Organisations partners to create a multi-disciplinary team to identify and support more carers, enabling timely discharge, avoiding unnecessaryhospital admissions and reducing eligible care needs

Ambition:

Our “Commitment to Carers” was approved by the STP in October 2019 ensuring a system-level mandate for improvements for carers explicitly aimed at improving their health and wellbeing and involving them as expert partners in care. This boosted the impact of local collaboration, the work of a Joint Carers Lead and jointly commissioned carers support services (Caring Well in Devon), supporting the involvement of Primary Care and a Carers Hospital scheme.

In re-commissioning carers support services carers had told us that they wanted the Hospital scheme to continue. To that point it had low usage but it was plainly valued. We identified that relying on carer self-referral and referral via Social Care discharge teams was insufficient and that proactive direct links into the Hospitals themselves was necessary with a dedicated staff resource. We undertook a pilot “proof of concept” with encouraging results and we established a formal project with the RD&E in May 2019 envisaging a formal health economics evaluation completed in November 2020 and a decision on the future of the service for the long term in December 2020.

The partner organisations are: the Devon Clinical Commissioning Group; Devon County Council; the Royal Devon and Exeter NHS Foundation Trust; Westbank providing “Devon Carers”, the carer-led delivery partner of carer services. The formal project structure, details of operations, and documents are in the uploaded document. Commitment by the partners is strong: DCC was flexible about financial controls; the Hospital provided Honorary Contracts for the staff; the Third Sector partner contributed to funding.

The goals for integration were simple: the integration of the carers hospital team in the Hospital operations to identify and support more carers; the integration of the project in the management of the Hospital to optimise the Benefits of the scheme. The Strategic Alignment was identified as strong: reduced lengths of stay and delayed transfers of care; admission avoidance; reduction of carer stress post-discharge, prevention of breakdown and re-admission. The service also aimed to meet needs promptly to reduce “Care Act” Eligible Needs arising or persisting.

The context which created the demand was the recognition that many carers who went on to have needs which demanded a response or who suffered silently were being “missed” by the system set up for their support and that avoidable harm and demand was resulting. As covid 19 hit, the project showed resilience as the scheme was able to continue and grow.

Outcome:

Improved identification is one of our six key objectives.

Between May 2019 and end August 2020, we saw an average monthly increase in new referrals of 12%. 74% of all referrals are Carers newly identified to the health and social care system. The impact of early identification has been seen in feedback including: “I couldn’t lift the mattress, take the washing out of the machine and hang it up, I couldn’t even change the pillow cases let along the duvet! I couldn’t have managed without your help, just knowing someone was there”.

From April to August 2020, during the peak of covid-19, we have seen over 1,300 carers newly identified with roughly 75% in ‘pathway 0’ of the discharge to asses model brought in by the Department of Health and Social Care, important because this represents those a hospital does not consider as having needs or require onward referral to other support. 96% of carers supported through our project do not require a Care Act assessment afterwards.

Since the start of our project our team has been able to prevent carer breakdown in 15% of cases, has enabled a more timely discharge from hospital in 4% of cases, has been able to avoid admission in 16% of cases and reduced ongoing eligible care needs in 22% of cases. Key has been on the spot decision making on support; this has included replacement care. During the pandemic the staff developed alternative means of support acceptable to carers reluctant to admit visiting staff.

Carer feedback is a routine part of the project’s approach to delivering this service, ensuring that a Carer’s outcomes are being met whilst always having an eye to continuous improvement: “The cleaning and food delivery has meant that I am able to go back to work, whilst mum recuperates and dad is looked after. Thank you so much I was finding it so difficult to cope. I would like to say a huge thank you for all the help that you have given to both my parents and myself over the past months. I don’t know I would have managed to cope with this whole caring process and trying to work as well. It’s very much appreciated, and you seem to have gone beyond the call of duty”.

Spread:

Our original scope was the Royal Devon and Exeter NHS Foundation Trust (RD&E) as the largest acute hospital wholly in Devon. Specific wards were chosen as areas of focused activity, particularly where we would anticipate seeing optimal benefits, such as pre-admission units or wards discharging patients that are more likely to be readmitted such as stroke, orthopedic, and cardiac units.

As we made progress with the project, and as our workers started to become part of the normal hospital life on these wards, word began to spread between wards opening the doors for our team to start supporting more departments in the RD&E.

