A co-provision approach to post acute re-enablement has reduced lengths of hospital stays in pilot areas, as Katie Donlevy and James Heffron explain
The clinical and financial efficacy of reducing hospital capacity by relocating care to community settings
Liberating the NHS white paper committed to an “NHS that measures its performance on patient outcome [in which] doctors are free to focus on outcomes that matter”. But this sits alongside October’s spending review, which protected the NHS from inflation but not growing demand and prices. So, how do you deliver quality and savings?
One solution is the reduction of hospital capacity by relocating care to community settings. But the research into the clinical and financial efficacy of this has been ambivalent (see table 1, above).
In 2009, NHS London invited two NHS providers to work with health and social care partnership company Saigei to study the efficacy of home-based medical care. One site was in south-east London, the other in north-east London.
Acute episode healthcare resource groups and community block contracts do not encourage fluidity of resources or a degree of co-working likely to release costs tied up in overlapping provision and transfers of care across boundaries. The localities were invited to explore co-provision in which clinicians work across payment boundaries, moving resources between organisations. This approach became known as PACE.
Outcomes and experience
Clinical outcomes were measured using the Modified Barthel Index and the EuroQol (EQ5D) patient reported outcome measure. Results showed reduced dependency and improved perceived wellbeing (see charts).
Patient experience was looked at with a questionnaire that uses Likert Scales and narrative feedback. Results were effusive, with 80 per cent of patients agreeing or strongly agreeing that their care was “just about perfect”.
The pilot sites applied a pre-agreed basis for estimating reduction in acute stay. This indicated an average reduction of 3.8 days for elderly patients, and 6.5 days for a more medical cohort of patients. The results are consistent with those being achieved by the 2010 adopter sites.
For the pilot localities this indicated a return on investment of 12 per cent to 33 per cent depending on patient cohort (assuming £145 as the realisable value of an acute bed day). Both places assert that PACE helped avoid increased acute capacity over winter and has supported reduction of acute capacity. The first of the 2010 adopter localities is reducing capacity now.
By the end of 2010-11, three more localities will have tested PACE. Already, two have indicated their intention to establish the service.
PACE teams are developing local per-patient tariffs linking price to care bundles - achieving what HRG unbundling did not.
While there is no “one-size” PACE (each local infrastructure is different) it is a clear contributor to the re-enablement and long-term condition management agenda.
Co-provision is a route to accessing some of the opportunity promised by vertical integration without changing organisational form. Creative commissioning could unlock the payment and provision anomalies that constrain the potential of PACE.
Katie Donlevy is chief operating officer for Barnet Community Services. James Heffron is managing director of Saigei.
Experienced and authoritative band 7+ community clinicians (case-finders) work in the hospital, alongside acute teams to identify candidates for PACE.
The eligibility criterion is that the consultant and case finder agree the patient falls outside Royal College of Physicians guidelines regarding when an inpatient episode is required. A care plan is then agreed that ensures it is safe to continue the patient’s medical treatment at home.
The case finder facilitates transfer of the patient to PACE. Community nurses, therapists and social care professionals then co- deliver the agreed care plan.
The home service operates extended hours seven days a week. Maximum intensity of care is four double-handed visits a day but the significant majority need one or two single-handed visits a day.
Care plans typically combine some of the following:
- personal assistance with daily living
- medicines review and management
- medical monitoring/nursing intervention
- therapy assessment and intervention
- transfer to on-care services or LTC management
Transfers to PACE occur on average three to six days earlier than traditional discharges. IV antibiotic, and long-term condition exacerbation cases can be much earlier. Duration of PACE care is consistent with acute bed days recovered.
Governance and traceability are at the heart of the service design. The acute team is updated on every patient’s progress, and escalation procedures (provided by the acute team without recourse to GPs) are in place should patients regress.