Alan Long Geoff Vale Procuring Outcomes – Help to Live at Home

Mears Group

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 The ingredients of care today create an unattractive outcome

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 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

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 Housing and taps are different

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 has undertaken research into outcome based commissioning in care

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 LGIU reports summary.

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 Achieving great care needs change..

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

Comprehensive Assessment Initial Support On-Going Support Closure Re- assessment and review Initial Assessment Initial Contact Referral from family, relative, GP NHT Referrals Hospital Discharge STARR Team

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

Domain Headings 1I can manage my personal care 2I can keep myself safe all of the time 3I can eat, drink and prepare my meals 4I can make decisions and organise my life 5I can participate in my local community 6I can maintain my home 7I can manage my actions ………..but we always capture what the customer has said in the support plan

I CAN WASH 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. Assessed outcome: Maintenance – I am supported to have a full body wash on the days that I choose. This is a Payable Outcome.

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 residents they will also facilitate and enable a range of social activities Rapid response service linked to your alarm New service provided by Wiltshire Medial Services (WMS) Paid directly to your support provider This is a rapid response team who will come to you when needed for example if you have fallen or you are feeling unwell and need someone to sit with you £3.50 for Aster and Wiltshire tenants; £4 for Greensquare and Selwood tenants. This charge varies because of differing charges by the alarm monitoring service. It is subject to a forthcoming review

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 Final Outcomes Payment Amount Final Payment First Payment First Payment Amount Approval of Support Plan Review Date Initial Support Plan Duration (max 6 weeks) PCP* Assessment & Outcomes * Person Centred Planning

Payment by results Ongoing Support Plan Final Outcomes Payment Amount Final Payment First Payment First Payment Amount Staged Payments (no. depends on length of plan) Approval of Support Plan Review Date

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