Refreshing the High Impact Change Model

This model was developed in 2015 by strategic system partners, and has been refreshed in 2019 with input from a range of partners including the Local Government Association, the Association of Directors of Adult Social Services, NHS England and Improvement, the Department of Health and Social Care, the Ministry of Housing, Communities and Local Government and Think Local Act Personal Partnership.


It builds on lessons learnt from best practice and promotes a new approach to system resilience, moving away from a focus solely on winter pressures to a year-round approach to support timely hospital discharge resulting in quality outcomes for people.

While acknowledging that there is no simple solution to creating an effective and efficient care and health system, this model signals a commitment to work together to identify what can be done to improve current ways of working.

Throughout implementation of the model, people need to be kept at the centre, with information and advice to support them to make decisions about their care.

The model is endorsed by Government through its inclusion in the Integration and Better Care Fund (BCF) policy guidance.

Change 1: Early discharge planning

In elective care, planning for discharge should begin before admission. In emergency/unscheduled care, robust systems need to be in place to develop plans for management and discharge, and to allow an expected date of discharge to be set within 48 hours.

‘Making it Real’- I/We statement

When I move between services, settings or areas, there is a plan for what happens next and who will do what, and all the practical arrangements are in place before change happens.

We support people to plan for important life changes, so they can have enough time to make informed decisions about their future.

Tips for success

  • Ensure the MDT set a proposed date of discharge prior to admission for elective admissions and within two days of an emergency admission.
  • Ensure the individual and their family and carers are involved and central in discussions about discharge and that this occurs as early as early as possible. Encourage and support them to take responsibility in discharge planning.
  • Draw up a simple but practical discharge plan and ensure practical considerations are accounted for (for example, keys, clothes, heating). Identify potential barriers to discharge and review these on a daily basis (for example, the individual is homeless or their home will be unsuitable to return to meaning they need a move to more suitable short-stay or permanent accommodation, or aids and adaptations to their home).
  • Ensure there is clear ownership of actions and all agencies required for resolution are involved. Staff should have a strong understanding of procedures and escalation processes.
  • Ensure all staff are aware they all have a role in discharge planning.

Early discharge planning maturity levels

Supporting materials

Examples of emerging and developing practice 

Introduction of a ‘transfer of care bag’, helping to improve communication between hospital and care home teams when residents moved between both settings, and raising the profile of older people living with frailty and very complex needs in care homes.

Newcastle Gateshead: Bringing care homes from the periphery

Change 2: Monitoring and responding to system demand and capacity

Develop systems across health and social care to provide real-time information about demand and capacity. All partners should work together to match capacity and demand by responding to emerging system needs, making effective strategic decisions, and planning services around the individual. Data should should also be used to identify and respond to system blockages.

‘Making it Real’- I/We statement

I have care and support that is coordinated and everyone works well together and with me.

We work in partnership with others to make sure that all our services work seamlessly together from the perspective of the person accessing services.

Tips for success

  • Establish a digital platform to provide real-time information about people and capacity across the system. You might develop a bespoke platform for your area or adopt an existing system. You might develop a bespoke platform for your area or adopt an existing system. You might develop a bespoke platform for your area or adopt and existing system.
  • Use data analysis to understand system trends, to lead medium and long-term strategy, and to anticipate service demand.
  • Create plans to manage variance in system demand on a seasonal, weekly and daily basis, and to respond to unanticipated demand. This may not mean increasing capacity, but instead arranging staff rotas etc. to put resources in the best place/time.
  • Identify key system blockages and take action to resolve them. This may involve other high impact changes, such as discharge to assess or seven-day services, depending on your system’s needs.
  • Utilise ‘Red and Green Bed Days’ system help understand flow through the hospital by identifying wasted time in a person’s journey in both acute and community ward settings.
  • Give frontline staff the information they need to understand service capacity and to make the best decisions for individuals.
  • Make plans for sharing relevant information easily and in a timely manner among partners. This will require an understanding of what information is useful to which system partners, and consideration of data governance.

Monitoring and responding to system demand and capacity maturity levels

Supporting material

Examples of emerging and developing practice

Kent: Use of SHREWD: Use of a daily reporting system to view capacity and demand within Home First/ Discharge to Assess pathway.

