Practice examples: Hospital discharge and admissions

• Prevention, admission avoidance and community
  Somerset Open

  Prior to COVID-19, Somerset had already built a strong ‘Home First’ discharge model and had spent four years developing ‘Community Connect’, which solves problems closer to home by working with and supporting communities. This model – with its mix of VCSE and micro-provider provision – became crucial to the response away from the hospital settings.

  Whilst all the national guidance focused on discharge from hospital arrangements, Somerset took the opportunity to take its already established intermediate care system to the next level. Avoiding admission and preventing illness became the top priority as an effective way of avoiding the debates around testing; rapid discharge into a setting not always of your choice and the risks of acute hospital and care home infections, as well as de-conditioning risks.

  So, whilst many scrambled to set up D2A models, Somerset looked to expand its own D2A model to support admission avoidance and link it more closely to the community model. The key was to mix the key health and care responses with the community one, ensuring that the right range of tools were available. In intermediate care, this meant that all admission avoidance and end of life cases could access all the options available for discharge:

  • rapid response
  • D2A (home with therapy support and reablement beds)
  • Community Connect/voluntary sector.

  Of course, the preference was to avoid the crisis in the first place, and this is where the previous years of hard work in the community sector really helped: Somerset had previously used village and community agents, and micro-providers to help with discharge, but as part of the response they were also called upon to help prevent admissions. This was possible thanks to a robust community infrastructure which already included village agents (people who link their local communities to the services and information they need and at times deliver it themselves) county-wide enabling Somerset to influence and change conversations or provide support earlier and solve problems quickly before they became issues. This was done collaboratively via:

  • peer forums with social care team – part of local decision making
  • part of hospital teams
  • part of health and care community/neighbourhood teams and increasingly supporting primary care multidisciplinary teams
  • sixteen Talking Cafes across the county.

  Somerset’s village agents have been running Talking Cafes – local events where people can go to get information, advice, support, or even just some company – since June 2017. However, lockdown meant that these events – which were usually hosted in local venues such as cafes or libraries – had to be cancelled. In response, Talking Cafes adapted very quickly, moving daily sessions online to allow people to stay in touch and to still have a point of contact and reassurance. The village agent service worked with the local authority and GPs to identify and support the most vulnerable, setting up their own food and equipment networks, and harnessing support from within communities rather than relying on others to direct and fund.

  Micro-providers became an even more key local resource than they had been previously. As a county, Somerset has one of the fastest ageing populations in the UK, with half the population living in rural areas. Micro-providers can offer people in remote areas access to home care – coming out to them where they live to offer the kind of support they want at times they choose. This local, individual, tailored support at home prevented the risk of infection across multiple clients and continued to support people whilst they stayed within their community. Somerset County Council quickly made sure that micro-providers were recognised as key workers despite being a non-regulated provision and enabled its teams to support them to support each other. Micro-provider networks – small groups supporting each other in a local area – quickly moved online. Existing infrastructure meant that the transition was seamless and quick to coordinate.

  Without the strength in its communities, there is no doubt that Somerset would have had significantly busier acute hospitals, more discharge issues and a system in danger of spreading COVID-19, rather than isolating and preventing it. Instead they saw communities strengthen, the community offer increase, and people receive care closer to home, whatever their need. The data from the period 23 March to 31 May shows the impact that this had:

  

  The work taking place in Somerset is founded on the principle that people deserve more than a clinical pathway or a central generic response. So, what’s next on the list? A doubling of the intermediate care model to ensure that 50 per cent of it is geared for admission avoidance support and only 50 per cent focused on discharge. It will need the continued join up of health and care community teams to make this work, and perhaps, more importantly, will need to keep the resolve, faith and strength in its community approach to truly become a system based on prevention.