Care ‘in between’

EXPLORING CARE NEEDS BETWEEN ACUTE HOSPITAL AND HOME IN MORAY

Project AIM

The project used a design-led approach to explore opportunities for how care could be provided in a way that meets the needs of people in Moray (in between acute hospital and home), enabling sustainable change across the system. The process enabled all stakeholders to explore the current understanding of care ‘in between’ and the care needs in Moray, and to be open to possibility in terms of how care could be provided differently in the future. By collecting different perspectives on care needs, places of care and lived experiences, stakeholders were enabled to creatively explore future opportunities for sustainable care.

“What support do we need in the future for people who are not in secondary (acute) care and who are not able to be supported in their own home?”

OBJECTIVES

• To understand the care needs of people ‘in between’ hospital and home.

• To understand the current ways care is provided in this space.

• To understand the lived experiences of people with these care needs.

• To understand the experiences of staff providing care (what works well and where are the challenges and what are the future aspirations).

• To identify areas of opportunities for a new model(s) of care.

MEthodology

Exploratory Workshops

Two exploratory workshops were designed to bring together stakeholders from health intelligence, public health, health planning and others who hold and have access to relevant data, in order to build an understanding of the current landscape of care ‘in between’.

The first workshop (June 2019) aimed to collectively define and identify key data requirements to understand the current care provision and care needs ‘in between’ hospital and home. The workshop involved discussion around the definition of care ‘in between’ in order to build a shared understanding of which places are included in this space. Participants were asked to define the types of data that need to be collected from each place to create a clear picture of the current landscape of care provision and finally, how this data could be collected. This enabled the creation of a visual map to communicate the identified places of care ‘in between’ in Moray.

The second workshop (September 2019) aimed to collectively understand the data collected around each place of care towards understanding the care ‘requirements’ for Moray. Participants were asked to bring the data they were responsible for collecting to input to a large data table for each place of care. This supported the group to discuss and refine the data in more detail and identify key trends and gaps.

Interviews: People receiving and providing care

A series of interviews and focus groups were undertaken in order to engage with people receiving and providing care ‘in between’. The interviews and focus groups were designed to collect in-depth, qualitative insights around people’s experiences of receiving and providing care in Moray.

An interview tool was designed to map a person’s care journey from hospital to home. In addition, a focus group engagement tool was designed to engage staff around the current process, challenges, aspirations and care needs related to providing care. Group engagements with staff included: Dr Gray’s hospital, discharge planning, community hospitals, care homes and social work.

co-design workshop

A co-design workshop was held (December 2019) to bring together health and social care stakeholders who are currently providing care ‘in between’, and also organisations who could play a key role in the care ‘in between’ in the future. The workshop aimed to share the current landscape based on the previous workshops and engagements, and to build from this future scenarios around how care ‘in between’ could be provided in the future.

Insights from the interviews and focus groups about people’s experiences of receiving and providing care informed the creation of four themed briefs (see section ‘Understanding the context’) to explore in depth during the co-design workshop. In total 51 people participated, who worked in small groups based on the four themes:

1. Transitions from Dr. Gray’s to home: Transparent assessment and communication

2. Practicing person-centred care: Understanding roles and utilising appropriate skills

3. Building resilience through prevention: Integrating support at the ‘right’ time

4. Changing perceptions through awareness: Creating and communicating a new language for ‘support’ in Moray

The group activities were structured in two parts. Firstly, participants were invited to respond to good practice question cards related to the theme by sharing an example from their own experience. This supported the group to share perspectives on the theme and also discuss the challenges and opportunities that exist in practice.

In order to support people to build support around the person receiving care, each table had visualised set of care values and aspirations to share the insights from people experiencing care ‘in between’ support.

Secondly, each group had a designed template to explore future scenarios and responses to the theme briefs. The templates designed for each theme were:

1. Template theme 1: Exploring future scenarios for the discharge process

2. Template theme 2: Exploring future ways of working to practice person-centred care

3. Template theme 3: Exploring a future roadmap for building community-based resilience

4. Template theme 4: Exploring future engagements for changing perceptions about care ‘in between’

Findings

Understanding the Current landscape of care ‘in between’ in Moray

Understanding the context

The insights of the interviews with people receiving and providing care ‘in between’ informed the creation of four themed briefs used at the co-design workshop that each addressed a challenge.

Theme brief 1: ‘Transitions from Dr. Gray’s to home’ focused on recognising the need for more transparent and streamlined assessments and discharge process that could allow the person to be more informed and involved in decisions around their care and ensure they experience a positive transition to home.

