Service Evaluation
Rapid Response Assessment Service
Thurrock Council & North East London NHS Foundation Trust
April 2014
Contents
Page:
1.
Key facts – relevant to current and future set up of RRAS
1
2.
Executive summary
2
3.
Background
5
4.
Methodology adopted
7
Findings from data and information related to RRAS
5.
- Demand
9
6.
- Source & reason for referral
10
7.
- Visits related to referrals
11
8.
- Assessments
12
9.
- GP practice
13
10.
- Admission avoidance
15
11.
Summary - service user review
16
12.
Feedback collated from stakeholder engagement
17
13.
Overall conclusions
20
14.
Recommendations
21
15.
Appendices
23
© 2014 Merra Ltd. All rights reserved
1
Key facts – relevant to current and future set up of RRAS
 Rapid Response Assessment Service (RRAS) is an integrated joint health
and social care team which provides rapid response and assessment for
people in crisis and went live in April 2012. RRAS co-ordinates and
redirects care to the appropriate intermediate provider or service.
 National demographics - over the next 20 years the number of
people >85 yrs is expected to increase by 106% by 2030. The
number of people requiring care needs will increase by 61% by
2032.1
 The RRAS was developed following the success of the Thurrock Rapid
Response Duty pilot in Thurrock, with the aim to respond to service
users who needed to be seen within four days to prevent the situation
reaching crisis and also respond when they are in crisis. The pilot
identified the need for urgent social care support outside of the usual
ways of working and dedicated health care input.
 By 2018 the number of people with 3 or more Long Term Conditions
(LTC) is expected to rise to 2.9m. People with LTC account for 70%
of all inpatient beds.2
 Nationally, Reablement funding is available until 2015, when it will
become part of the Better Care Fund (previously know as the
Integration Transformation Fund) during 2015/16. Other budgets
impacting both health and social care will be pooled to form this
fund, for example carers’ break funding.
 The team does not hold a caseload and is therefore able to rapidly
respond to crisis intervention calls.
 Data collated from September 2013 to end of November 2013 (a period
for which data on time was recorded) showed 86% of service users were
seen within the same day and 85% of these were seen within two hours
of the referral being received by the team.
 From 1st April to 30th of November, 1,355 referrals were received and
80% had assessments undertaken. The average range of inappropriate
calls or redirected referrals was 10 – 20% during the same time period.
 Details of age profiles and summary of conditions assessed during this
time period were not available for this evaluation review.
 Funding for the RRAS team is sourced from the PCT reablement budget
in Thurrock.
 Better Care Fund will entail a substantial shift of activity and
resource from hospitals to the community. Hospital emergency
activity will have to reduce by 15%. 3
 Local plans on how integrated services will be commissioned using
this Better Care Fund will need to be developed and agreed during
the early part of 2014. Key areas will be integrated models of care,
seven day working, joint approach to assessments and care planning
as well as managing unplanned care.
 Robust evidence on the impact of Rapid Response type teams is
lacking. The set up of these teams varies between organisations
e.g. some are nurse led with no social input or vice versa, resulting in
different delivery outcomes. Comparisons are therefore difficult.
 The RRAS is an essential service to further support the unplanned
care agenda in Thurrock, however, robust evidence is required to
demonstrate performance against outcomes achieved and ensure
the service continues.
1 King’s Fund 2013, 2 Department of Health 2012, 3 King’s Fund 2014
© 2014 Merra Ltd. All rights reserved
2
Executive summary (1/2)
Rapid Response Assessment Service (RRAS) is an integrated health and social care team
 The main sources of referrals are family/friend, GP and other, with the main
which provides rapid response and assessment for people in crisis in Thurrock.
reasons for referrals recorded as health related. This could explain why the
majority of assessments are health only assessments. Having joint visits and
The original goals set for the RRAS were to:
assessments will identify both health and social issues which will support longer
 Provide a timely joint health and social crisis management service for adults aged
term management, preventing potential further crises from occurring.
18+ which included assessments;
 Service users registered at 15 particular GP practices (out of 35) account for
 Facilitate onward referrals to other community providers and support independence
50% of all referrals received. There seems to be a link between high user and
of the service users so that they remain in their own homes; and
repeat referrals in terms of the registered GP practice. Additional analysis is
 Support the unplanned care pathway so service users are not seen or admitted to
required to explore this further e.g. obtaining details on patient list size,
the acute provider and do not need emergency social placements.
proportion of elderly patients, acute admissions, etc.
Service Evaluation
 The majority of referrals received are recorded as seen once by the RRAS (70%).
The remit of this evaluation was to gain an in-depth understanding of how the service
The range for repeat referrals was 2-8 times, the same pattern as 2012/2013.
has been delivered and whether this meets the original aims and goals set out in April
Further analysis is required to understand whether single or repeat referrals are
2012 when the service began. The time period for the review in terms of available data
an indicator of the effectiveness of the RRAS.
st
th
and information was agreed as 1 April to 30 November 2013.
Service
user review
The evaluation was conducted using the data and information related to the RRAS,
 20 service users (5% of a total of 521 referral and 392 service users) were
service user reviews and stakeholder feedback.
reviewed using the IAS numbers from 2nd December 2013 to 31st January 2014.
A detailed service user review was undertaken in late February 2014 to gain further
 Detailed review of each service user was undertaken using both social care (IAS)
understanding.
and health (SystmOne) records (see appendices for further details).
Summarised Findings
 16 out of the 20 were repeat users of the service.
Data and information related to performance
 19 were known to social care, with a mixture of interim and permanent care
 RRAS does provide crisis management for service users in a timely manner,
packages commissioned.
typically within 1-2 hours of the referral being received.
 Main reasons for referrals were health related with 15 out of the 20 for short
 Demand for the service has increased over time, with over 200 referrals in
term health and 4 for long term health reasons.
October and November.
 End outcome of service users at time of the review (26th of February)
 The most intensive period for receiving referrals is between 09:00 – 12:00.
17 service users were at home (1 in original care home)
There are few referrals from 19:00 onwards.
2 deceased
 Based on the data available there does not appear to be justification for a 24
1 in residential care home
hour RRAS. To optimise the operating hours and days, a demand vs capacity
 Overall, following service user review 18 of the service users seen by the service
model analysis is required.
were considered to have been appropriate use of the service , 1 was seen due to
 83% of total referrals received result in an assessment, the majority of which are
gaps in existing services and 1 was considered an inappropriate referral.
undertaken by health. It appears only a small proportion are joint assessments
with both health and social representatives. This is not in line with the goals of
the service and needs to be addressed.
© 2014 Merra Ltd. All rights reserved
3
Executive summary (2/2)

