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Procuring Outcomes – Help to Live at Home Alan Long Geoff Vale Mears Group The ingredients of care today create an unattractive outcome • Task and time based billing takes little account of quality or long term cost reductions achieved • Single product thinking not service thinking • Poor partnership working between Commissioner and provider • Not enough done to ensure a sustainable workforce to meet rising demand Housing and taps are different In the past… Housing maintenance services commissioned on the basis of task and time Commissioners compared providers on the basis of their cost to fix individual items such as taps 3000 + individual rates, numerous invoices and no incentive to invest in prevention and long term cost reduction Race to the bottom --Cheapest taps etc Unhappy customers, rising long term maintenance costs… Housing and taps are different Today….. Housing maintenance services often commissioned on the basis of outcomes Providers provide an overall price per property for all maintenance in the home Providers tasked with reducing this over time by investment in quality that lasts We now buy the best taps that don’t breakdown Housing and taps are different Impact… • Customer service levels at all time high • Real, long term cost reductions achieved • Risk lies increasingly with the Provider • Incentivised work force • Broader outcomes included in tenders e.g. • Job and skills development • Investment in community projects LGIU has undertaken research into outcome based commissioning in care • 210 responses from 113 Councils • 75% said Time and Task system is an important blockage to development of outcomes thinking • 90% say they pay on task and time system • 13% say they pay by the hour minute LGIU reports summary. • • • • • • The concept of outcome-focused services is highly valued but rarely delivered ‘Time-task’ models can cause a challenge in times of shrinking resources. Paying providers on a time basis gives them a poor incentive for investing in the maintenance and rehabilitation of service users Also pushes commissioners into a position where their only means of making savings is to reduce the hourly rate. Over time, this has a serious impact on care quality and on care workers. Defining and measuring outcomes is challenging, but possible. Relationships with providers are central to achieving better outcomes for individuals in receipt of care Achieving great care needs change.. • Quality is the best way to reduce long term cost • Price for the delivery of outcomes not minutes • Reward quality of care that delivers real long term cost reduction e.g. reduced residential care, fewer hospital admissions • Integrate services together- Care, Assistive technology and Community equipment • Accept we should be paid less if we don’t deliver outcomes • Create the choice that service users want, not what is forced upon them Help to Live at Home “Help to Live at Home is at the forefront of practice in England at the present time because of its strong emphasis on outcomes for the customer” John Bolton, Case Study Report (2012). Help to Live at Home • • • • • • Challenge Vision Process Personalisation and Outcomes Contracts and Payments Some Lessons Help to Live at Home – the challenge Problems we are trying to fix • System that created dependency • People going into care homes • Poorly paid and devalued workforce • Self funders excluded • Fragmented and inaccessible services WHAT CUSTOMERS TOLD US Wiltshire • Population of 470,981 • The county measures 55 miles north to south and 34 miles east to west • Swindon has is governed by its own unitary authority • 92,000 acres of Wiltshire is owned by the MOD • 20 community areas • 18 Area Boards Help to Live at Home – the vision National Context The Caring for our Future White Paper • Focus on well being and independence and not waiting for a crisis • People with control over their care and personal budgets • Help people to stay connected with their communities • People understanding how care and support works – information and advice • Stop contracting by the minute • Minimum training standards for staff HTLAH – Design Principles • Service should be available to everyone • Lives not services • Don’t make long term decisions at a point of crisis • Get support in quicker to avoid long term needs • Offer initial support to all new people to maximise potential for independence • Invest in putting resources in early with benefits long term • Potential to improve in all support HTLAH Programme HTLAH Care and support service are supported by: • Telecare and response • Equipment and practical help • Independent support planning and brokerage • Specialist financial advice • Accommodation strategy • Wiltshire Centre for Independent Living • Wiltshire and Swindon Users Network Help to live at home, Care and Support – what is in scope • • • • • • • • • Non-complex support – for everybody Reablement Domiciliary care Social Care support for Community Health teams Housing support across sheltered accommodation Extra Care support Live in Care & Night Time Care Support planning – trusting providers Initial support and ongoing support Help to Live at Home – the process Doing things differently: Shifting the focus from crisis to wellbeing Old System New System Better information Living Well Low Level Needs Crisis Need for intensive care and support Living Well Low Level Needs Crisis Need for intensive care and support and advice to plan ahead to prevent care needs, and will be better connected to those around them. support within communities, better More housing options and improved support for carers to help people maintain their independence and avoid a crisis. HTLAH for reablement and crisis response to help people regain their independence at home after a crisis. Referral from family, relative, GP