Central Bedfordshire: Hospital Discharge Service - Person Tracker : To support the working of the co-located discharge teams, a ‘person tracker’ was developed, which has enabled the council to provide a single point of monitoring for its residents’ admission, hospital stay and discharge data.

Southampton: managing delayed discharges digitally: Implemented an electronic system as a more effective way of managing complex discharges, which includes a user dashboard designed to provide “at a glance” status reports.

Change 3: Multi-disciplinary working
Multi-disciplinary teams (MDTs), including the voluntary, community and social enterprise (VCSE) sector, work together to coordinate discharge around the person. Effective discharge and good outcomes for people are achieved through discharge planning based on joint assessment processes and protocols, and shared and agreed responsibilities.

‘Making it Real’- I/We statement

I have care and support that is coordinated and everyone works well together and with me.

We work with people as equal partners and combine our respective knowledge and experience to support joint decision-making.

Tips for success

  • Work out who to involve in your MDT. Independent and VCSE organisations are important, particularly for supporting people who are funding their own care. Members of your MDT could include doctors, nurses, therapists, mental health practitioners, pharmacists, carers, dietitians, social workers, housing representatives (such as housing or homelessness officers or home improvement agency staff), and any other specialists who may bring useful expertise and coordination.
  • Foster a collaborative and integrated working culture in the MDT, for example through joint training and co-location.
  • Ensure social care and representatives of other discharge support services are involved in board rounds.
  • Train your MDT to take a strengths-based, person-centric approach to coordinate care and support around the individual. Use continuous feedback and evaluation to improve the experience for staff and people accessing care.
  • Make sure people have a named point of contact within the team and know who to talk to about planning their discharge.
  • Tackle barriers to smooth and effective MDT working: ensure processes are clear and well-understood, and take measures to reduce funding disputes or confusion about responsibilities.
  • Communicate clearly with staff so they understand who should be referred to the MDT. Overcome potential bottlenecks by not sending simple discharges to the MDT.
  • Ensure the individual is treated as an equal partner in co-planning care.
  • Work towards taking a multi-disciplinary approach more widely across your system, and embed multi-disciplinary working at the heart of your approach to other high impact changes.
    • Durham: Multi-disciplinary discharge teams: Teams Around Patients (TAPs) is a virtual model of integrated care delivery, which uses a multi-disciplinary working platform involving social workers, nursing and allied health professionals.
    • Lincolnshire: Hospital avoidance response team: aservice delivered by members of the Lincolnshire Independent Living Partnership, which takes referrals from secondary care discharge hubs, A&E in-reach teams, the ambulance service, primary care and community health providers, to help either prevent an avoidable A&E attendance or admission, or speed up discharge from secondary care.
    • Luton and Dunstable: Integrated discharge hub co-location of the team which has regular multi-disciplinary sessions to track and discuss complex patients and their length of stay.

Multi-disciplinary working maturity levels

Supporting material

Examples of emerging and developing practice

Change 4: Home first

Home first is as much a system mindset as a service. It means always prioritising and, if at all possible, supporting someone to return home before considering other options, because home is best. Home first requires staff across the health and social care system (including VCSE organisations) to understand that a hospital is not a suitable environment to carry out an assessment of someone’s long term need, and to work together with the individual, family, carer or advocate to discharge people from hospital as soon as they are medically optimised and it is safe to do so.

Discharge to assess (D2A) is a model that can achieve the home first aim. Providing short-term care and reablement in people’s homes or using ‘step-down’ beds which work with therapies or reablement staff to bridge the gap between hospital and home means that people no longer need to wait unnecessarily for assessments in hospital. In turn, this improves how the system flows and the quality of the assessments made. A strong system-wide emphasis on reablement and recovery improves long-term outcomes for people.

‘Making it Real’- I/We statement

I can live the life I want and do the things that are important to me as independently as possible.

We talk with people to find out what matters most to them, their strengths and what they want to achieve and build these into their personalised care and support plans.