Stakeholder feedback
Approximately 26 individuals were interviewed during this evaluation, including RRAS,
team, other teams linked with RRAS e.g. MDT, JRT, SEEDS, plus 5 GP practices. A set
framework of questions was developed and agreed and used as part of this process.
The findings include:
 The majority of those questioned understand the main roles and functions
of the RRAS, however, more clarity is required for other community services
(especially for health). This would support longer term management and
prevent repeat crisis situations occurring for service users. There seems to
be a lack of understanding on what social care actually does in the service
which needs to be addressed.
 The current poster and leaflets do not give enough clarity about what the
service does. Most people interviewed are aware that the team has grown
over time and that the operating hours have increased due to on-going
demand The actual operating hours and days was not always known.
Clarity and marketing of the unplanned and planned care pathway is
required to prevent duplication of resources and delays in interventions
being delivered.
 The RRAS is well received by those who refer to it and work with it. The
location of the team is conducive to partnership working with other
community services e.g. MDT, SEEDS. The actual office space for the team
is too small and the IT systems are not efficient or effectively used.
 The service is perceived to ‘add value’ but there are concerns in terms of
on-going demand and dependency. Joint visits are considered the most
valuable and ‘unique selling point’ even though in practice this does not
often take place.
 Most of the GPs interviewed praised the prompt feedback following visits
and assessment of service users referred directly or by others. There seem
to be informal discussions with social by health colleagues, however, this is
either before or following a health visit without social representatives.
 The input provided by social is then not captured in records for social care,
especially if the service user is not seen. Again joint visits and assessments
need to be increased and informal joint discussions formalised in records to
promote longer term management.
Formalisation of onward referrals is required, especially to other community
services, however, speed of response by others does not always support
management of the crisis. As the RRAS does not hold cases, feedback from
these onward referrals is not followed up.
 The impression formed is that service users already known to social care are
directly referred to locality for crisis social care input. This needs to be
addressed as this seems to imply that social care does not respond in a timely
manner during crisis for known service users.
 There are regular compliments received with minimal complaints. Feedback
directly from service users and family would be useful to further refine the RRAS.
 RRAS seems to be a community focussed solution to crisis management, though
some have argued that the traditional model does not apply for the frail elderly
as these types of service users were previously in hospital settings and not
managed in the home environment.
Conclusions
The RRAS does support the unplanned care pathway, however, clear focus on what the
service will or will not do has to be discussed and agreed to prevent potential
duplication of interventions and to secure on-going funding (via the Better Care Fund).
Given the number of changes that the RRAS has gone through, there needs to be
refocussing and communication of the goals of the service and formalisation of
processes both internally and externally to the RRAS.
Overall, based on the findings RRAS does deliver a valuable and well regarded service
for residents in Thurrock. The interventions delivered by the service seem to be
appropriate to the crisis situation and appear to reduce or avoid admissions to both
hospital and residential care for the short team.
The type of service user group using the service requires support for proactive long
term management, which requires more than the RRAS, with more robust coordination
of health and social care needs. This may be difficult for social care due to funding
arrangements.
Next steps
Detailed recommendations can be found in the report.
Sharing the report will benefit others especially the RRAS team, CCG and other key
stakeholders.
© 2014 Merra Ltd. All rights reserved
4
Background (1/2)
Evaluation purpose

