable A&E attendance or admission, or speed up discharge from secondary care. This is achieved through:
- facilitating a supported discharge and providing up to 5 days (where appropriate) of care and support to resettle a person at home, with the majority requiring up to 72 hours of support.
- offering a ‘bridging the gap service’ for a 72-hour period to give other domiciliary or reablement services the opportunity to commence later in the pathway
- supporting the clinical assessment service to avoid hospital admission and/or attendance at A&E
- offering a telecare unit, enabling access to the responders 24/7 – provide powerful assurance for the individual and helps tackle risk aversion around discharge/level of care need from professionals.
- offering a wellbeing service assessment with onward referral as appropriate.
Since the original case study, they have extended support provision from 72 hours to five days, learning from earlier experience of service delivery that this will help more people have access to HART. In addition, they promote admissions avoidance through temporary social care service Friday afternoon-Monday morning to bridge the gap.
Another key aspect of the program is how it dovetails into other services. HART responders spot other issues that might make home discharge dangerous and refer to other services. For example, they might find out about missing home equipment or a lost dog, and they seek to resolve these quickly to prevent readmission.
By working with organisations across Lincolnshire and emerging neighborhood teams, they are supporting a one neighborhood team to develop a step-up/step-down facility which looks after people with a higher level of acuity by providing 24-hour care.
During a recent review of HART the service was noted for filling “a distinctive gap in service provision and has made a materially important contribution to the quality of life of its beneficiaries.” It was found that individuals supported by the service were almost universally positive about it, and that it was becoming increasingly integrated in the wider pattern of healthcare provision in Lincolnshire.
HART is supporting around 120 hospital discharges and 25 admission avoidances per month, and the review suggested that based on the scale and volume of overall hospital discharge delays a case could be made that HART has contributed to supporting almost 25 per cent of all individuals so far in 2018/19. Through quantitative assessment of the 6 months reviewed, 967 individuals were accepted onto the service and £565,100 of savings (£245,100 net) were delivered to the NHS, and in terms of social value it has delivered £8.43 per £1 invested.
A key challenge has been around explaining to partners what the service is, engaging with them and staying on their agendas. However, through a slow, repetitive, continuous process they have kept partners reminded about HART and engaged with the program. In addition, part of solution is managing expectations and being clear about what can be delivered; knowing key contacts who support HART and who can help them to embed and get buy-in from teams.
There are plans to organise a home first planning week to get partners around the table to develop solutions and embed HART in the system. And they hope to develop a service in the future that supports carers in crisis, as well as develop palliative care and a transport model.
The ambition for the service is to develop further work around admissions avoidance to support the health and social care system.