Tips for success

  • Establish system-wide principles between partners and develop a single narrative across the system about getting people home as a default option. Concentrate on costs to the system, not provider versus commissioner or health versus social care costs.
  • Simplify pathways for hospital discharge, and ensure discharge pathways are set up so home first is the favoured option.
  • A home first approach and understanding that home is best also involves system-wide work to support people to stay at home: consider how multi-disciplinary teams and community/home care services can be developed to prevent escalation of need and avoid unnecessary hospital admissions or readmissions.
  • Start with domiciliary support (rather than bed-based options) both in terms of service development and choice. The quality of providers needs to be ensured and that they can deliver the care which is needed.
  • Remember there is strong evidence that therapy-led services achieve the best results. Consider merging reablement and rehabilitation services with VCSE sector support.
  • Regularly review and evaluate intermediary care to ensure ‘temporary’ beds are not becoming permanent. Take measures to ensure the focus here is on reablement and recovery, not on getting people out of acute hospital beds.
  • Ensure Continuing Health Care (CHC) and other assessments of long-term need are made after a period of reablement and recovery, during which a person’s support requirements may change.
  • Consider using trusted assessment to provide speedy access for discharge to assess pathways or other discharge support services.
  • To have a good home first support service you need it to be fully integrated i.e. NHS, the local authority and VCSE and independent sector as well as having support structures of families, carers or advocates.
  • Make sure these services will work for everyone: consider a single point of access, including for people who fund their own care, people who need only low-level support such as that provided by the voluntary sector, people who appear to meet the Care Act eligibility threshold and people who don’t, and people with ongoing care needs
  • Track people to see where they are six months after discharge to monitor progress and impact of home first initiatives. You should expect to see a reduction in support for those with ongoing support needs. Monitor services as to their quality and effectiveness in terms of reab lement and do not use services that will not provde that information or whose results are poor.
  • Consider joint commissioning and strong market management interventions where they are needed. i.e. it is not helpful to have an excellent intermediate service if there is a lack of capacity to provide ongoing support.
  • Work with consultants and therapists to build confidence and overcome risk aversion to discharge, using positive stories to achieve a hearts-and-minds culture change.

Home first maturity levels

Supporting materials

Examples of emerging and developing practice

North Staffordshire: Track and triage - replacing the assessment functions on the acute site, it tracks patients from entry-to-end of D2A, with a ‘pull’ function once the patient is judged medically fit for discharge.

Bath: Home first/D2A - a step down service (which uses apartments), and can be commissioned by any hospital clinician or health care professional involved in the discharge process. 

Tower Hamlets: Admission avoidance and discharge service - consists of rapid response in the community; an admission avoidance team; in-reach nurses and admission avoidance and discharge service (AADS) screeners; and an intermediate care team using a D2A model and offering up to six weeks intensive rehabilitation in the community.

Medway: Home First - an approach and ethos which has sought to achieve Medway Health and Social Care Partners’ pledge to: minimise patients’ acute hospital length of stay; maximise independence through enablement; support care at home or closer to home; and make no decision about long term care in an acute setting. 

 

Change 5: Flexible working patterns

Where it will help to deliver the “right care, right time, right place”, consider how seven-day working, weekend working and extended hours for services across health and social care can be utilised. This will help to deliver care throughout the week, reduce delays moving through the system and improve individuals’ experiences.

‘Making it Real’- I/We statement

I can choose who supports me, and how, when and where my care and support is provided.

We make sure that people can rely on and build relationships with the people who work with them and get consistent support at times that make sense for them.

Tips for success

  • Consider your system’s demand, capacity and bottlenecks (see change 2) and identify where extended hours or weekend working could have the biggest impact. Local systems tell us that seven-day working does not need to be in place across the whole system for benefits to be seen. Be prepared to start somewhere even if corresponding services are not in place.
  • Take a pragmatic approach to responding to your system’s need: this does not need to be 24/7 working across all services; instead it is about placing staff well to ensure consistent flow throughout the week. Practical alternatives to seven-day services may work better for parts of your system, for example having a bigger volume of staff on Mondays to handle a weekend backlog.
  • Think broadly about your whole system: identify where seven-day working could be helpful across health and social care, including pharmacy, transport and housing services. Talk to all partners, including care providers and work out cost implications.
  • Developing trusted assessment (change 6) can help to enable individuals to be assessed throughout the week or weekend.
  • Engage with practitioners to understand how increased seven-day working would affect them personally and what you can do to help. Don’t assume staff won’t work weekends – talk to them about how it could work.
  • This change is undoubtedly challenging, so work gradually and draw on shared best practice and resources.

