As the model has been in use for several years, it was felt a refresh of its effectiveness was appropriate.
- The refreshed model
The review broadly endorsed the model as a positive tool to support the continued reduction of delayed transfers of care. There were, however, a number of requests for more clarity, a strengthening of focus on the person, and the key Home First policy. The resulting refresh therefore includes a number of additional components including:
- I and We statements: expand on the impact of the changes from the perspective of the person or staff member; these were chosen from the Making it Real framework, and supported by Think Local Act Personal’s (TLAP’s) National Coproduction Advisory Group
- Tips for success: these are in addition to the outcomes in the performance matrix and ore often key principles
- More outcome-focused maturity levels: these will not all match every system, but are intended to reflect what the changes should feel like
- Expanded links to case studies and other supporting materials, including up to date case studies and fuller papers on certain changes
- Advice on measuring and monitoring success: a separate document provides suggestions on how to monitor progress, based on the principle of continuous improvement and using live data proactively and responsively, rather than conducting time intensive analysis and evaluation projects.
- Review of the High Impact Change Model
As the model has been in use for several years, it was felt a refresh of its effectiveness was appropriate. This included a review of a wide range of materials, as well as consultation events to invite views from those using the tool. The evidence gathered included:
feedback from nine consultation events in each local government region, gathering reflections of over 550 colleagues from across health and local government online questionnaire inviting reflection on the model, completed by 44 respondents performance and reporting data, such as reflections on the tool from the BCF quarterly reports work of partner organisations and various regional projects underway to develop HICM support and collate good practice at a more local level new sector research, quick guides and guidance (links to some of these materials are at the end of the introduction).
- What is the High Impact Change Model?
This HICM aims to focus support on helping local system partners to improve health and wellbeing, minimise unnecessary hospital stays and encourage them to consider new interventions.
It offers a practical approach to supporting local health and care systems to manage the individual’s journey and discharge. It can be used to self-assess how local care and health systems are working now, and to reflect on, and plan for, action they can take to reduce delays throughout the year.
The original model identified eight changes which will have the greatest impact on reducing delayed discharge; we have added an additional change in the refresh; these are:
- early discharge planning
- monitoring and responding to system demand and capacity
- multi-disciplinary working
- home first
- flexible working patterns
- trusted assessment
- engagement and choice
- improved discharge to care homes
- housing and related services (the new change)
The new change was created in response to feedback about the importance of home-based support in facilitating discharge, and includes the use of effective housing, home adaptations and assistive technology services. The change is focused on what is needed in terms of the ‘living environment’ in order to enable a safe and effectibe discharge. Respondents to the review also asked for the model to extend to cover admissions avoidance and other preventative actions. National partners concluded this area of focus was too important and expansive to include as one change in this refresh and instead are now developing a separate good practice tool. This new tool will seek to identify actions which delay, divert or prevent the need for acute hospital and statutory care, and instead increase focus on maximising people’s independence and helping to keep them well in their usual place of residence.
- Principles behind the model
This model is not designed to be a performance management tool. Instead, it takes as its starting point a recognition that even the best-performing systems can experience challenges in relation to hospital discharge. Its inclusion as a national condition in the BCF is intended to support implementation of good practice, rather than to performance manage local systems.
The model is underpinned by a sector-led improvement approach which emphasises the importance of triangulating both hard and soft types of data and insight to tease out local stories within a culture of openness and trust. This model supports genuine, honest reflection and discussion between trusted colleagues within local health and care systems and includes a suggested action plan so that decisions arising from conversations using the model can be implemented.
There are a number of overarching principles that underpin the model:
Home First is a mindset that everyone involved in a system needs to understand and implement.
- A hospital is a very poor place in which to make long-term decisions about somebody’s care
- An asset or strength-based approach, as espoused in The Care Act as part of a personalised approach, is essential.
- A whole-system response is necessary, and changes need to start to be implemented as early as possible.
- Systems should be supported to share good practice and challenges.
- The changes apply to all delayed discharges, although systems may want to focus on specific populations, particularly around their duties in reducing health inequalities.
- The changes are inter-linked and interdependent, they are also solutions to problems and, not necessarily needed in their own right. So, set out to improve outcomes for people not tick a performance tool.
Although there is no specific reference to overarching enablers of the good practice highlighted in the tool, these – including workforce, communication, culture, governance among others – are crucial and should be considered in any local conversation.
- ‘Making it Real’ Framework
Providing personalised care and support is central to improving better outcomes for people transferring from hospital to an appropriate setting. Consequently in this updated HICM there is a greater prominence to this, linking the High-Impact changes to a person-centred approach. This model borrows from Think Local Act Personal’s ‘Making it Real’ framework, which is a set of “I and We” statements that describes what good care and support looks like from a person’s perspective and encourages organisations to work together to achieve good outcomes for people. TLAP’s National Co-Production Advisory Group, made up of people with lived experience of accessing care and health, including family carers, were engaged to help decide how best to incorporate a more person-centred approach through inclusion of the Making it Real framework.
