What is the challenge your project is going to address and how does it connect to the theme of 'How can improvement be used to reduce delays accessing health and care services'?

Amid the persistent hospital flow pressures, care at home providers don’t always have capacity to absorb the demand for clients awaiting care at home.

To address this and have a positive and significant impact on hospital flow, we must implement a new way of delivering care.  The ‘Proactive Home Team’ would be focused on enabling and promoting independence of clients discharged from hospital, with a view to reducing, or even eliminating the ongoing direct support needed.

Part of this will involve exploring and seeking support from external organisations and agencies offering meals services, day centre opportunities, befrienders, and other assistance.

This proposal is a natural next step in GCC’s ongoing work and collaboration with Aberdeen H&SC Partnership in facilitating the timely return home of clients from hospital, freeing up hospital capacity. The impact is easily measured through current data collection methods e.g., delayed discharge numbers, hospital capacity and unmet needs.

What does your project aim to achieve?

Without the constraints associated with traditional ‘rounds’, and the flexibility that the Proactive Home Team would have to respond and engage with unique social support around each client, resulting in minimal delay in receiving care/support needed to regain independence.

During the initial 6–8-week period with the Proactive Home Care team, if identified through assessments, that some level of ongoing care will be required, the GCC team will liaise with the GCC providers around capacity to accommodate clients, allowing a natural pathway from the interim support the Proactive Home Team provide, to a longer-term arrangement. Our intention is to enable a decrease in the initial care at home support required, following short-term intensive help provided.

With the transfer from the Proactive Home Team to a standard care at home arrangement within GCC, we can ensure that the capacity of the team remains able to accept new clients awaiting discharge timeously.

How will the project be delivered?

The Proactive Home Team would be set up with single and double-up (2:1) support capacity – 3 sub-teams for each City locality, with shifts covering visits between 7am and 10pm. It is anticipated that this project will be resourced through a collective group of GCC providers.

The remit of the team will be supporting people to return home from hospital, providing care and support for 6-8 weeks.  They will assess the client’s progress on an ongoing basis, adjusting the support accordingly and identifying which elements of the care can be delivered in an enabling way.

Prior to discharge, the team would liaise with the hospital team around the client’s outcomes.  A home visit would be requested, to confirm there were no safety concerns, and that basic needs can be met. This pre-work would minimise the potential for failed discharge.

To further manage risk, there would be collaboration with the MDT team, and weekly check-ins.

How is your project going to share learning?

Granite Care Consortium (“GCC”) are ten third and independent sector providers, with decades of experience in delivering health and social care services. We are commissioned by Aberdeen City Health and Social Care Partnership (“ACHSCP”) to provide outcomes-based care and support services to adults in their own homes/local communities.

Traditional procurement processes and contracting for social care, typically puts providers in competition with each other, whereas GCC is constituted on an equal partnership basis.  This model removes organisational boundaries, encouraging collaboration and empowering providers to concentrate on making things better for people who use services.

With the proposed extension of the Proactive Home Team to impact positively the ongoing challenges around hospital capacity, we plan to share further evidence/learning of how a collaborative approach to social care provision can lead to improved outcomes for people.

With ACHSCP, we would propose to share a case study around the project.