This service evaluation was commissioned by Thurrock Council to assess
the current set up of the Rapid Response Assessment Service (RRAS).
This included exploring whether the original strategic vision of the service
was being delivered, if the service is still ‘fit for purpose’ and if the service 
is perceived to be of ‘added value’ in managing the unplanned agenda for
the residents of Thurrock. The review was designed to include the
following:


Brief review of the types interventions delivered by RRAS and were
they deemed appropriate to the service user’s needs;

Determine the interventions delivered and evaluate whether the
focus was on a community service solution rather than a traditional
service solution;

Evaluate the impact of the crisis support via the RRAS and further
determine whether the service user’s resilience increased in order
to prevent further crisis management via the RRAS or other service
providers; and

Gain further understanding for the ongoing service requirements,
exploring options to support the design of a revised service model
for ongoing use in accordance with the organisational needs.
The Rapid Response Assessment Team was formed following a
successful Thurrock Rapid Response Duty Pilot (social care only)
which commenced in April 2011. This pilot demonstrated a
significant need to manage certain service users differently to
mitigate crisis situations from arising and the need for health input
to support crisis management.
There are two IT systems used by the team:
- social care, Integrated Adults' System (IAS)
- health, SystmOne
Main aims - respond quickly to a crisis situation which may be health
or social care related or both for adults aged 18+. Deliver timely
assessments of the crisis situation and intervene as appropriate to
minimise the need for further intervention from acute provider or
emergency social placement. Promote independence of the service
user and carer or family involved.

The referrals received are triaged using information from both
systems to support the management of the referral. This process can
prove to be difficult if the GP practice is not on SystmOne, resulting in
duplication of process or investigations.

The RRAS is linked to a number of other health and social care
services to support the unplanned care agenda. The team coordinates and redirects care to the appropriate intermediate provider
or service during the management of the referral. The main
difference of RRAS is the response time and having a holistic
approach.

Funding for the team is via the Reablement budget, the format of this
budget will change during 2015 as it will be pooled to become part of
the Better Care Fund.