Flexible working patterns maturity levels

Supporting material

Examples of emerging and developing practice

Hertfordshire: Seven-day working - Seven-day working strategy with the aim of improving the flow from acute to community settings, ensuring discharges were not delayed over the weekend while people waited for a package of care due to processes outside of the Monday to Friday norm.

Hackney: A continuous cycle of improvement in patient flow - development of weekend working in strategically important service areas to help improve patient need and capacity. START HERE

Milton Keynes: Getting people home -  Seven-day working through home first reablement supporting discharges every day of the week as part of wider strategy to “get people home”.

Change 6: Trusted assessment

Using trusted assessment to carry out a holistic strengths-based assessment of need avoids duplication and speeds up response times so that people can be discharged in a safe and timely way.

‘Making it Real’- I/We statement

I am supported by people who listen carefully so they know what matters to me and how to support me to live the life I want.

We know how to have conversations with people that explore what matters most to them – how they can achieve their goals, where and how they live, how they can manage their health, keep safe and be part of the local community.

Tips for success

  • Start by agreeing what the problem you are trying to solve is
  • Remember a trusted assessment can be either
    • An assessment completed earlier in the persons pathway being used, with agreement for a second purpose and thus avoiding a delay
    • An assessment carried out by a third party on behalf of another organisation
  • Think about using trusted assessment at any time where there is a delay in the pathway caused by an assessor not being able to do their assessment when needed – this includes access to home care.
  • Remember trusted assessment can be used in a variety of settings e.g. 
    • to agree restarts and ensure the person gets home more quickly
    • to support hospital discharge to a residential or a community service, both permanent and interim in place of the provider carrying out their own assessment
    • to move between services
    • to make a local authority eligibility determination
  • Consider how trusted assessment interlinks with home first and discharge to assess pathways – think holistically about your approach to the changes.
  • Without trust between partners, trusted assessment will not work. Think about how to achieve and build trust to avoid poor outcomes for people. Trusted assessments can only be used with the agreement of all parties, so a co-design approach is essential. This involves engagement with care providers too. 
  • People should be informed that it is not necessary to make decisions about a permanent move when they are in hospital.

Trusted assessment maturity levels

Supporting material

Examples of emerging and developing practice

Newcastle Gateshead: Trusted assessment

North Yorkshire: Trusted assessment - implementation of integrated discharge pathways and to use trusted assessment to facilitate discharge to assess.

Lincolnshire: Care home trusted assessor - creation of a trusted assessor role to improve the trust between acute sector assessment team and care home managers.

Blackburn and Darwen: Home first with trusted assessment - focus on people waiting for packages of care. Led by a home first approach in which ward staff undertake a partial assessment before the person is discharged to their home, with wraparound care offered until a full assessment is completed.

 

Change 7: Engagement and choice
Early engagement with people and their families and carers is vital so they are empowered to make informed decisions about their future care and take ownership of their choice. The voluntary sector, carers and advocates can be a real help with this. A robust choice protocol, underpinned by a fair and transparent escalation process, is essential so that when people have capacity they can understand and consider their options.

‘Making it Real’- I/We statement

I can get information and advice that helps me think about and plan my life.

We provide information to make sure people know how to navigate the local health, care and housing system, including how to get more information or advice if needed.

Tips for success

  • Talk to people (including family and friends) on or, where possible before, admission about their likely discharge route (see Change 1).
  • Provide information in community settings and on wards about discharge routes
  • Be creative to deliver the message in the best way for people e.g. use videos in waiting rooms, or leaflets in mailings. Take a co-design approach and involve patient groups and other organisations in developing the message.
  • Get the whole team involved, it’s everyone’s business.
  • Don’t be afraid to be clear – waiting in hospital is not an option.
  • Utilize key messages and communications support issued as part of initiatives to reduce length of stay in hospital – these should focus on information around harm and deconditioning as the key drivers to people, their families and carers to seek earlier discharge.
  • Work with colleagues across the health and social care system to manage people’s expectations of the care they will require after discharge, and to avoid unrealistic claims about the support people will receive. Managing expectations requires giving people the right information and advice throughout so they are fully informed.
  • Remember long term decisions should rarely be made in acute hospital. D2A and other intermediate care are not subject to a choice protocol but should be seen as the next stage in the treatment programme.
  • Remember The Care Act 2014 guidance on choice of accommodation is that while any choice should be real they should also be within the personal budget and practicable.
  • Do involve the VCSE sector to support discharge.
  • People who fund their own support are often forgotten, it is important to engage with everyone to provide appropriate information and support so that everyone can make informed decisions.
  • Do carry out a demand, capacity and quality audit of your independent care market, as a system.
  • Try to avoid the need for choice letters, but when necessary don't be afriad to issue them, as they are in the person's best interest.
  • Ensure the choice protocol is part of team induction training.