Theme brief 2: ‘Practicing person-centred care’ focused on the need to embrace an attitude of enabling and reablement across the system which requires leadership and empowerment to support staff to have this mindset and approach. Having flexible caring teams, reviewing care in a continuous cycle and following people across the system rather than working in silos of acute and community were all seen as opportunities to work differently in the future.

Theme brief 3: ‘Building resilience through prevention’ explored ways to integrate community-based and third sector support. Requiring a collective approach that focuses on prevention this could enable people to access and understand the services available, with clear collaboration among all stakeholders.

Theme brief 4: ‘Changing perceptions through awareness’ explored the need for a common language of what care ‘in between’ means, what can be expected and how people can become ‘partners in care’ to make informed decisions about their own health and wellbeing.

Understanding the data

The outcome of the first exploratory data workshop consolidated the focus of the project on ‘fluid’ places of care ‘in between’ in Moray - places that people ‘stay but then move on’ as part of their journey between hospital and home. Six key groups of places of care were identified for inclusion: Community Hospitals, Care Homes in Moray, Jubilee Cottages in Elgin, Guest Rooms in Sheltered Housing, Muirton Ward and the Augmented Care Unit in Forres. The data collected with the support of data analysts of Health and Social Care Moray were translated into visual infographics to communicate and understand how these places are currently used:

Understanding the current discharge process BETWEEN hospital and home

There is already a piece of work underway which is exploring delayed discharges across places of care in Moray. However, for the purpose of this project, it was important to understand the process and pathway for discharge which starts on the ward and involves a number of key stakeholders in the decision making process (see visual below). Discharge is complex which makes it difficult for the person receiving care to make an informed decision about their care destination after Dr. Gray’s when home is not an option. Furthermore, changing admission criteria, different referral process requirements for different places of care and a lack of clarity around appropriate places of care can cause a lot of confusion for staff members at the point of discharge.

themes

A number of key themes emerged across the project which highlight the complexity of care ‘in between’ and also provide clear thematic areas which should underpin the development of a future model.

Theme 1: Data measurement and evaluation

The theme of data measurement and evaluation recurred across all parts of the process and was particularly evident when collating data to try to understand the care needs of people receiving care ‘in between’. Currently people’s care needs are not recorded in a way which is easily accessible and makes it difficult to truly understand people’s support needs and practice person-centered care across places of care and services. The data that is recorded and reported is predominantly for audit and performance purposes and there is a need to review the types of data that are recorded and the purpose of the recording to ensure that data can be used for evaluation to drive innovation, improvement and transformation. Participants highlighted the need to identify and capture where improvements can be made but also use data to understand and communicate the bigger picture, good practice and what is working well. 

Theme 2: Navigation and coordination across the system (personal and professional)

Throughout the project, all participants (people receiving and providing care) aspired for joined up care and integrated services to support navigation of the system in terms of access to information and services, and ability to coordinate care to enable seamless pathways and experiences. Supporting people to be able to access the right information can allow them to effectively navigate the system. This can help in situations such as connecting older adults living alone to local support and it was acknowledged that more support is needed to enable rapid access to services in situations of crisis and sudden onset symptoms. Having a ‘wide MDT’ was also suggested, as well as providing signposting and mechanisms to recognise ‘red flags’. The importance of having time to listen and reassurance was also highlighted.

Theme 3: Building trust and understanding other roles

The need to build trust and gain an understanding of roles across the system was a key theme across the project with key implications for assessments and how people who require support interact with and access the most appropriate professional or service provider.

Theme 4: honest and courageous conversations

A common theme that emerged across all groups during the co-design workshop was that professionals found it difficult to have honest and transparent conversations with patients, e.g. about availability of support when being discharged or about a patient’s weight or age-related difficulties. Having robust conversations about where the person would prefer to receive support after discharge is not easy, but by providing clear and realistic options about people’s discharge destination this can help to manage expectations (individual and family) as often care is perceived to be a ‘quick fix’. At the workshop participants shared that Mental Health professionals are experienced in having honest, and often ‘difficult’ conversations because building a trusting relationship is crucial. It was also acknowledged that involving family members in conversations can be difficult given patient confidentiality and sometimes people do not want their family to know. Participants also shared the importance of strengthening relationships at all human levels from the individual, to family, the community, the professional and government, to support prevention and self-care.

