1. Why move to outcome-based commissioning – Out of Hospital care?
Discussion led by Professor John Bolton

2. The way in which social care is delivered makes a big difference?
Supporting recovery or Building Dependence?
Research from University of McMaster, Ontario, Canada 2000s
Markle-Reid M, Browne G, Weir R, Gafni A, Roberts J, Henderson S. Seniors at risk: The association between the 6-month use of publicly funded home support services and quality of life and use of health services for older people. Canadian Journal on Aging. 2008; 27(2);
“A little bit of care may be bad for you”
Challenging a person or colluding with their current state?
The benefits of reablement/recovery/rehabilitation/frailty
Aston University research into Extra Care Housing/ Work of University of Newcastle –Centre for Ageing (ADL Smart Care)
ExtraCare Project - Aston University research project between Aston Research Centre for Healthy Ageing (ARCHA) and the ExtraCare Charitable Trust.
Help a person through a crisis or respond quickly?
My work on out of hospital care

3. Tackling Frailty In Older People
Re-able
Acitivies of Daily Life Hierarchy
Compensate
Care
Time since starting on ‘curve’
©2016 Professor Peter Gore CEng FIMechE

4. Variations in outcomes for citizens
In the United Kingdom there is a six-fold variation as to where you live and the likelihood that you would be placed in older people’s residential care funded by the local authority (not related to levels of deprivation)
In the United Kingdom there is a twelve fold variation as to where you live and the likelihood that you would be placed in a residential care home for adults with a learning disability
In the England it is twice as likely in some places that your problems can be resolved without the need for formal care when you seek help
The number of hours of care a person is assessed as needing also varies significantly e.g. in extra-care housing between 15 hours and 36 hours required at highest level
The impact of domiciliary care reablement varies between 25% and 75% of older people who will recover

5. Over-proscribed care?
There is significant over –proscribing of social care
Low level care – tackling social isolation or just checking
Discharge from hospital 1in 5 packages
Partnership with carers
Care can be delivered in a way that further incapacitates the recipient or it can be enhancing and supportive – a “dollop of care” can increase someone's needs by 120%
Unmet needs at lower levels don’t lead to poor well-being

6. Managing demand in social care
Diversion – Community
NHS

7. What is an outcome?
A person is happy/ pleased with the service/ getting their needs met?
Contentment OR
A person is making progress and needs “less” longer term care and support?
Challenged but fulfilled

8. Hospital Discharges

9. Coventry City Council
Providers of domiciliary care who support hospital discharges are required to maximise an older person’s independence as part of the contract.
The measure used is that 66% of those people receiving help require no further help after 6 weeks.
Service supported by Occupational Therapists but delivered by independent/private sector care providers
This is about contract compliance – no reward just an expectation
Variations of the approach used in Glasgow, Scottish Borders, Nottinghamshire, Carmarthenshire, Pembrokeshire, Bridgend, Monmouth, Newport…..

10. Other approaches…….
Single biggest challenge for places – securing stability in the care market prior to moving to outcomes
Different from Wiltshire where the outcome is for each individual and the price set according to the agreed interventions – and all domiciliary care is reablement based – did achieve 66% in first 6 weeks but since fallen?
Leicestershire – 2 week rule – review after 2 weeks to see if care still required (about 50%)
Reducing budget in Nottinghamshire for adults with learning difficulties
Glasgow contracts with Voluntary Sector

11. Measuring outcomes from health and care system - over 65s?
Prevention – falls, incontinence, dementia….
% of those who have had a fall who received recovery advice after first fall – over 90%
% of those who are incontinent who have received advice and support to manage the condition – over 90%
% of admissions from residential care homes
% of re-admissions to acute hospital from a care homes within 6 weeks – less than10%
% of re-admission to hospital
% of re-admissions to hospital from those discharged in previous 10 weeks – less than 5%

12. Measure impact of out of hospital care system
Speed of response to needing care– within 24 hours
% of people needing care and support who could receive that help within 24 hours – 90%
% of permanent admissions to residential care direct from acute hospital
% of new permanent admissions to residential care should be less than 5%
% receiving of those requiring help being supported with their recovery through community or bedded facilities
% of people who recovered through short-term residential intermediate care – 75% of people were able to be discharged to their own home
% of those recovered – “outcome of the system”
% of people who were helped at home who required no further assistance after 8 weeks – over 66%

13. Outcomes from Reablement – Variables – who is accountable for the outcome?
How are people assessed for the service?
How focused is the service on the range of different interventions that are required for different conditions?
How much training is offered by reablement workers for customers:
To Manage their condition
To use equipment provided (including telecare)
To link to local community
How well supported is the service by nurses and therapists?
Is the demand for the service understood?
How does it fit with other Intermediate Care Services?
How are people assessed for longer term?
Are other client groups helped?

14. Supporting a person to remain in their own home assessments/interventions
Short-term recovery (domiciliary care reablement versus self- managed recovery) – hospital discharges?
Longer term recovery (evidence at which point do people recover and who will benefit)
Helping a person to live with / manage a long-term condition (or more likely set of long-term conditions)
Helping a person live with /manage having memory loss or dementia
Helping a person receive end of life care
Supporting a carer who is helping any of the above
Supporting a person with health care
Helping people who experience social isolation
Helping a person/family with anxiety and worries

15. How might we measure success?
Percentage of people who completed short-term reablement but were assessed as still requiring a service after 8 weeks – less than 33%
Percentage of people whose needs are reduced within first year of receiving the service – over 20%
Percentage of people whose needs either remain the same or reduce over time 70% (do not increase)
Percentage of people who are admitted to residential care who are in the service – less than 10%
Percentage of people who are admitted to hospital within 2 years of receiving the service – less than 15%
Percentage of people who have to visit GP?

16. Percentage who are not readmitted to hospital – over 95%
People receiving palliative care
People receiving auxiliary nursing
Percentage of people who do not need to see a District Nurse except for discharge– over 75%
Percentage who are not readmitted to hospital – over 95%
Percentage of people who died in their own home – over 80%

17. Some other challenges
How do we jointly commission an out-of-hospital care system?
Who should be held to account for the outcomes – Providers? How much trust – who assesses a person needs no more care?
How do we overcome the other variables?
How do we address the shortage of therapists/community nurses?
How do we ensure that risks are managed and that we build the resilience and capacity within older people – challenging but supportive?
How do we ensure that clinical staff don’t pre-empt recovery?

18. Conclusion
We should state the standards we require from providers in relation to outcomes and pay accordingly
Each customer should have a stated set of goals to which they aspire – these should be challenging
We should reward those providers who can assist people to progress to a greater degree of independence – where that is feasible
We should ensure that all providers focus on helping people to remain in their own homes – where that is feasible
From hospital we should ensure both speed of response and outcome from service – managing the flow

19. More Information
Papers on Managing Demand and Outcome Based Commissioning:
John Bolton

20. Professor John Bolton Qualified Social Worker - 1974
Former Director of Social Services and Interim Director – four authorities (2002/07; 2010/14)
Former Director of Joint Reviews (Audit Commission/DH) (1999/2001)
Former Strategic Finance Director at Department of Health (2007/10)
Visiting Professor at Oxford Brookes University – Institute of Public Care (2010- present)
Advisor to Local Government Association Productivity Programmes
Senior Advisor to Newton (Europe) – efficiency in adult care (2010..)
Independent Consultant on cost effective care across United Kingdom
Author of papers on prevention, promoting independence, managing demand and outcome based commissioning in adult care