Initial Contact Hospital Discharge NHT Referrals Initial Assessment Initial Support Comprehensive Assessment STARR Team On-Going Support Reassessment and review Closure Changes in requirements • Minor adjustment – Change in resource £100 - £500 • Service break – Temporary stop in service • Exception – Change in outcomes Help to Live at Home – Personalisation and Outcomes Personalisation • HTLAH is the Councils response to personalisation • HTLAH is intended to promote real choice and control how a person is supported • Everyone should be offered a personal budget and the option of a direct payment Help to live at home – outcomes not hours We buy outcomes not hours • Hours build dependency and don’t incentivise providers to work towards promoting independence • Outcomes focus on both improvement and maintenance • Person centred assessments capture the exact wording customers use • Use payable outcomes to standardise and measure outcomes 1 2 3 4 5 6 7 Domain Headings I can manage my personal care I can keep myself safe all of the time I can eat, drink and prepare my meals I can make decisions and organise my life I can participate in my local community I can maintain my home I can manage my actions ………..but we always capture what the customer has said in the support plan I CAN WASH Assessed outcome: Maintenance – I am supported to have a full body wash on the days that I choose. This is a Payable Outcome. Provider’s Support Plan said: As with a shower I sit on the perch stool at the sink in the bathroom. Please run the water for me and make sure I have flannels and the soap my daughter bought me. Verbally prompt me to wash and dry as much as possible for myself and assist me to wash and dry my back, legs and feet. I like to clean my teeth in private after you have left. Help to Live at Home Service Model • Trusted role for Providers • Whole system way of working • Guarantees around single area contracts • Cost effective support plans (geography and customer outcomes) • Integration of social care and housing support roles • Long term contracts so Providers can invest in workforce Process requirements • • • • Shared I.T. Shared training Improved communication Shared strategic direction Help to Live at Home – some key requirements • Provider to deliver support between 7:00am and 10.00pm, 7 days a week • Contact with the customer to commence 4 hours from referral for emergencies 7 days a week • Providers do support plans and reviews • Providers case manage support • Now will include Live in and night time care) • New relationship with providers based on joint working Sheltered Housing Model Your alarm system (pull cord) the equipment Landlord’s responsibility Paid for in your service charges This is your pull cord or pendant Charges will vary depending on your landlord The alarm call centre Landlord’s responsibility; different providers Paid for in your service charges These are the people who reply when you pull the cord or press the pendant they will decide with you what help is best. This could be calling your Doctor or a family member or the emergency services or a person (rapid response) Charges will vary depending on your landlord Sheltered support service Responsibilit y of the Help to Live at Home providers Paid directly to your support provider This is the support team who works in your scheme to help you remain independent Everyone pays £5 , this includes: an introduction to your provider; an initial assessment of your needs and a support plan if needed; regular surgeries on site and access to a care and support team. Together with Help to Live at Home – Contracts and Payments Help to Live at Home – the contract • • • • 5+ 2 years (2018) Indicative rather than specific volumes Joint with NHS but separate contracts Council contract includes all social care and support for neighbourhood teams around intermediate care and end of life • Health contract for CHC • All customers except those requiring specialist services Help to Live at Home – Contract Management • • • • • Contract Management meetings Managing Provider performance Mable reporting – no surprises Protocols for reporting issues Role of customer reference group Help to live at home – paying for outcomes • Outcomes focus providers on quality of life not traditional hours based support • We buy fixed price support plans for a specified period of time, to avoid dependency building • We don’t adjust support for small variations • We have an exceptions process for when things don’t go to plan • No-one wins if a provider does not achieve the outcomes Help to live at home – Payment by Results • Contract means the Council doesn’t pay if Providers don’t achieve outcomes and they are at fault • 3 rules for payable outcomes – Observable – Attributable to providers work – Defined in standard ways Payment by Results • A Positive Step: – Removing constraints from providers – Paying for what we want – what we want is outcomes – Incentive to identify problems • Will only work in partnership – Assessment to Support Plan – SMART Payment by results Initial Support Plan Duration (max 6 weeks) Approval of Support Plan Review Date PCP* First Assessment & Payment Outcomes Amount Final Outcomes Payment Amount First Payment * Person Centred Planning Final Payment Payment by results Ongoing Support Plan Approval of Support Plan Review Date First Payment Amount Final Outcomes Payment Amount First Payment Staged Payments (no. depends on length of plan) Final Payment HTLAH Some lessons learned • • • • • You can transfer customers Project management is vital Needs sign off “from the top” Culture change takes time, lots of time Operational staff need to be involved from the beginning • Communications with Members, MPs, staff, customers, providers – a full time job • In house training and development key to change – including refresher training • Marketing social care