Exploring the future of care ‘in between’

Exploring a Future discharge process BETWEEN hospital and home

When discussing future transitions from Dr. Gray’s to home participants shared the need to collect a baseline of information to understand their current care needs and any existing support. It was suggested that the MDT can record people’s needs and basic information e.g. Key Information Summary (KIS), Anticipatory Care Plan (ACP) and a comprehensive medical review, which can be made available when someone is admitted to Dr. Gray’s. Furthermore, people can be provided with an ‘admission’ and ‘ready to go home’ information leaflet along with conversation and discussion to inform people’s expectations about their stay in hospital from the start. Currently, when people are assessed and have more complex needs there is often a ‘limbo’ period in terms of aligning the different professionals that are required to assess. A 24 hour emergency decision making unit was proposed as a way to provide a support team to give more time to make an appropriate discharge plan and avoid assessment in an acute setting. When transferring patients there was a clear need for consistent patient information recording that can be shared across the whole system which can be updated from different locations and includes an overview of the process of decision making to understand the full story of a person’s journey by others. In addition, when considering options for care ‘in between’ it was discussed that care homes are currently only seen as long-term options, however, to support people who need more time to recover before going home there is an opportunity to explore how care homes could support this need in the future.

Practicing person-centred care

Two groups explored the theme ‘Practicing person-centred care’ which focused on understanding care ‘in between’ needs (see Visual: Care ‘in between’ needs) and considering the most appropriate forms of support that could meet these needs. The findings of the activity suggest that the social and practical needs that are often experienced in care ‘in between’ could be met at home if the right type of support is provided. Self Directed Support (SDS) can also play a key role in tailoring support based on the person’s needs and aspirations.

In order to support coordination the participant’s identified the need for a ‘case manager’ role (suggested terms for this role were a: wellbeing advisor, wellbeing worker, community development/volunteer development) which would be a community connection role based within Dr Gray’s who can work with the person and the MDT to ‘match’ needs with services, coordinate these and then review at appropriate intervals. Participants stressed the importance of the relationship between the person receiving care and the ‘connector’ role to begin in the care environment in order to foster and build trust. This type of role could also support sign posting and helping to link people to things in the community, as well as act as a champion for the person (similar to a named person ‘lead professional’ in the context of children’s services).

In addition to this type of role, the focus of all conversations across the system need to be about ‘wellness’, rather than focusing on individual ‘segments’ of the person. Conversations and a holistic approach are also important given that the most appropriate form of support will continue to change along a person’s journey. These types of conversations can also set realistic expectations, particularly in relation to how long a journey might take and what steps may be involved. Engaging family members was also highlighted, particularly organising family meetings to provide support for families, and documenting discussions so that families are involved and can discuss needs. However, when families are at a distance there is also a need to consider who is in the person’s ‘care circle’ that can be a form of support.

A range of more immediate changes were also suggested across both groups that relate to the pathway of care ‘in between’. These included collecting a baseline of what is ‘normal’ for the person, initiating early assessment at the point of admission in order to understand the current care package, and involving the patient in the MDT as part of an initial meeting. Aligned to this was the need for people to access information while they wait for support to be put in place and be informed of what the process is. The need to have flexibility and a tailored approach to the MDT was also discussed in terms of building the ‘right’ MDT to meet the person’s needs. In addition, the opportunity to develop a flexible workforce and 7 day working service was also discussed as well as who is the right person to make decisions about when a person is ready to return home, appropriate care package and how this is assessed. Staff having confidence and competence to make decisions was also raised and the need for a process or training in order to be able to think in a more multi-disciplinary way e.g. involving patient, family and other care professionals in discussing realistic expectations.

The ethos of the place of care and the environment within which support is provided was highlighted as important. Participants also discussed the need to support patients understanding of different places of care and the types of needs they can meet which can also help in communicating appropriate places or practices of care.

Challenges remain in terms of risk adversity (24 hour care can minimise risk), guardianship and availability of care packages, however participants discussed strategies to help overcome these. For example, in relation to guardianship, early education is important and prevention work in GP practices could help to make contact with families and have conversations with people at an earlier stage to raise awareness. In addition, the challenge of stigma was also discussed and the need to remove stigma in relation to mental health in terms of understanding the concept of being ‘ill’ in relation to both personal and societal perceptions of what this means.

The slideshow below summarises the ideas and opportunities suggested by participants to meet Practical, Social and Clinical needs of care ‘in between’:

tools to explore the future of care ‘in between’

The following tools have been designed to support the development of care ‘in between’ towards a future model of care and support. The tools embody the findings, insights and ideas generated across the project and translate these into actionable propositions that can be taken forward by Health and Social Care Moray. They are designed to support dialogue among health and social care professionals and their wider partners towards decision-making and implementing change, but also to critically evaluate the future of care ‘in between’. The proposed tools are offered as a ‘guide’ rather than be solutions in themselves. Further refinement and appropriation are required before these are considered for implementation more widely.

