Managing transfers of care – A High Impact Change Model

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, achieving the right outcomes for people is key, enabling them, with the right information and advice to make the best decisions about their ongoing care. The model is endorsed by Government through its inclusion in the Integration and Better Care Fund (BCF) policy guidance.

The refreshed model for Managing transfers of care

The 2019 review broadly endorsed the High Impact Change Model (HICM) as a positive tool to support the continued reduction of delays in transferring people home from hospital. Respondents asked for more clarity, a strengthening of focus on the person, and greater emphasis on the key Home First and discharge to assess policies. The resulting refresh therefore consists of a number of additional components including:

1. I and We statements: these expand on the impact of the changes from the perspective of the person or worker supporting them; these were chosen from Think Local Act Personal’s Making it Real framework, and their usage is supported by the National Coproduction Advisory Group.
2. Tips for success: in addition to the outcomes in the maturity matrix and are often key principles.
3. The maturity levels are more focused on outcomes for both the system and people: these will not all match every system, but are intended to reflect what the changes should feel like.
4. Expanded links to supporting materials, including up-to-date case studies and fuller papers on certain changes.
5. Advice on measuring and monitoring success.

2019 review of the Managing transfers of care - a 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 asking for reflections on the model, completed by 44 respondents.
• Performance and reporting data, such as on implementation of the tool from 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.  

Purpose

The Managing transfers of care 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; 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 effective discharge.

Respondents to the review also asked for the model to extend to cover admissions avoidance and other preventative actions. This is being developed by national partners as 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. 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 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 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 practice emerging from the COVID experience
• The changes apply to all discharges although systems may want to focus on specific groups, such as around health inequalities or risk groups needing targeted support post-COVID infection.
• The changes are inter-linked and interdependent, are also solutions to problems, and may not be 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 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 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 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. For more information, visit How to do personalised care and support

How to use the Managing transfers of care 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 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.

Emerging and Developing Practice

This refresh has incorporated the Emerging and Developing Practice resource, providing examples of work being undertaken across the country for each of the nine system changes. These reference a range of initiatives where there is already evidence of impact, and point to examples of emerging practice that are starting to make a difference. The examples are 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. The LGA/ADASS summary of Care Home Support Plans describes recent COVID good practice examples.

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 change is working. The Measuring and Monitoring Success 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 change or the overall model. For more information, speak to your Better Care Manager or LGA Care and Health Improvement Adviser, or visit the Better Care section of our website.

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

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