Engagement and choice maturity levels

Supporting materials

NHS quick guide, describing the choice protocol and providing sample template policy and template patient letters

The Care Act: see 30, cases where adult expresses preference for particular accommodation, and Annex A of 2014 Statutory Guidance

Care Navigation: A Competency Framework

Change 8: Improved discharge to care homes

The NHS Enhanced Health in Care Homes framework supports ways to join up and coordinate health and care services to support care home residents. In considering how to achieve timely and safe transfers of care, the initiatives in this high impact change focus on how to improve outcomes for care home residents by reducing unnecessary admissions to hospital and facilitating smoother hospital discharge into care homes.

‘Making it Real’- I/We statement

I have a place I can call home, not just a ‘bed’ or somewhere that provides me with care.

We have a ‘can do’ approach which focuses on what matters to people and we think and act creatively to make things happen for them.

Tips for success

  • A person should not be making long-term decisions about their care from a hospital setting. See Change 4, for further support and guidance on how people can be supported to move to a suitable environment from where they can make decisions.
  • Join your local care forum and hear what care providers find unhelpful when admitting people from hospital.
  • Refer to best practice in discharge planning as can be found in other high impact care changes. particularly change 1 and the supporting material. Involve care homes in the discharge planning process, and provide the information they need in good time.
  • Find out the top reason causing care homes to delay or refuse to take a discharge and fix it  such as ensuring all medication sent home with people comes with clear guidance.
  • Ensure each care home is linked to a consistent, named GP and wider primary care service.
  • Provide access to out-of-hours/urgent care to prevent unnecessary hospital admissions and to support care home staff. Areas have taken an innovative approach to this – for instance Airedale’s telehealth hub connects local care homes directly with the MDT.
  • Develop channels for sharing information with care homes – NHSmail accounts for care homes can make it simpler to share personal details.
  • Involve your ambulance service in planning. It will have valuable information on care homes in need of support, and can help develop solutions.
  • Include care homes in system conversations. Talk and listen to them to understand the pressures they face and their support needs; work together to develop the market and workforce.
  • Link work on Enhancing Health in Care Homes with other high impact changes: a MDT approach helps to coordinate care; early discharge planning should involve care homes (including using the red bag scheme); and information sharing is crucial.
  • Consider how your system can provide enhanced services to better support vulnerable people in community settings, such as through rapid response.
  • Build upon the existing learning and training opportunities to ensure that staff who are employed by social care providers receive a wide range of training and development opportunities.
  • See the NHS guidance on Enhanced Health in Care Homes for additional components of this work which can support your system. Evidence shows certain relatively small investments can yield significant results both for people and the system.

Improved discharge to care homes maturity levels

Supporting material

Examples of emerging and developing practice

Wirral: Care home teletriage service: care homes have been provided with HD iPads and secure nhs.net email addresses to access a triage service, and staff have been trained to take basic observations and equipped with blood pressure monitors, thermometers, urine dip sticks and pulse oximeters.

Surrey: East Surrey care home multi-disciplinary project - the aim of the project was to enhance the level of care to all residents of care homes by increasing GP time to support care homes; care coordinated approach; and improved medicine management support and training.

Change 9: Housing and related services

Effective referral processes and good services which maximise independence are in place to support people who have no home, or cannot go straight home. The need for safe and accessible housing, housing and related support services, home adaptations and equipment are recognised early in discharge planning and readily available when needed.

‘Making it Real’- I/We statement

I live in a home which is accessible and designed so that I can be as independent as possible.

