NHS Norfolk and Waveney Discharge to Assess 2: Reablement and Recovery Pathway in appropriate Care Home Settings

This is a Provider Selection Regime (PSR) intention to award notice. The awarding of this contract is subject to the Health Care Services (Provider Selection Regime) Regulations 2023.<br/><br/>The broad outcomes required of the Central Norfolk Reablement and Recovery service are specified below:<br/><br/>

• Provide a time limited (up to 6 weeks) period of bedded reablement and recovery, outside of a hospital environment, to promote independence and enable discharge home/ usual place of residence (UPOR) or to a least restrictive suitable bedded environment<br/>
• Reduce length of stay in Acute Hospitals<br/>
• Reduce potential for deconditioning<br/>
• Provide personalised care for all individuals accessing the service including delivery of a person centred reablement and discharge plan<br/>
• Delivery of reablement and care plan interventions for individuals on the pathway; agreed with the individual, their families, carers and the care home team<br/>
• Improve quality of life for individuals and their families/carers.<br/>
• Contribute to the reduction of avoidable re-admissions to hospital<br/>
• Improve professional relationships between care home staff, GP practices and MDT members<br/>
• Contribute to reduction in the number of pressure ulcers<br/>
• Contribute to reduction in the number of falls<br/>
• Streamline communication to enable patients to get appropriate non-urgent intervention<br/>
• Promote continuity of care by improving communication and handover to enable seamless transition from the pathway to relevant long-term care Providers<br/><br/>Project Deliverables<br/><br/>To deliver a Reablement and Recovery pathway within the designated N&W ICB commissioned care home beds, with a clear expectation that residents will remain on the pathway for up to 6 weeks and that the individual shall either return back to their own home/UPOR, with support if needed, or transfer into a suitable longer-term placement.<br/><br/>To support delivery of the pathway, Care Home Providers will be expected to provide a timely response and access to the commissioned beds for eligible individuals, proactively work with the individual and the in-reaching multi-disciplinary team (MDT) to enable progression of discharge plans and timely exit from the pathway.<br/><br/>The Central Norfolk HomeFirst Hubs will be responsible for sharing Transfer of Care (TOC) referrals with Care Home Providers for consideration. Care Home Provider requirements:<br/><br/>
• During operational hours (Mon-Friday 08.00-18.00), Care Home Providers will respond within 2 hours of TOC receipt to identify whether or not the individual is provisionally accepted and/or outlining any additional information that may be required to make a decision.<br/>
• The Care Home’s Registered Manager or nominated deputy may need to attend the Acute Hospital to assess the person face to face to ensure they can safely meet their needs. Where this is required the assessment and decision should be made within 48 hours of receiving the TOC Monday to Thursday and within 72 hours for TOCs received on a Friday.<br/>
• NB: Please note the intention to develop a Trusted Assessor role working with Care Home Providers and on their behalf to support timely decisions and transfer to the pathway in future, with the aim to transfer suitable individuals to the pathway within 48 hours of TOC referral. This also allows the opportunity to enable transfers 7 days a week. It is anticipated that this role will be part of the Central Norfolk HomeFirst Hub and operate 7 days a week to enable safe and effective transfers 7 days a week. The role will be developed with Care Home Providers, informed by the CQC Guidance on Trusted Assessors and Local Government Authority (LGA) Guidance on Trusted Assessors.<br/>
• Care Home Providers will receive a handover from the Acute Hospital ward or Hospital Discharge Team on the day of transfer. Wherever possible transport booking times will be shared to enable an estimated arrival time.<br/>
• Care Home Providers will temporarily register the person with an agreed Primary Care practice, within 24 hours of admission or as soon as possible for out of hours admissions.<br/>
• Care Home Providers will ensure the designated rooms are available for admitting individuals 5 days a week, Monday to Friday, during the contract period, with an intention to move to 7 day admissions including bank holidays, once the pathway is fully established and Providers are assured regarding quality of discharge information and transfers. Admission times will be dependent on the needs and safety of each individual with aim to transfer between 08.00-18.00.<br/>
• Care Home Providers will, when beds are available (Monday to Friday 08.00-18.00), admit individuals within 24 hours of an accepted TOC referral, unless otherwise jointly agreed with NCHC, the Central Norfolk HomeFirst Hub and Acute Hospital team arranging the discharge.<br/>
• Care Home Providers are required to build good working relationships with their aligned GP practice for the pathway and the in-reaching MDT.<br/><br/>
• Care Home Providers will work with MDT members to support achievement of the outcomes specified within the individual’s care and reablement plan.<br/><br/>
• Care Home Providers will liaise effectively, sharing their professional insight, during weekly MDT meetings to inform planning, and be proactive in supporting the individual to return home/UPOR or new bedded care environment in a coordinated, safe, effective and timely manner.<br/>
• Care Home Providers will be expected to always have suitable staffing levels available to safely meet the needs of individuals on the pathway, which will include double assist care. People who are eligible for care will have varying levels of dependency and are likely to have both physical and cognitive/mental health needs.<br/><br/>
• Care Home Providers will be able to provide temporary 1:1 support, if required, to safely manage short term escalations of behaviour e…