The speed and success at which the project has worked and achieved has been noticed by other acute hospitals in Devon, notably the Northern Devon Healthcare NHS Trust (NDHT) acute hospital and Torbay and South Devon NHS Foundation Trust (Torbay) acute hospital. We have been able to replicate the project in NDHT to great success and with Torbay we are working with our counterpart Local Authority who shares the hospital’s resources to ensure we have a service that works with all.

Currently we are also exploring how we could deploy the service in University Hospitals Plymouth NHS Trust (Derriford) where there is greater challenge due to the hospital’s resources being shared by three Local Authority areas.

It is clear that the project can be easily replicated in hospitals, across many different medical discipline wards, serving a single Local Authority area and that we are beginning to now demonstrate success for hospitals that serve multiple Local Authority areas.

We have had interest from other Local Authority areas such as Cornwall in replicating our approach and have had interest from NHS England and our regional neighbours in whether similar initiatives can be deployed in their individual areas of responsibility.

As part of our response to Covid-19 we have also been able to demonstrate the ability for our project and service to operate in a different delivery model but still be able to achieve positive outcomes for Carers and the persons for whom they care, as well as support the ability of acute hospitals to respond effectively during times of pressure. This includes adapting the service in partnership and consultation with senior hospital staff to respond to Covid-19, and to be part of the routine planning of response to winter pressures.

Value:

Our initial investment appraisal, based on Department of Health and Association of Directors of Adult Social Services (ADASS) research, was that for an investment of £210,603 per annum (averaged across the three-year lifetime of the project) the whole health and social care system should benefit by a minimum of £1,317,500 per annum.

Our proof of concept prior to the project running officially lasted for four months at a smaller scale and based on our analysis of Carers supported and the resources required we calculated that savings in the range of £277,000 to £341,000 were achieved. This is broadly comparable to the initial investment appraisal and giving us and our system leaders confidence in our success criteria and key objective and larger scale investment working.

The Covid-19 pandemic has delayed our full economic evaluation, which we intend to commission independently in collaboration with our partners, however our ongoing data and financial figures continue to align with our initial projections and as staff have gained experience the importance of the emotional support to carers has overtaken the practical and financial support available although this is still important.

Our case studies and the exit survey demonstrate the impact and value Carers have placed on the support received for themselves and their cared-for persons. Some extracts:

“Mum can maintain her personal dignity and alleviates some of the pressure from me, I was just finding it so difficult to juggle all aspects of care with everything else that is going on at the moment.

Debbie calmly went through everything that I needed to do and also tried to take some of that responsibility off my hands so that I could breathe a bit.”

“Allowed me to sleep through the night for the first time in ages.”

“When the OT at the hospital kept saying “he wants to come home” I don’t think they were very up with the effect on ME and they didn’t take on board the severity of my condition and I felt you did. I felt very hopeful that someone, somewhere would understand. I’ve been dismissed in the past. You can feel encouraged that Devon Carers has helped.”

Involvement:

The multi-disciplinary project team established to run the project consisted of system leaders that had the authority to make decisions and enable change; it undertook a comprehensive Stakeholder Analysis

Building on existing relationships with community and voluntary organisations which had supported the previous Hospital scheme, Devon Carers grew the involvement of the sector and developed new relationships with social care providers and local businesses to ensure support was delivered promptly.

During the peak Pandemic period the partners sought to extend the benefits of the scheme to other Acute and Community Hospitals; this was significantly taken up by the North Devon District Hospital. This is now part of the same Trust with the RD&E, which has provided further confidence and support to NDDH in this development. Community Hospitals are now also referring. The proposed extension to the Nightingale and newly established interim discharge facilities during Covid 19 peak were not needed in Devon.

The inception of the project was led by carers telling us they wanted this included in our carers service in 2016/17, as stated. Our Carers Partnership Steering Group, including carers themselves, has played an active part in the development, as has the Board of Devon Carers parent body Westbank, itself carer-led. Carer Ambassadors who are carers and former carers who volunteer strategically with our Partnership, have been involved in guiding development, interviewing for staff and shaping the service throughout.

We required a 100% survey of service users in order to develop evidence to evaluate the service and guide its progress. This has been an extremely fruitful way of involving carers who are at a difficult point in their lives without burdening them with more formal involvement.

Prior to covid 19 closing the Hospitals to visitors and increasing the work rate, we intended to develop a specific cohort of volunteers linked to the Hospital scheme, and when this becomes possible again we will complete this plan. We also have an identified Carer Ambassador as part of our coordination team (operating across all the Hospitals, not the RD&E project alone) to help guide and steer development.