Robust evidence to support schemes like RRAS is lacking. Similar
teams which have been reviewed have been set-up differently, either
social care led or health, and hence outcomes measured were
different.
Rapid Response Assessment Team – start up

Following this, the (RRAS) started in April 2012. The skill mix included
a combination of advanced nurse practitioners (able to prescribe),
social workers, support planner, Occupation Therapy Assistant,
Health Care Assistant and dedicated administrator support.
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5
Background (2/2)
Operational process for RRAS
Operational process for Rapid Response Assessment Service
 The set up for RRAS has evolved since it started. This has been partly due to
demand on the service, with increasing referrals, further investment and the
need to operate at the weekends. The service operates from Thurrock
Community Hospital, where it is co-located with Out Of Hours provider and
other community services.
 Initially operating hours for the service were set as Monday – Friday 9am10pm and weekend cover once further investment was secured. The service
operated as 9am-5pm until full staff recruitment was completed. This later
became Mon-Fri 9am-9pm. Weekend working (Sat-Sun 9am-5pm) started in
the second year. For health this was September 2013 and for social care
November 2013. There has been further interest to deliver a 24 hour service,
seven days a work. Before this is agreed the demand for this should be
explored.
 The current information related to RRAS seems to contain different operating
times and times for delivery e.g. assessment and visits.
 The diagram to the right has been developed as part of this evaluation to
explain what the current operating pr ocess is for the team.
(Mon-Fri 9am – 9pm, Sat-Sun 9am – 5pm)
Community Solution
Team (CST)
Referral deemed
inappropriate and referred
back to referrer either by
admin or professional from
RRAS team
 Increase and improve partnership working and care co-ordination, especially
with end of life care; increase the number of appropriate referrals to
community based services.
 Regularly review user evaluation feedback to support improvements in
service.
RRAS admin receive referral, collate personal
information via SystmOne and IAS systems pass
onto health, social or both for triaging, time of
referral plus other key information recorded
manually
Referral deemed
inappropriate and referred
back to referrer either by
admin or professional from
RRAS team
Referral managed over the phone
with onward referral if required.
Either discharged or follow up call
before discharge
Response results in visit from health or social alone
based on referral information. When referral has an
allocated social worker liaise with locality team for
further review, management and decide the most
appropriate person to respond*
Response results in joint visit with both health &
social based on referral information & when referral
is unknown to social care





 Reduction in inappropriate use of respite beds; long term residential care and
promote independence.
Direct to RRAS team
Single Point of Access
Referral deemed appropriate &
relevant actions undertaken
Expected outcomes include*
 Reduction of avoidable use of secondary care via non-elective admissions;
A&E attendances; and reduction in repeat attendances and admissions.
Referral from health or
social care professional
Referral from self or
family or carers
Health or Social assessment undertaken
Health outcome – following assessment,
diagnose, provide acute treatment directly, or
direct referral to community teams or beds, or
admit to acute based on situation via direct
referral. If managed in community via team,
deliver relevant follow-up when required and
discharge, usually within 48 hours.
Social – following assessment relevant urgent
equipment provided. If deemed critical and
substantial needs, social care package
commissioned & started (can commence on
the same day) within 4 days of assessment or
admitted to interim residential care depending
on situation and needs of patient/client.

Joint assessment undertaken
Health outcome – following assessment,
diagnose, interim treatment & onward referral
once relevant follow up undertaken, discharge
usually within 48 hours
Social – following assessment relevant urgent
equipment provided. If deemed critical and
substantial needs, social care package
commissioned & started (can commence on
the same day) within 4 days of assessment via
Joint Reablement Team. Or emergency interim
respite placement provided based on situation
Long term management for both health & social
RRAS does not hold a caseload

Following crisis management in the community via the RRAS team – verbal and written feedback given to GP practice via SystmOne

or electronic summary
On-ward referral for long term management of condition via Community Matrons, Integrated Community Teams or other specialist

community teams
When short term care packages agreed and commissioned, link with JRT and or locality teams to assess whether long term care is

required and further full social care assessment is required which will include financial assessment
Clients known to social care locality teams will undertake earlier review of previous care package due to immediate crisis and tailor

future packages of care based on new needs
Information on outcome of referral given to admin support for RRAS to be input in manual spreadsheet

