DOMICILIARY CARE

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DOMICILIARY CARE

• AN OUTCOME BASED APPROACH TO COMMISSIONING

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DOMICILIARY CARE

• A traditional approach to commissioning based
  upon-
• Identifying the activities to be completed on
  each visit
• Allocating time for each activity
• Specifying the time of arrival and departure
• This approach is not applied to other forms of
  care provision, in particular residential/nursing
  care

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WHY IS THIS APPROACH NO LONGER APPROPRIATE?

• Very rigid and inflexible
• Not focussed on the needs of the individual on a
  day to day basis
• Does not enable providers to meet the
  requirements of the National Minimum Standards
  (eg Standard 7, Service User Plan)
• Costly bureaucratic in terms of the
  commissioning process
• Commissioning domiciliary care needs to become
  more sophisticated a 3 way partnership between
  service users/commissioners/providers

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OUTCOME BASED COMMISSIONING

• Based upon care assessors identifying the
  eligibility specific outcomes to be achieved
  for each person
• Blocks of time for providing the care are then
  allocated on a weekly/monthly basis
• The service provider then identifies with the
  individual receiving care, how the time is
  allocated and the activities to be undertaken in
  order to achieve the objectives ( Standard 7
  Service User Plan)
• The effectiveness of the service is monitored
  evaluated against whether the outcomes required
  have been achieved

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3 MODELS OF OUTCOME BASED COMMISSIONING

• FOLLOWING ASSESSMENT OF ELIGIBILITY AND
  IDENTIFYING THE REQUIRED OUTCOMES
• Blocks of hours are allocated to providers for a
  group of people receiving care
• Hours are allocated for each individual but there
  is flexibility to move hours between people
  according to need, eg family visiting or extra
  hours needed because of illness.
• Hours are allocated to each person only
• Most authorities are favouring the 2nd model

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EXAMPLE Gordon

• Overall outcomes-
• Gordon is able to continue to live in his own
  home with his wife for as long as possible.
• Gordons wife is supported as his principal carer
  at key times to enable her to continue to provide
  care for her husband

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EXAMPLE GORDON

• Specific outcomes
• Gordon is assisted to maintain his personal
  hygiene each morning
• Gordon is dressed appropriately each day for that
  days activities
• Gordon is assisted in eating his meals

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OTHER EXAMPLES

• Medication (Specific outcome)
• Mrs X takes the prescribed medication at the
  correct times and in the right dosage
• Rehabilitation (Overall outcome)
• Mobility and independence is increased and
  maintained

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TYPES OF OUTCOMES

• Maintenance outcomes for the user
• Eg Kept safe, Live in a clean comfortable
  environment
• Maintenance outcomes for the carer
• Eg actively supported in the caring role
• Change outcomes for the user
• Eg regain skills and capacities
• Change outcomes for the carer
• Eg enhanced motivation or capacity to care
• Improve relationship with the user

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STRENGTHS OF THIS APPROACH

•          The care needs of the individual are at
  the centre (focus) of care provision
•          The actual care provided is flexible
  on a day to day basis and can respond
  appropriately to changes in personal
  circumstances
•        The service user has greater influence
  over when and how care is delivered
•       

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STRENGTHS OF THIS APPROACH

• The continuity of care to the service user
  should be improved
•        The time between the care assessment and
  the provision of care should be reduced
•        There should be greater flexibility for
  care providers
•        Costs of care assessment, commissioning
  and contracting should in time be reduced
•        Will enable care providers to meet the
  requirements of the National Minimum Standards
  in particular Standards 6, 7, 8, 9

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WEAKNESSES OF THIS APPROACH

• Likely to take longer for the care provider to
  set up the new approach than is originally
  anticipated cannot happen overnight.
• In short term is likely to prove more costly for
  service providers and LAs will need to pay
  accordingly but in longer term when this approach
  is adopted across the organisation costs will
  reduce
• Software installed for staff scheduling is not
  programmed for the flexibility that is built into
  outcome based commissioning
• People receiving care who are use to the previous
  way of providing care (set tasks at set times)
  will need to accept the new way of working this
  may take time

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OPPORTUNITIES OF THIS APPROACH

• To make user centred services a reality
• For care providers to undertake regular reviews
  of care needs and refer to care managers if a
  full re-assessment is required as a result of a
  significant change in care needs
• To develop close, collaborative working
  relationships between care assessors/contractors,
  care providers and the person needing care
•    Direct Payments

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OPPORTUNITIES OF THIS APPROACH

•    To use the limited resources available, most
  efficiently and effectively
• Possibility of making the work more interesting
  for care staff by not having to do the same task
  everyday with the same person needing care.
• Opportunity to provide incentives for providers
  and thereby aid recruitment and retention
• To evaluate the effectiveness of outcome based
  commissioning and compare it to other approaches
  to commissioning

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THREATS TO THIS APPROACH

•     Impact of extension of Direct payments
•      Key stakeholders (eg care assessors,
  contracts dept. some care providers) are not
  committed to the new approach and way of working
•       Need to be able to identify performance
  targets in relation to the provision of intensive
  home care (C28, BVPI 53)
•       Outcomes identified may be too vague
•       Local authority/PCT fails to recognise the
  increase in costs for the care provider (eg time
  required to develop Service User Plan Standard 7
  of National Minimum Standards and pay a
  realistic rate for the provision of care)

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PILOTING OUTCOME BASED COMMISSIONING

• Set clear objectives underpinning principles
• Establish clear working protocols
• Consider role of service providers
• X reference all activity to relevant standards
• Identify training/development needs how to meet
  them
• Recognise there will be start up costs monitor
• Identify criteria for monitoring evaluating the
  pilot
• Identify the problems difficulties in changing
  the approach to commissioning as well as the
  positive
• Anticipate likely impact of DP PA
• Develop detailed project plan

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DIRECT PAYMENTS

• Expansion to people over 65 laudable but-
• Care services under DP often provided by lone
  workers
• Lone workers are not regulated in any way
• Lone Workers do not have to have CRB or POVA
  clearance could fail clearance but still set
  themselves up as lone workers
• Do not have to have any training or meet the
  requirements of the NMS
• Expansion in numbers of LW could further
  destabilize the home care market
• Lack of regulation of LW leaves vulnerable people
  exposed to exploitation.
• Could lead to destabilisation of the home care
  market

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WHAT OF THE FUTURE?

• Conflicting tensions in the system
• Green Paper on the future of social care for
  adults v
• Proposed White Paper on Health Social Care
• Role of community matrons
• NCSC gt CSCI gt Healthcare Commission
• Restructuring of PCTs v
• Demise of SSDs separation of adult
  childrens services

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WHAT OF THE FUTURE?

• In relation to domiciliary care
• Demand will continue to increase
• Possible developments eg-
• Teams attached to GP practices
• Amalgamation of posts roles with that of Health
  Care Assistants
• Continued specialisation
• Whatever happens we need to ensure we meet the
  needs of the people requiring care particularly
  personal care

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CONCLUSION KEY WORDS

• The provision of real person-centred care
• Collaboration and co-operation
• Partnership joint ownership
• Outcomes
• Trust mutual professional respect
• Quality provision
• Realistic pricing
• This means-

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SUMMARYTHE WAY FORWARD

• Commissioners, contractors and providers working
  collaboratively and in partnership
• Commissioning based upon achieving specific
  outcomes rather than undertaking particular
  activities
• Contracting for blocks of time per week/month
• Letting service users and providers mutually
  agree the activities to be undertaken at the
  times most convenient for service users
• Providing a care service that has the needs and
  preferences of the service user at its heart