Managing transfers of care – A High Impact Change Model

This model has been refreshed, building on further lessons learnt, operational experience and good practice in systems. This resulting refresh therefore consists of a number of additional components including:

• The addition of an enabler section to the model to help local systems implement changes more effectively. The enablers consist of: 1. Culture and leadership; 2. Digital and data; 3. Workforce and 4. Strategic commissioning. 
• Review and additions of the high impact changes, in particular. splitting the home first and discharge to assess into two separate changes and more significant iterations and additions to early discharge planning, proactive demand and capacity planning, care transfer hubs and multi-disciplinary working (MDTs) to coordinate discharge, and trusted assessment. 
• Additional tools to support in the implementation of changes, including making changes happen and stages of design.
• An update to the action planning template to include a section focusing on the practicalities of change, such as risks, stakeholder management, and governance.

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 improve flow throughout the year.

The original model identified eight changes which will have a significant impact on effective transfers of care. There are now 10 change areas: 

• early discharge planning
• monitoring and responding to system demand and capacity
• multi-disciplinary working and care transfer hubs
• home first
• discharge to assess and effective intermediate care
• flexible working patterns
• trusted assessment
• engagement and choice
• improved discharge to care homes
• housing and related services.

And four enablers:

• culture and leadership
• digital and data
• workforce
• strategic commissioning

There is a separate good practice tool covering admissions avoidance and other preventative actions. This new tool will seek to identify identifies 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.

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. It reinforces the values set out in The Ethical Framework for Adult Social Care, written in response to COVID-19. 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 an approach which expects people to return home as the preferred option, rather than end up by default in bed-based care. Discharge to Assess (D2A) enables this approach through a single point of access building on the successful joint working developed during and since the COVID period.
• A hospital is not the right environment for people to make long-term decisions about their ongoing care and support needs. Home First and Discharge to Assess (D2A) enable assessments to be completed at home with families, carers or advocates, after reablement or rehabilitation if required
• It is important for the system to follow best practice in safeguarding, giving due consideration to deprivation of liberty, Mental Capacity Act (2005), and any other concerns that have been identified.
• An asset or strength-based approach to assessment and planning, as set out in the Care Act as part of a personalised health and social care approach, is essential.
• The whole-system response needs to support a hospital ‘place-based approach’, enabling local systems to develop creative solutions which meet local demand and capacity.
• Systems are encouraged to share and learn from emerging practice.
• The changes apply to all discharges although systems may want to focus on specific groups, such as around health inequalities or risk groups.
• Set out to improve outcomes for people, not tick a performance tool. Be mindful on how to prioritise change areas, as not all changes will be a priority in your area and changes are interdependent.
• For the changes to be effective and sustainable, it is important to consider the systems’ enablers for change. There are four we focus in this model: culture and leadership, digital & data, workforce and strategic commissioning.

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 Coproduction 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. 

These principles support a Home First and D2A approach which measures success by achieving the best outcome for people after treatment in hospital, avoiding their readmission and maximising independence through timely provision of reablement where needed with due consideration being given to any safeguarding concerns, for a safe and timely discharge.

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 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

Through engagement with TLAP’s National Co-Production Advisory Group and the Making It Real framework, the 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. For more information, visit How to do personalised care and support

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 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, 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 it is performing well in any area but not always delivering as the matrix suggests. Given the flexibility of the model this is entirely possible. Systems can go back to the problem the change is designed to address and show how they have achieved success.

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:

• The Department of Health and Social Care and the Department of Levelling Up, Housing and Communities' guidance on Discharging people at risk of or experiencing homelessness
• 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
• Intermediate care framework for rehabilitation, reablement and recovery following hospital discharge (NHS)
• A community rehabilitation and reablement model (NHS)
• Reducing preventable admissions to hospital and long-term care – A High Impact Change Model
• Home first: Discharge to Assess and homelessness

• 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.