Improving outcomes for vulnerable adults after hospital discharge

Full Application: Not funded at this stage

We are seeking to address a strategic priority of the Council Plan; to enable older residents and vulnerable adults to live independently & a strategic main theme of our Joint Health & Well Being Strategy; to enable residents to maximise their capabilities & life chances; specifically to improve the outcomes & independence for elderly & vulnerable adults leaving acute hospitals within a short re-ablement period & reducing the impact on long term social care. Our application aligns to citizens managing their care & support across social care, health, primary & secondary care & managing own care through digital channels.

RBWM & our partner Wokingham Borough Council (WB) have two similar re-ablement services; RBWM recently adopted a strengths model, WB deliver a traditional assessment model, both delivered through Optalis Ltd, our jointly owned LATCo. Both teams deliver person-centred re-ablement care for residents who are elderly or vulnerable adults;Well enough to be supported at home;In need of short-term help (1-6 weeks);Needing social care support.

Main Objectives:Determine assistive technologies (AT) suitable to support effective short-term care after hospital discharge, reducing hospital re-admission or entry to long term care.

Explore valid circumstances & the limitations for the use of AT to deliver improved home-based independence outcomes for service users.

Explore suitability for other Community Health, GP & Social Care single use applications.

We propose to adopt a “user led workshop design” approach for the discovery phase. The primary focus is to involve service users & family or carers together with health & social care professionals to capture their home based support experiences that would be applicable to using home based assistive technology (AT) to support the service user in their independent living. Each workshop will be independently facilitated by Thought & Impact Ltd.

Design workshop 1 will be for service users, family & carers, health & social care professionals to hear their stories & experiences & identify those most suited to an AT solution.

Design workshops 2 will use the user experiences & stories to explore the AT solutions that could be deployed to address some of the re-occurring home support needs. Design workshops 3 will involve a combination of users, health & social care professionals, family & carers & technology providers that best fit the design brief from the earlier workshops. If the design scope needs to be further narrowed a 4th workshop will be used to determine the priority to shape the scope of the application for the implementation phase.

The first design workshops are scheduled for week 2 & 3, the technical design workshop is planned for week 4 & the combined workshop in week 6. The Implementation Phase application will commence draft & internal planning from week 9, final submission due in week 13. The Project team will meet between workshops & in the implementation draft stage to evaluate project progress, manage risks & issues arising in the Discovery phase.

Phase Outputs

Workshop 1 User story for 6 week re-ablement. User priorities for potential AT. High level system/app design brief.

Workshop 2 Understanding the art of the possible. Technical design brief for engagement with future technical partners.

Workshop 3 User priorities for AT, User led design brief for drafting implementation phase application.

Prospectus discovery phase outputs

The primary problem we are seeking to address in the discovery phase is a strategic priority of the Council Plan; specifically to improve the living independently outcomes for elderly & vulnerable adults leaving acute hospitals within a short re-ablement period & reducing the impact on long term social care.

The discovery phase will use a design workshop approach to engage service users, their family & carers, together with health & social professionals in determining the priorities to be developed in the implementation phase that support service users with “Efficiency & strengths based approaches” to manage their own care through digital channels & citizens to manage their care & support across social care, health, primary & secondary care.

We will seek to find solutions that support family & carers to meet the independent living needs of the service user in their home.

We will explore with service users, family & carers, health & social care professionals & technology companies to identify the simple & effective solutions to address the highest volume of issues, & use a cost benefit analysis approach to rationalise the cost of a home-based support solution by volume of need, compared to cost of long term care. A simple illustration would be a Medication Observation solution where non-specialist professionals capture The National Early Warning Score (NEWS) calculated in accordance with the Royal College of Physician’s process.

Any solution that is to be developed & trialed in the implementation phase must

  • meet the main objectives & success criteria set out in question 1
  • be economic & scalable to meet any working model
  • be a home-based intervention support focusing on prevention & wellbeing of service user
  • improve the citizen, or Carer/Family managing support across social care, health primary & secondary care.

We propose to collaborate with Wokingham District Council (WDC) in the development and delivery of shareable user research in this phase of the work. WDC are joint shareholders in the LATCo Optalis Ltd who deliver adult social care services for both local authorities. The Wokingham delivery model is more traditional in it delivery approach, compare to the RBWM strengths based mode of delivery. The research will compare outcomes from the assistive technology approaches to clarify if either delivery model will have greater or lesser outcomes for users. The discovery workshop approach is replicable for other councils or health bodies to follow in the future.

We will share findings more broadly with the Directors of Adult Social Services across Berkshire and with the CCGs, Acute Healthcare Trusts, GPs and the joint Health leads.

 

Any solution that is to be developed & trialed in the implementation phase must

  • meet the main objectives & success criteria set out in question 1
  • be economic & scalable to meet any working model
  • be a home-based intervention support focusing on prevention & wellbeing of the service user
  • improve the citizen, or Carer/Family in managing their support across social care, health primary & secondary care.

This will be outlined within a final business case highlighting costs to the local authority and where relevant savings against current practice that can be realised and how this could be scaled across local authorities.

A research paper will be published following completion of all the workshops with both service users, families/carers and the professionals. This customer led design session approach will determine whether a single AI application can meet all needs or whether multiple appliances/applications may be required to fulfil the desired outcome.

The primary focus is to involve service users & family or carers together with health & social care professionals

The project team will invite up to 50 service users who have used the re-ablement service of either local authority in the past 12 months to attend the design workshops.

Design workshop 1 will be for service users, family & carers, health & social care professionals to hear their stories & experiences & identify those most suited to an AT solution.

Design workshops 2 will use the user experiences & stories to explore the AT solutions that could be deployed to address some of the re-occurring home support needs. The workshops will involve a limited number of users & professionals to explore potential solutions with technology providers.

Design workshops 3 will involve a combination of users, health & social care professionals, family & carers & technology providers that best fit the design brief from the earlier workshops.

Design workshops 4 – If the design scope needs to be further narrowed a 4th workshop will be used to determine the priority to shape the scope of the application for the implementation phase.

At this stage we are not aware of any further support requirements. However, would welcome the opportunity to call upon support at any time during the discovery phase and beyond.

Previously applied for funding from Social Care Digital Innovation but unsuccessful.

 

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