NHS England has published for integrated care boards an intermediate care framework for rehabilitation, reablement and recovery following hospital discharge, with recommended actions for ICBs including improving data use for planning and implementing digital tools to support workforce efficiency.
The framework brings together learnings from eight sites across the country where new approaches have been trialled for people to access high quality, step-down intermediate care. The learnings have been split into four priority areas: improving demand and capacity planning; improving workforce utilisation through a new community rehabilitation and reablement model; implementing effective care transfer hubs; and improving data quality and preparing for a national standard.
Improving demand and capacity planning
Here, the framework highlights the role of data in planning and commissioning services. “It is important to undertake demand and capacity planning within an ICS footprint,” it notes, “stratified down to health and wellbeing board footprints (used for Better Care Fund planning) and, if relevant, to neighbourhood-level.”
A recommended action is for commissioners across health and care to agree projections of demand based on need; identify capacity commissioned and additional capacity required; and work with providers to identify the best way to deliver it.
A number of sources and types of data can be used to develop understanding in this area, the framework adds, including Better Care Fund demand and capacity plans; ICB planning data versus ‘actual’ data, including from waiting lists and hospital discharge pathways; community bed audits; “any other relevant plans for expenditure on intermediate care service capacity within the ICS footprint”; health inequalities data; operational data; and information on current productivity and potential for improvement.
Another recommended action for ICBs is to develop a single approach to ICS demand and capacity planning for intermediate care across Better Care Fund and NHS planning footprints.
Improving workforce utilisation through a new community rehabilitation and reablement model
The document notes that the new community rehabilitation and reablement model, also published in the last week, should be read alongside the framework. Implementing this model will require a particular approach, the document continues, including application of digital solutions where required and appropriate.
The framework emphasises the need to ensure that resources are in the right settings, stating that “having timely access to the right expertise in community settings is essential to a responsive model”. An example is provided of a rotational workforce model in which therapy staff move between hospital and community settings to enable staff to gain exposure to different parts of the pathway and broaden their skillset. This “can be supported by digital staff passports,” the framework says, “which enable staff to be deployed into other organisations”.
Increasing efficiency within the workforce can be “achieved through a competency-based approach,” the framework states, allowing the system to “optimise its workforce based on skills available… aligned with the competencies identified through the workforce planning exercise.” It suggests that this can be supported through use of digital solutions to enable remote delivery of rehabilitation and to improve remote access to registered therapist knowledge, ensuring that specialist expertise is accessible in a timely manner and reducing the need for travel.
As such, a recommended action is to release therapist capacity by utilising digital interventions for remote assessment, advice and delivery where appropriate.
Implementing effective care transfer hubs
Next, the framework moves on to discuss the role of care transfer hubs in intermediate care, describing them as “focal point(s) for coordinating discharge” for people requiring post-discharge health and/or social care support.
The framework shares a number of priority actions for systems in this area, including ensuring that information is shared appropriately through hub pathways, and ensuring effective use of capacity and demand data, with appropriate information governance arrangements in place.
A medium-term action is to develop measures to monitor timeliness and effectiveness of care transfer hubs in supporting people to access post-discharge support.
Improving data quality and preparing for a national standard
In this area, the framework notes that whilst NHSE is developing a new national standard for rapid discharge into intermediate care, “data in this area is not standardised, consistent and is often collected at a local level in multiple formats”, which “limits the understanding of the timescales and processes that support optimum discharge into intermediate care”.
The steps in the framework are intended to “facilitate rapid improvements to data quality, coverage and completeness at system, regional and national level,” it continues, “with care transfer hubs acting as custodians of operational system-wide demand and capacity real-time data”.
A recommended action is to embed system-wide visibility of data across all partners into day-to-day operational working with clinical leadership in care transfer hubs. The framework adds that these hubs will be “critical” to information oversight and to help make the transition between hospital and home “as seamless as possible”.
Providing two examples of system visibility tools, the document highlights how Leeds Health and Care Partnership is using a technology solution to bring data together from across the system and visualising it with key insights to understand system pressures. Humber and North Yorkshire ICB, meanwhile, is using digital tools alongside revised pathways to improve flow and reduce discharge delays, with a solution providing shared visibility of all people using acute and community services and tasks relating to discharge.
With regards to data sharing, the framework also recommends that ICBs ensure that their data sharing agreements are aligned to the NHSE Information Governance Framework. An example of best practice comes from Frimley Health Foundation Trust; the trust has worked with local partners to develop an agreement allowing them to securely share confidential data across systems, with their framework enabling “the real-time use of risk stratification data at the point of care for people with the most complex needs.” Another example is The Dorset Intelligence and Insight Service, a collaborative project designed to deliver a live linked dataset across Dorset ICS. “It is being used to support data-led service improvement and planning at a system and organisational level,” the document shares, and is now “being used every day by health and care professionals to support evidence-based decision-making”.
The framework moves on to evaluation and ongoing monitoring of interventions, sharing a recommended action for ICBs to continue to evaluate improvements made to increase capacity of intermediate care services. As such, data is required for quality assurances purposes. An example of this in action is highlighted from Oxford, where a data dashboard is under development for specialist intermediate care focusing on people experiencing homelessness. The dashboard captures patient experience, outcomes and effectiveness for public services and makes use of a range of metrics, allowing for comparison of trend data against benchmarks and “serving as a valuable management tool for intermediate care to drive long-term service improvements”.
With regards to developing data, the framework states: “Investment in building data skills and capacity is vital. Data as business intelligence will be a key component of the implementation support available to systems and providers.”
It shares that NHSE is working with the Chartered Society of Physiotherapy to deliver health informatics e-learning resources which are to be made available for Allied Health Professionals early next year. NHSE will also set out an intermediate care minimum dataset for individual records, “to evidence the impact of interventions on outcomes, aligned to initiatives including proactive and personalised care, virtual wards and initiatives to develop client-level datasets within social care settings.”
Finally, the framework notes that NHSE is “committed to supporting local teams to work towards automated data extraction from online systems, and to creating opportunities for systems to access data to benchmark the efficacy of their commissioning practices.” It advises systems to familiarise themselves with the plans around the Federated Data Platform rollout, and provides a full list of data tools and resources here.
To access the intermediate care framework in full, please click here.
