Striking the balance between system flow, patient outcomes, and financial sustainability is a challenge facing all health and care systems. Launched in March 2020, Dorset’s Home First programme aimed to overcome this challenge by embedding strengths-based working that delivers:
· Financially sustainable, stronger patient outcomes
· Improved operational outcomes
The initial focus was addressing the challenges of supported discharge during Covid restrictions. This was a whole system priority in Dorset with leaders from BCP Council, Dorset County Council, Dorset Healthcare University NHS FT, Dorset County Hospital NHS FT, Dorset CCG, and University Hospitals Dorset NHS FT driving the change.
Home First’s ambition is to enable people to live independently in their own homes wherever possible, avoiding hospital admissions unless necessary, and getting people back home as quickly as possible with the right support.
Since August 2020, IMPOWER have been supporting Home First by working on a twin-track basis; developing a strategic business case and programme design to inform the medium term and delivering high impact interventions on the front line – our Valuing Home approach. The aim of this approach is to help Dorset meet the immediate challenges of Winter 2021/22. So far, the programme is delivering widespread benefit and will continue to support recovery and a person-focused future intermediate care model.
Everyone working in the Dorset health and care system is passionate about achieving the best outcomes for the near 800,000 people living in Dorset. The challenge in Home First has been to take this high-level shared ambition and shape an inclusive ambition, with tangible outcomes and service delivery models that partners can work towards. An additional complication has been the impact of two years of navigating Covid, putting pressure on all elements of the system, and limiting capacity to engage in change activity.
Recognising the day-to-day operational pressures in the system, IMPOWER’s role has been to develop the emerging programme without overly drawing on system capacity. During Autumn 2021, the IMPOWER team created a revised Home First programme by developing a shared vision, which involved taking ownership of the design principles together with Dorset. A clear benefits case for intermediate care over the medium term emerged. A delivery plan for 2022/23 was defined based around eight workstreams, focused on maximising the impact and outcomes from the current system.
This work has enabled the system to set an agreed delivery direction, informed by clarity of the likely benefits to be delivered. This allowed a programme infrastructure to be established during spring 2022.
We apply behaviour change to improve outcomes, especially for the most vulnerable, such as the frail elderly. Working shoulder-to-shoulder with frontline NHS and social care professionals, IMPOWER’s front-line interventions focused on two main areas:
Embedding on a frail elderly ward in a large urban acute hospital, the IMPOWER team found the ward staff to be exhausted, stressed, and disempowered. IMPOWER were an empathetic partner, listening to staff concerns and understanding the areas for improvement. There was a focus on applied behaviour change to work to the needs of each staff member. This enabled them to introduce several tools to smooth the discharge process.
The cumulative effect of these personal, everyday changes was significant, as individual ripples became a positive wave. Compared to baseline weeks, the number of daily discharges from the ward doubled from two to four, with a halving of the time* from medical readiness to discharge.
Empowering staff, building on their ideas, and smoothing process blockages all served to improve the discharge process. Crucially the discharges were sustainable, with a focus on increasing pathway zero (no support required) discharges instead of incurring unnecessary delays in waiting for support.
The cluster work also delivered significant impact. IMPOWER’s focus was the same – introducing small changes that empowered staff. These interventions enabled a more collaborate, multi-disciplinary approach that drove a holistic, outcomes-focused discussion of the patient’s needs, whilst accelerating decision-making. The impact of this was an increase in patient satisfaction, alongside a decrease in the time from referral to decision – with the approval time for new packages decreasing by 60%. *
Following the successful interventions delivered during Autumn 2021, the Home First programme continued the ward-based and cluster work throughout the Winter period – recognising the impact of this work on flow.
The programme has committed to an eight workstream programme for the 2022/23 financial year, with a focus on maximising patient outcomes and value for money from the current service offer. Concurrently work is underway to shape a revised service model, that builds on the good practice currently being delivered, that will provide medium term outcome, and financial benefit.
This work is enabling the Dorset system to meet the planning horizons and challenges of Winter 2022/23 and 2023/24 with confidence in a resilient integrated care offer.