EHSS PILOT

1. EHSS PILOT Introducing Integrated Commissioning Manager  Adult Social Services  Registered Manager Caring Together (Formally Known as Carers Trust Cambridgeshire, Peterborough & Norfolk)

2. Enhanced Home Support Service (EHSS) • Facilitate discharge home from hospital or prevent admission to hospital or care home and help individuals • remain at home. • Short-term, rapid response service – often same day. • Covering the whole county • The service is delivered by 3 providers, who work closely together: Home Support Matters, Caring Together and • Carewatch. • The type of support provided depends on individual need but will typically focus on: • meal preparation • personal care • well-being monitoring • medication • night visits/sitting. • EHSS can also help with specific support, such as dementia respite care for a family carer or end of life care • Referrals come directly from the 3 acute hospitals and from the community via the Brokerage.

3. Geographical Areas and Providers Care Watch Home Support Matters Caring Together (Formally Carers Trust) Home Support Matters

4. What Are The Pilot Aims & Outcomes • To provide Short Term Support (weeks not months), bridge service gaps, promote Independence, assess longer term care and support needs. • Outcome 1. Facilitate hospital discharges and reduce bed blocking • Outcome 2. Avoid hospital admissions with shared care and support • Outcome 3. Provide crisis support • Outcome 4. Collaborative working with Norfolk First Support, Swifts, Night Owls, Discharge teams, GP practices, other home support providers, private sector providers, EOL services, acute hospitals, Brokerage, NCC Emergency Duty Teams.

5. Operational Support by Caring Together • 3 x Care Team Assessors. Assessments, Reviews, undertake first 48 – 72 hours of care and support until care package is stable. Directly employed for the EHSS pilot. Salaried 74 hours over 2 weeks. • EHSS Team Manager Coordinates referrals, over sees processes and systems in place, audits, rostering and line manages the CTA’s 0.75 % of Job Role is directed for the EHSS pilot • Team of Care Workers North, East, South and West Norfolk. Staff employed for generic services rostered to EHSS service when needed by the CTA team.

6. Operational Process by Caring Together • Referrer calls EHSS referral phone 9am – 8pm • Details of referral taken to check appropriate • Referrer completes Short Term Assessment Form & outlines plans for follow on services • Capacity confirmed within 30 mins • Door to Door transport service via EHSS assessors offered at the QEH • Take service user home or meet client at home on day of discharge. • Assessments carried out. Care Plan written and left in property • Care delivery starts within 2 hours of discharge. • Review of care packages every 4 weeks if required. • Signposted to other services • Handover to new services

7. Case Study – Mrs S.

8. What is working well • Facilitating Discharges/Avoiding Admissions • Collaboration between services • Flexible, adaptable service • Commissioners supportive • Seamless service with joined-up approach • Assessor meets service user home from hospital. Same day assessments • Assessors have team of care staff trained in re-ablement approach • Ability to transfer to our own generic home support services • Ability to signpost to other services on discharge • Customer satisfaction high

9. Challenges Recruitment of Staff with right skills & experience for emergency service Communication between services Referrers understanding of the service and making appropriate referrals Exit plans fail and change Misinterpretations of ‘need’ and ‘want’ Service user expectations, i.e. only wanting female carer, specific times, certain tasks Monitoring and reporting requirements Shared Care Package documentation Knowledge of the service Service user/family expectations of the service Exit plans & Misunderstanding of the service specification

10. Thank you for Listening Any Questions?