Implement services that empower individuals to maximise their independence, embed prevention into every contact, and proactively support high-risk cohorts through advance planning for future crises
The primary focus of High Impact Change Model: reducing preventable admissions is to reduce admissions to hospitals by remaining in or returning to the community.
F1: Putting in place services to support people to maximise their independence
- Following a crisis event, people should be supported to regain their independence as much as possible. Intermediate care services with therapy-led models should be available for both community step up and hospital discharge purposes.
- Improve the commissioning and use of auxiliary support services such as peer support networks, health coaching, equipment services, personal assistants
- Allocate resources to reaching people who might be receptive to managing their health conditions and building their support networks – this is one potential role of Neighbourhood MDTs. This could also help support harder-to-reach people who do not interact with other services regularly.
F2: Make every contact a prevention opportunity
- Across all health and care services, having one eye on preventing future crises alongside delivery of treatment for today
- Train and support staff to promote self-management as part of their routine practice and to trust people’s ability to manage their health and wellbeing. Be proactive in checking on individuals and their carers so they continue to feel supported to self-manage and know what to do if their condition changes. Use technology to support self-management and promote independence where appropriate.
- Identify where existing services could supplement their existing interactions with high impact preventative actions such as falls risk assessments, structured medicine reviews and advance care planning (see F3).
F3: Support high risk cohorts with advance planning for responding to future crises
- People of all ages with palliative care or end of life care needs are one of the frequent cohorts identified in admission avoidance studies.
- Those in receipt of social care are often high risk cohorts – both those in residential and nursing homes and those in receipt of domiciliary care packages.
- A breakdown in care can increase the risk of an unplanned or prolonged admission to hospital or care home. Work with unpaid carers to identify and address their needs so that they can continue to care.
- The suggested actions below for supporting each of these cohorts, with common themes around communication with individuals and their support network, and the effective use of advanced plans during a crisis response.