The framework is based on the following principles and values of personalisation and community-based support:
- People are citizens first and foremost.
- A sense of belonging, positive relationships and contributing to community life are important to people’s health and wellbeing.
- Conversations with people are based on what matters most to them. Support is built up around people’s strengths, their own networks of support, and resources (assets) that can be mobilised from the local community.
- People are at the centre. Support is available to enable people to have as much choice and control over their care and support as they wish.
- Co-production is key. People are involved as equal partners in designing their own care and support.
- People are treated equally and fairly and the diversity of individuals and their communities should be recognised and viewed as a strength.
- Feedback from people on their experience and outcomes is routinely sought and used to bring about improvement.
Through engagement with TLAP’s National Co-Production Advisory Group and the ‘Making It Real’ framework, the refreshed HICM ensures that the tool reflects the voices of people and enables a focus on what matters to people when transferring in, out and through hospital. To find out more, read Making it real: how to do personalised care and support.
- How to use the HICM
The self-assessment matrix forms part of the model, and the intention is for the matrix levels to describe the journey to what good looks like. This should enable a system to see where they might benchmark their current performance and thus inform their development plans. The wording of the matrix has been purposely chosen to provide systems with the flexibility to make a judgement call on where they would self-assess to be against a particular level. For example, instead of specifying exact timings or figures, the matrix uses words like ‘many’, ‘often’, and ‘early’. While it is important to make an accurate assessment of your system, it is also important to ensure there is consensus across partners.
This tool is about supporting improvement, so once a level is agreed upon, the crucial point is that partners come together to create an improvement plan. The outcomes in the matrix are not set in stone. As a result, a system may feel they are performing well in any particular area but not always delivering as the matrix suggests. Given the flexibility of the model this is entirely possible. Systems should be able to go back to the problem the change is designed to address and show how they have achieved the change in their part of the world.
- Emerging and developing practice
The Emerging and Developing Practice resource supplements the HICM by bringing together examples of work being undertaken across the country for each of the nine system changes. It references a range of initiatives where there is already evidence of impact, and points to examples of emerging practice that are starting to make a difference. This resource is designed to be used alongside the HICM to provide a sense of what ‘good’ looks like when self-assessing, but also provide inspiration to support the development of joint improvement plans.
- Measuring and monitoring success
As part of the refreshed model, one of the key challenges identified by many systems was how hard it could be to monitor and measure progress against each change. While systems implement the changes and make improvements to patient flow, it can be hard to show the impact or to maximise how well a particular change is working. The Measuring and Monitoring Success [link] document is designed to take learning from what systems are already doing and offer suggestions on how to best measure and monitor success, with a focus on continuous improvement.
In addition, there are a number of support options available to systems if they require further help in implementing a particular change. For more information, speak to your Better Care Manager or LGA Care and Health Improvement Adviser.
- Supporting materials
Throughout the tool, there are links to further information, case studies and guidance. There are a range of materials which apply across more than one change.
- NHS good practice guides: focus on improving patient flow; reducing long length of stay
- Why not home? Why not today? — (Newton, 2017)
- People first, manage what matters — (Newton, 2019)
- Reducing delays in hospital transfers of care for older people — (Institute of Public Care)
- London’s mental health discharge top tips — (ADASS, 2017)
- Factsheet: hospital discharge — (Age UK, 2019)
- NICE guideline – NG 27
- NHSE/I hospital to home activities
- Rapid improvement guide to: red and green bed days — (NHS)
- NHS benchmarking report – (NHS)
- Transforming out of hospital care for people who are homeless - support tool complementing the High Impact Change Model
- Self-assessment matrix levels
- Not yet established: Processes are typically undocumented and driven in an ad hoc reactive manner
- Plans in place: Developed a strategy and starting to implement, however processes are inconsistent
- Established: Defined and standard processes in place, repeatedly used, subject to improvement over time
- Mature: Processes have been tested across variable conditions over a period of time, evidence of impact beginning to show
- Exemplary: Fully embedded within the system and outcomes for people reflect this, continual improvement driven by incremental and innovative changes
Refreshing the High Impact Change Model
This model aims to focus support on helping local system partners to improve health and wellbeing, minimise unnecessary hospital stays and encourage them to consider new interventions.
Integration and the Better Care Fund
Health and care systems across the country are joining up services to improve the health, wellbeing and experiences of individuals, through both national and local transformation programmes.
Working with hospitals
Working better with hospitals is essential in developing good integrated health and care services, be that to reduce demand for acute services, as well as to ensure people are discharged home in a safe and timely way.