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The Elder Interview

Understanding ‘Home First’ – Featuring an interview with Sarah Mitchell

As we enter a further national lockdown, in the face of a second COVID-19 wave, it’s important to pause and reflect on the lessons of this past year – one of which has to be from the tragic spread of the virus throughout the nation’s care homes. In this piece, we explore the potential benefits of a Home First strategy in relieving hospital capacity pressures in a way that doesn’t risk the same thing happening again and providing a safer and more person-centred option in the process.

In our last issue, we heard from Chris Thomas, from the Institute for Public Policy Research. He observed that while “people have recognized how important social care is”, there is still a long way to go to put in place much-needed reforms that would future-proof resilience into the sector and protect those in care.

He said we must also acknowledge that “the population is ageing, we know that disease outbreaks like coronavirus are actually getting more and more likely, and we also know that the people that are at risk when that happens are the kind of people that are receiving social care.”

Clearly, the tragic unfolding of events that occurred throughout the social care system in the first wave cannot be replicated as we move into winter. In reflecting on lessons learned and to help prepare for the challenging months ahead, Elder Magazine aims to explore and understand innovative integrated health and care models that will fundamentally improve individual and population health outcomes throughout these testing months and into the future.

“Lack of staff awareness and understanding of the services available was also seen to prevent the most effective possible decisions at the point of discharge.”

Newton Europe and the Better care fund

During the spring outbreak, COVID-19 exacerbated existing pain points in the fledgeling integration of our health and social care systems. Nowhere was this pressure more acutely felt than in discharge, where – although somewhat improved in recent years – delayed transfers of care still mean far too many people remain resident in hospital wards while awaiting a care package to be arranged.

Daphne Havencroft shared her mother, Dorothy’s, care experiences with the Health and Social Care Committee (HSCC). According to the HSCC report: “After Dorothy was admitted to hospital, in common with a lot of older people, she wished to return home with a care package in place rather than move to a nursing home. However, this did not happen, despite the involvement of a total of 101 different people in trying to coordinate her care. Dorothy remained in hospital awaiting discharge before eventually being transferred to a nursing home where she spent six months, and from which she had three emergency admissions to hospital.”

By remaining in hospital, it was patients like Dorothy who were left particularly exposed to COVID-19. Then, quickly, they themselves were put at risk of exposing others – as, en masse, many were discharged into residential care homes without being tested. In both instances, the toll on mortality for the elderly was at historically tragic levels. 

In preparing for winter, it’s clear that both mass testing and discharge to more secure settings are the two vital tools in any commissioner’s box. To date, there has been very positive progress on the former – with mandatory testing on discharge, as well as the imminent reduction in lead times of testing. For the latter, there is still some way to go to prevent more experiences like Dorothy’s and to improve hospital discharge on a systematic level.

Ongoing guidance incorporates the “Where Best Next” campaign which asks the question “Why not Home? Why not Today” and promotes early planning and multidisciplinary collaboration to design discharge pathways around person-centered health and care outcomes. 

“After Dorothy was admitted to hospital, in common with a lot of older people, she wished to return home with a care package in place rather than move to a nursing home. However, this did not happen, despite the involvement of a total of 101 different people in trying to coordinate her care.”

Health and Social care commitee

To better understand the “Home First” approach and its relevance in COVID-19,  we had the pleasure of speaking with Sarah Mitchell, a Care and Health Improvement Adviser who has also worked with the Local Government Association (LGA).

As one part of her remit, Sarah provides peer support to local authorities to promote an exchange of best practices, implementation of relevant guidance, and designing system flows around a personalised approach. She also advises councils on local relationships with the NHS to ensure that individuals who have to go into hospital can return home with the support that they require or have viable care alternatives in place. 

Sarah affirms that ‘Home First’ has been a philosophy within social work for a long time – a vision of ensuring that those individuals who could go home would have the domiciliary or home care support they required, with residential care as an option on an absolute need basis. She observes that, over the years, with demographics shifting and pressures on the NHS, there has been an increase in admissions into residential care homes for individuals who did not have critical health or nursing needs.

This is while advisors have demonstrated evidence that people’s outcomes are best achieved in their own homes, thriving in an environment of familiarity and surrounded by family and friends. The `Home First’ approach is therefore setting people up with a tailored support package, that includes long or short term live-in care services to foster a period of reablement and help people regain independence in their own home. 

Home First, while a long-held philosophy, will require wholesale systematic behaviour and cultural change within systems, shifting from a focus on quantitative measures to improving person-centred outcomes.

According to the “People First, Manage What Matters” white paper conducted by Newton Europe and the Better Care Fund, real or perceived lack of capacity in service, particularly in-home care, presented a major reason for patients being discharged to a more intensive setting than required or desired. The study further reports that “lack of staff awareness and understanding of the services available was also seen to prevent the most effective possible decisions at the point of discharge.” 

What has become increasingly apparent during COVID-19, is that many of the perceptions around capacity shortfalls are unfounded. Across the country, local authorities and clinical commissioning groups looked to expand inpatient capacity to cope with the peak of the pandemic, while reducing infection risk to vulnerable populations. For many, particularly as infection rates spiked in residential care, home first became the only logical step.

Sarah’s work around making this process smoother has recently been focused on co-authoring the LGA’s High Impact Change Model. This is guidance intended to support local system partners implementing new interventions and minimising unnecessary hospital stays.

The model was refreshed as of July 2020 to incorporate learnings from COVID-19 and now includes nine high impact areas or “Changes” – including early discharge planning, multi-disciplinary working, and home first discharge to assess. Discharge to Assess enables a single point of access with assessments completed at home with families, carers or advocates, after reablement or rehabilitation if required. With the need to discharge at scale yet again on the horizon, the model has never been more relevant. 

COVID-19 has magnified both the urgency to discharge individuals out of the hospital and the importance of ensuring adequate care support and follow-up procedures await them at home. The ‘Home First’ approach and implementation guidance found in the High Impact Change Model present more informed approaches to this critical intersectional point across health and social care. 

The Elder Magazine is open to additional perspectives from those who work in the health and social care sector. Please reach out to us if you are interested in interviewing on topics of interest and importance in your community. 

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