Supporting people at home
What are our overall aims by 2028?
An improved and more responsive coordination and delivery of health and care within an individual’s own home when urgent and emergency care is required – this will help prevent people making unnecessary visits to hospitals.
Where ongoing support, health or care or both, is required, people are enabled to continue to live independently – this is reliable, sustainable and responsive to change as people’s requirements change.
Where people need to visit hospital for treatment, this is undertaken in a patient-centred and effective manner, with the focus on people returning home as soon as possible.
Where people have had a change in their health as a result of deterioration or a specific episode in their life, they are supported to recover and re-able to maximise their individual health and wellbeing outcomes.
What’s our starting point?
Enabling and supporting people to maintain their independence at home is at the heart of our approach. The work that we are doing through our Improving Lives Programme in Coventry and our Hospital Discharge Community Recovery Programme in Warwickshire is underpinned by this principle and an opportunity to transform our local offer.
Relationships are robust across health and care partners with commitment to working together and sharing learning to improve population health and individual outcomes. We have a number of joint strategies and delivery plans that will be a focus for us to improve our support offer for people, including, but not limited to, people with dementia, autism and informal carers. We also work collaboratively with wider partners, including housing and the independent, voluntary and community sectors, to support our at home offer.
Working together to consider new ways of working, including how to maximise the use of remote and digital technology to meet people’s health and care needs, is another key areas of focus. Alongside collaborating to support market shaping and development to ensure that we have a sustainable care market able to meet the needs of our residents.
What are some of the key links to other parts of the plan?
Collaboration and Integration – expanding care delivered outside of hospital so that people can access the care that they need closer to home without the need for hospital admission will be critical in supporting the delivery of the overall aims above.
Improving Access to Services - Urgent and Emergency Care and Primary Care – so too will planned collaborative work in each of our Places to develop integrated urgent care pathways in the community and planned activity to improve access to primary care services.
Digital, Data and Technology – equipping our population with digital tools to help people to stay well, get well and manage their own health and wellbeing, is one of the key priorities within our local Digital Transformation Strategy.
System Transformation – our two geographic Care Collaboratives will drive integration across services, with urgent care and out of hospital services being two of their initial areas of focus.
What will we be focusing on in the next 2 years?
In Coventry, delivering the Improving Lives Programme, which is bringing partners together to implement an integrated model that focuses on delivering more effective care and improving outcomes for people who require hospital or alternative care. Three sub-programmes have been established, with oversight of delivery of the overarching Programme Plan sitting with the Improving Lives Programme Board.
Key planned activities within the Improving Lives Programme include:
- Providing effective intervention points in the community to direct patients who would otherwise attend hospital to alternative community services to meet their needs.
- Developing a Coventry level view of patient flow and performance that will allow partners to understand how effectively the system is functioning, versus how individual organisations are functioning.
Hospital Processes at UHCW
- Developing a ‘front door process’ that can accurately determine the needs of individual patients and direct them to the most appropriate service.
- Reducing the overall length of stay for adult patients, including focused work around discharge processes.
One Coventry Integrated Team
- Creating a single Coventry Integrated Team of professionals able to effectively and efficiently provide care to people in Coventry, providing an alternative to being admitted to UHCW or supporting patients after a period of care in UHCW.
- Tracking benefits delivered through the Improving Lives Programme across five key areas via a dedicated benefits realisation dashboard.
In Warwickshire, delivering the Hospital Discharge Community Recovery Programme, which is bringing partners together to develop innovative solutions to provide care and support for people after a stay in hospital. Oversight of delivery of the Programme Plan is through a multi-agency Programme Board reporting to the Warwickshire Care Collaborative.
Key planned activities within the Hospital Discharge Community Recovery Programme include:
- Piloting a new Community Recovery Service for Warwickshire residents to include streamlined referral processes, new commissioning arrangements for domiciliary care to start within 24 hours and increased capacity for therapy at home;
- Monitoring the impact of the Community Recovery Service, including the financial impact, and developing proposals for the future model of care and support;
- Progressing lead commissioning arrangements for Discharge to Assess across Warwickshire.
Through joint working between the ICB and the two geographic Care Collaboratives, reviewing and re-designing commissioning arrangements for NHS Continuing Healthcare (‘CHC’) services to support a transition to more integrated delivery at Place – key planned activities as follows:
- Establishing a dedicated CHC Transformation Programme;
- Evaluating options for future commissioning and delivery, and agreeing a preferred model for each Care Collaborative;
- Developing a Transition Plan for each Care Collaborative detailing the steps required and agreed timelines to achieve the agreed future configuration, and then implementing the Transition Plans;
- Establishing a market management workstream and aligned action plan for care homes, supported living, hospices, and domiciliary care;
- Establish quality, finance and performance reporting streams.
In Coventry and Warwickshire, further developing and implementing our Market Sustainability Plans with a focus on strengthening care at home capacity and quality.
In Coventry and Warwickshire, finalising and implementing co-produced Carer Action Plans including activities to increase and improve the quality of statutory Carer’s Assessments, review and enhance carer breaks and develop the universal and digital offer for carers to facilitate self-support.
Working jointly across Coventry and Warwickshire on initiatives to support working carers, support the wellbeing and psychological needs of carers and ensure the provision of appropriate support for Young Carers.
The sustainability of the social care market is a significant challenge impacting both key Programmes. For example, significant recruitment and retention challenges within the care market have been further exacerbated by cost of living pressures, with Providers exiting the market due to financial sustainability or quality issues.
Both Coventry and Warwickshire Local Authorities have developed Market Sustainability Plans to describe the actions being taken to improve sustainability but the challenge remains significant.
In addition to sustainability other challenges that will impact on this strategic objective include:
- The short term nature of funding to support the development of new hospital discharge arrangements;
- Long term transformation and improvement being impacted by a focus on short term actions and responses to crisis and challenges;
National pre-occupation with bedded care impacting on the need to move attention and resource to prevention and ‘Home First’ approaches;
Investing in the changes required across the workforce to deliver enabling and outcome based support rather than units of beds or hours of care.
Key Metrics and Deliverables
Number of clients accessing long term care and support per 100,000 population.
Key metrics in development through Improving Lives Programme and Hospital Discharge Community Recovery Programme.