We have conversations with people to discover what they want from life and the care, support and housing that will enable this, without restricting solutions to formal services and conventional treatments.

Tips for success

  • As part of early discharge planning, talk to the person and their family or carers about their current housing/home situation to understand if a person's home is going to be safe and suitable for them to return to if there may be any issues that could affect discharge.
    • Take action as early as possible – a person’s housing status and suitability should be known as soon as possible after admission. For example, do they own their own home, rent from a local authority, housing association or private landlord, or are they homeless or in insecure accommodation?
    • Are there specific issues with their home which may affect its suitability, for example, is it accessible to the person given any changed mobility or health needs; or is there a problem with heating or damp?
    • Don’t wait until the individual is medically optimised to refer. Talk to any relatives, particularly if the person does not have a normal place of residence, as this may mean they don’t have somewhere they can be discharged to.
  • Include housing/housing service provider(s) as real or virtual member of your discharge planning team.
  • Take a holistic, person-centred approach to understand what matters to the people in your care, taking a positive attitude to risk and how you can best help them to be as independent as possible in their home.
  • Consider how your VCSE sectors can help people to get home and access community support.
  • Ensure staff know what housing options and support services are available and understand how to make referrals to them. There should be well-developed links between the discharge planning team and these services. Consider creating a single-point of contact to help guide staff through the various housing options available. Staff should understand their statutory duties with regard to housing, as well as how to access specialist housing (such as extra care or supported housing). For example, there is a new statutory duty to refer people who are homeless or at risk of homelessness to the housing authority.
  • Educate staff about the housing support needs of different groups. These go beyond aids or adaptations for older people, and include, for example, support for people who are homeless or who may have mental ill-health, substance misuse needs, a learning disability or dementia.
  • Minor repairs and small home adaptations can make a real difference to the speed and ease of discharge when they are readily available, and delivered quickly. Identify needs as early as possible, not just what will help people get home without delay, but what will aid independence and help avoid hospital readmission or future health or care needs.
  • Housing-based short-term accommodation such as step-down or intermediate care can be appropriate for people who are medically optimised but waiting for a new home or adaptations. This is not a substitute, however, for late assessment of need or a lack of capacity for a more appropriate service.
  • Understand the demand for, and capacity of housing and related support services across your system, and ensure this analysis informs commissioning intentions. Work with partners to identify and prioritise addressing the most challenging areas for your system. Approaches to this change will vary greatly in different systems, and may involve developing better processes, improving services or investing in extra capacity whether to meet any planned care needs or help facilitate self-care.
  • Be creative in considering how technology and innovation can improve the way you support people to live at home; for instance telecare and assistive technologies can be very useful. Everyone involved in the discharge should know what is on offer and how to access it locally.
  • Homelessness should not be a reason for delaying discharge –
    • NHS trusts have a statutory duty under the Homelessness Reduction Act (2017) to refer people who are homeless or at risk of homelessness to a local housing authority.
    • Referrals should be made at the earliest opportunity as soon as it has been identified that a person may be homeless on discharge as this provides more time for the housing authority and other support services to respond. The person must give consent, and can choose which authority to be referred to.
    • Persons who have no recourse to public funds are not eligible for homelessness assistance, but are entitled to receive housing advice. It is not the responsibility of NHS trust staff to assess whether a person is eligible for such support - this is determined by the housing authority.
    • The local housing authority should incorporate the duty to refer into their homelessness strategy and establish effective partnerships and working arrangements with agencies to facilitate appropriate referrals.

Housing and related services maturity matrix

Supporting materials

Examples of emerging and developing practice

West of England - Reducing DTOC through housing interventions

Leicester: Lightbulb: the scheme involves housing enabler posts, their role involves aiming to assess patients as early as possible, and offer patients options to resolve housing issues.

Cambridgeshire: Technology Enabled Discharge (TED) : to help people overcome the complications of referral and installation, Cambridgeshire Technology Enabled Care offers a custom telecare discharge package, which includes installation and rental of the lifeline, alongside other pieces of appropriate equipment such as smoke alarms, temperature sensors and fall detectors.

Kirklees Council: Home from Home initiative -  the service provides seven accessible flats as temporary accommodation for people awaiting adaptations in their own home or changes in accommodation.