* visits undertaken via the RRAS team can be in the client/patient home, family home, care home or in A&E if not admitted to acute sector
*original service specification was used, updated version was not available
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6
Methodology adopted (1/2)
 The evaluation was conducted to understand whether the
current set up for RRAS delivers what it was set up to do. The
evaluation was not intended to demonstrate whether the
current model is the right model or to provide evidence based
comparison against other national or local models.
 There was a time restriction applied to this work (10 days) which
has limited the scope of the evaluation. The work started in mid
December 2013 and was completed over a number of weeks as
information and access to people became available. A further
detailed service user review took place in late February 2014.
 The type of data and information gathered was driven by the
project brief and was amended as required following initial
meetings with the RRAS team, Information and Contracting
teams and CCG.
 Information related to the RRAS team - a number of documents
were used including:
- Operational guidance for RRAS
- Draft service specification
- Skills for Care document on RRAS
- Case studies
- Information following RRAS workshops
 Data – there is a significant amount of data available on the RRAS
from both IT systems. A significant amount of work had to be
undertaken to cleanse the data to support this work. Data
cleansing was not within the scope of the work agreed but was
conducted to facilitate meaningful data analysis.
 The time period over which to review data was agreed as 1st April
2013 to 30th November 2013 and data was provided for this
period. It is important to note that during this time period a
number of changes took place in data entry methods and items
recorded. The service user review was undertaken using
additional information covering the period 2nd of December 2013
– 26th February 2014. 20 (5%) service users were reviewed out of
a total 392 seen during this time period. A service user template
tool was developed and agreed to support this part of the
analysis.
 A brief overview of the IAS system was undertaken to better
understand how information is reported and pooled. Time was
spent with the RRAS team to understand how information is
captured and recorded.
 Two systems record information which is different but relating to
the same service user. A separate manual spreadsheet has been
developed to manually record information to support reports by
the team. This spreadsheet collates information and data from
both IT systems and is analysed by the Thurrock Council Contract
Compliance Intelligence Officer. Information was requested from
both the IAS and SystmOne systems, however the data was not
complete as it only covers part of the referral information.
 The manual spreadsheet with the joint information was the main
source of data used for the evaluation review. Raw data was
requested for the agreed timeline and analysed further. Data
was further scrutinised with both the RRAS team and the
Contract Compliance Intelligence Officer. This information was
then used to support the service user review.
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7
Methodology adopted (2/2)
 A service user review was undertaken working together with the RRAS team for
approximately 20 service users. The aim was to include a mixture of repeat
referrals and those only seen once by the service from the information
provided, however 16 out of the 20 were repeat users of the service. Even
though a proportion of single and repeat users was chosen, the records
reviewed showed the single users had been seen before. This review was
undertaken using additional information covering the period 2nd of December
2013 – 26th February 2014.
 The following was captured as part of the service user review:
•
•
•
•
•
•
•
•






