Themes
- Home first approach to care
- Shift to early intervention
- Whole system productivity
- Innovation through technology
Background
Hertfordshire Community NHS Trust (HCT) provides community-based health care services to more than 1.2 million people living in Hertfordshire and beyond. HCT supports people at every stage of their lives, from health visiting and school nursing to community rehabilitation and palliative care. Leaders at the trust are developing their work with system partners to achieve the shift to prevention and proactive care – with particular concerns over ageing populations in the region, living with frailty and co-morbidities.
HCT strives to provide outstanding services and improve the health and wellbeing of the communities it serves. The trust provides joined-up local care, harnessing modern processes, systems and technologies to enable the best for staff and patients. This continual drive towards innovation has supported the trust in expanding its 'hospital at home' (HaH) service over the past few years, which is focused on admission avoidance and the delivery of patient-centred care to support people in their own homes.
Building on this, HCT is now focusing on how it can support people before they reach crisis point by identifying the individuals most at risk and making targeted early interventions. Leaders at HCT believe this direction of travel is vital to ensure it can support its ageing population both now and in the future.
Providing the Hospital at Home service
The HaH service was set up in 2022 and has since helped more than 13,000 patients receive care in their own home, with approximately 200 individuals using the service at any one time. The service operates from 8am to 8pm, seven days a week, taking referrals from health and social care partners across the system to provide both step-up and stepdown care, with approximately 80% of referrals relating to admission avoidance and 20% relating to early supported discharge. The core team is made up of GPs, paramedics, nurses, therapists, pharmacists, administrative support officers, mental health professionals and social care colleagues who provide a hybrid service of remote care from an Integrated Care Coordination Hub and face to face care in the patient's home.
The HaH service ensures joined up working across all parts of the care pathway to prevent people being unnecessarily admitted to hospital. The service takes a capability approach to ensure that any patient who can safely be supported at home rather than in hospital is accepted and this is not limited to specific patient cohorts. Once an individual has been referred into the service, the team has access to a wide range of support services and technologies to ensure individuals get the right care at the right time in the right place.
They make use of a myriad of health devices including a remote monitoring system that allows individuals to receive care from a team of healthcare professionals working in a central hub with access to the patient's health data. In addition, technology is being used to deliver a course of antibiotics that would usually require three to four nurse visits each day. Instead, a nurse is able to visit once to set up the elastomeric device which delivers the antibiotics throughout the day with their vital signs being remotely monitored. This reduces the level of disruption for individuals throughout the day and frees up time for staff to deliver care elsewhere.
A key asset of the HaH service is its access to local acute hospital consultants, who attend regular multi-disciplinary team (MDT) meetings with the core HaH team and can be accessed when required to provide specialist advice.
The impact of Hospital at Home
Since the service first started, HaH has prevented 2,600 A&E or ambulance referrals being admitted to hospital, instead delivering the care needed at home. It has also assisted 2,200 people on inpatient wards to leave hospital early, saving approximately 2.2 acute bed days per step-down referral. This is beneficial for individuals and is much more cost effective.
"My mother has severe Alzheimer’s and Hospital at Home offered her the very best care within her home so she didn’t stress about what was happening as they explained step by step to my mother and us. They came every day and didn’t sign her off until they (and us) were satisfied she was over her infection. Best hospital care ever."
Local acute trust data shows that in 2023/24 there had been a reduction in A&E attendances and emergency admissions across the three main patient cohorts of heart failure, respiratory and frailty compared to 2019/20. The HaH service has also boosted productivity for UEC pathways across the system. In Herts and West Essex Integrated Care System, the ambulance conveyance rate reduced from 47.5% in February 2023 to 40.2% in January 2024. Ambulance staff feel empowered to make referrals into the HaH team when they believe an individual would be best cared for in their own home. The HaH team also has access to the ambulance stack and can take referrals directly where they feel this is appropriate, saving ambulance staff time and freeing up resource to support urgent incidents.
The shift to early intervention
HCT is keen to build on the success of HaH and the trust is looking at how it can provide more proactive support for individuals through targeted interventions within their Minus nine project. The project aims to identify the need and intervene for patients approximately nine days before a hospital admission or crisis intervention. It is currently in its early stages, with rollout planned for winter 2024/25.
The project will look to identify the highest risk patients across the system – those who are likely to need additional support to prevent an admission due to their vulnerability and who could be better supported through the delivery of wrap-around care at an early stage. Interconnected communication systems will then provide a flagging system for these patients when they make contact with a healthcare service, and staff will aim to arrange a face-to-face appointment, ensuring they are seen by the most appropriate healthcare professional. Clinicians can also refer patients who are particularly frail and vulnerable into the service, where a member of the team will conduct a visit to ensure the individual has the right support to remain safe and well at home. These patients will also receive proactive case management for between six to 12 weeks to reduce their risk of admissions and improve their quality of life.
The case for change
In order to meaningfully and sustainably support the national commitment to shift care into the community, leaders at HCT believe that greater national investment is needed to enable community providers to scale up and develop existing community-led initiatives such as HaH and Minus nine. This will require an investment plan for community services that is upheld at a national level to ensure systems are incentivised to move towards more proactive models of care.