Care COmmunity Connector

The Care Community Connector is a speculative persona and job description of a future role based in Dr Gray’s that supports people to transition to home through connecting the person to local support and services. The persona and job description have been built from the insights collected across the project. This speculation is designed to support Health and Social Care Moray to critique the future should this role exist, what the resulting implications would be on people’s experience and ways of working and consider the types of roles that already exist within the system that could be adapted to support the purpose and responsibilities identified.

Download Care Community Connector

care recovery and wellness plan

The Care Recovery and Wellness Plan is a speculative communication tool designed to support communication with the person receiving care and enable shared decision-making. The tool has been designed to show the types of information that would be valuable to include in a plan that would enable people to understand their journey, how they could support themselves and the types of support that they may require as they transition to home.

Download Care Recovery and Wellness Plan

shifting perceptions through engagement

A series of conversation questions have been designed to support Health and Social Care Moray to develop an engagement strategy and methodology to engage communities across Moray around the future of care ‘in between’. The booklet provides key insight and questions that can be used in a group setting to form an engagement plan to help support communication with communities.

Download Communication Guide

‘Courageous conversations’ brief

The ‘courageous conversations’ brief is a design brief which outlines a future project which could be taken forward by Health and Social Care Moray (in collaboration with a design innovation student) in order to develop ways to support staff to engage in ‘courageous conversations’ with people who receive care. The brief outlines the key insights and opportunities, as well as a series of questions which could be explored through a co-design process.

Download Conversation Brief

Roadmap

A roadmap to guide implementation and future work to support Health and Social Care Moray in the future of care ‘in between’ was developed by consolidating the learning and insight generated across the project. The roadmap is based on five key areas with a set of actions for ‘now’ (short term) and ‘next’ (long term):

1. Building the future model of care ‘in between’

2. Workforce development

3. Evidence-based transformation

4. Building flourishing partnerships

5. Communication and engagement

Conclusion

The journey and transition from hospital to a place of care ‘in between’ was a key focus in this project and is proposed as a priority area for future work. The findings of the project provide a body of evidence to support Health and Social Care Moray to build a future vision for care ‘in between’ in partnership with key stakeholders across the system and through engaging the community. Building a sustainable model of care ‘in between’ means understanding the implications for this space when there are impacts from other parts of the system. As a result, this project has developed a model of system-wide innovation to enable the development of a future model of care ‘in between’ by considering the impact of a ‘destination home’ approach in Dr Gray’s, wider community-based prevention that is responsive not reactive, practicing person-centred care through a needs-based approach and shifting perceptions to support an informed population. Prioritising these areas going forward through a strategic set of transformational work programmes (outlined in the roadmap) will allow Health and Social Care Moray to build a model of care ‘in between’ that meets the needs of the people of Moray.

Building on the strategic vision theme of being supported at home or in a homely setting and the aspiration from people receiving and providing care to be supported locally, there is a need to explore future models of care where the journey begins at Dr Gray’s. The vision of ‘destination home’ would involve exploring the culture and practice within Dr Gray’s and the relationship to providers of care and support in Moray localities from a new perspective in order to reshape local care needs based on the experience of this journey and transition. The shift in perspective to consider ‘destination home’ at the outset has the potential to positively impact care pathways and transitions, as well as establish more coordinated working practices among staff.

Overall, the future of a sustainable model of care ‘in between’ is predicated on decision-making, leadership and ownership. Decision-making in order to begin the journey towards transformation and ensure this is prioritised and roadmapped appropriately; leadership in order to guide the pathway to change among key stakeholders and foster the collaborative approach that will be required to achieve a sustainable model; and finally, ownership to enable accountability but more crucially, to empower those who invest in this journey. The importance of decision-making, leadership and ownership should not be underestimated and is absolutely fundamental to the future of care ‘in between’ in Moray.

Download Project Summary: digital version

Download Project Summary: print version (print double sided on A3 and fold in half lengthways then in 4 accordion style)

Acknowledgements

We would like to thank all our participants for their energy, time and commitment in taking part in the engagements and workshops across the project, sharing their knowledge and experience. We would also like to give special thanks to Susan Pellegrom for project management support and analysts Catriona Campbell and Pauline Maloy for supporting the process of collating and visualising the data.

For more information contact:

Dr Tara French | t.french@gsa.ac.uk

Yoni Lefevre | y.lefevre@gsa.ac.uk

Sean Fegan | s.fegan@gsa.ac.uk