age & sex;
known to social care; known to RRAS; repeat referral;
primary reason for referral & primary source of referrals, was it related to
health/social or both;
brief summary of interventions delivered; summary of outcomes;
end outcome of where the service user was now;
timeline of RRAS involvement;
appropriate use of RRAS; and
main benefits of RRAS.
RRAS evaluation tool
Interview:
Date: December 2013
Q1. In your opinion what are the main roles and functions of the RRAS team
e.g.
Reduce hospital admissions
Reduce the need for interim residential or care homes
Reduce the need for permanent placements
Promote independence
Other
Q2. What works well with the current set up for RRAS team?
Q3. Has the current set up for RRAS team changed over time? If so Why? What have been the main
changes?
Q4. What are the major challenges for the RRAS team going forward?
Q5. What are the best practices adopted by the RRAS team both internally and externally
Q6. What are the key services linked to RRAS?
Q7. On a scale of 1 to 5 how well does the RRAS deliver services to the clients benefit?
1
2
3
4
5
Not very well
Very well
Users and carers feedback via a survey was not conducted due to consent
requirements and time constraints.
Details of complaints and compliments were reviewed from the start of the
service.
The evaluation process required gathering a number of service’s and
individual’s view points of the current model and delivery of the RRAS. A
framework of questions (see opposite) was designed, shared and agreed with
the project sponsors.
Meetings were organised with these individuals and teams linked with RRAS
team as per the project brief. The framework of questions was used as a
guide together with gathering other relevant background information to
ensure consistency with this part of the evaluation.
26 individuals were interviewed (see appendices for full list) and all but one
were face to face meetings.
The feedback gathered has been grouped into main findings and themes.
Q8. What are the current gaps in the services that need to be accessed for clients via the RRAS?
Q9. How could the current set up for RRAS be improved?
Q10. What are the main interventions delivered via the RRAS team?
Q11 In your opinion is the overall approach delivered via RRAS a community focused solution or traditional
service solution applicable or mixture of both? Explain your answer
Q12. Any other comments to support the evaluation of the RRAS service
RRAS feedback form
© 2014 Merra Ltd. All rights reserved
Merra Ltd. © 2013
December 2013
8
Findings from data and information related to RRAS – demand
 The total number of referrals received during the evaluation
period (1st April – 30th November 2013) was 1,355*, the number of
unique IAS numbers was 906.
 The number of referrals received has been increasing over time.
Demand to current capacity to understand the maximum number
of referrals that can be accepted by the team has not been
calculated. This is due to the complexity and types of service users
seen over time and data related to this was not available.
 Demand – the original Thurrock social care led pilot undertook
303 assessments from April 2011 to March 2012. RRAS started in
April 2012 and in the first year of service the team undertook
1,084 assessments during April 2012 – March 13. The number of
referrals received was not captured during this time period.
Referrals and Assessments by Month
Month, 2013
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Not recorded
Total
250
Referrals
200
Assessments
150
100
50
Referrals Assessments
119
138
144
196
158
153
206
236
5
1,355
 The demand for the service has increased with time. The data captured
has not been consistent from the start of the service. This is now becoming
more standardised, an agreed minimum data entry (via Excel spreadsheet)
was started in August 2012. A number of workshops with key
stakeholders have taken place recently to increase the quality of
information recorded by the team.
97
110
125
177
128
125
170
182
5
1,119
% of referrals
resulting in
assessment
82%
80%
87%
90%
81%
82%
83%
77%
100%
83%
0
Referrals
going up
over time,
assessment
undertaken
at average
83% of all
referrals
* NB: 5 of the 1,355 were highlighted as reviews only, they do not count as a referral or an assessment
 The percentage of inappropriate or redirected referrals ranged from 10 –
20%.
 There are number of referrals managed on the phone which did not
require a visit, the number was difficult to quantify due to inconsistent
data capture over time. Some assessments were completed over the
phone in certain situations, again difficult to quantify.
 November showed a peak in referrals but not assessments. When
reviewing the data further more referrals were received from specific care
homes during one week of November.
Warning: data entry during the time period reviewed has not been consistent, a number of changes
took place, which have been noted in this report where relevant.
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9
Findings from data and information related to RRAS – source & reason for referral
 Source of referrals is shown below, with the majority coming from
family/friend/neighbour, GP, other (not documented)
Sources of Referrals
Family/Friend/Neighbour
GP
Other
NELFT
Source not recorded
Care Provider/Agency
Care Provider
OOH/EDT
Self
EoE Amb
Social Services
Internal (in Team)
CST
OOH
Vol Orgs
Carer
SEPT
Total Referrals
No of Referrals
263
234
177
150
126
89
74
57
42
41
38
24
22
7
5
3
3
1,355
%
19%
17%
13%
11%
9%
7%
5%
4%
3%
3%
3%
2%
2%
1%
0%
0%
0%
100%
Main source
of referrals,
family/friend,
GP and other
Main reasons
for referral
Health –
related
 SystmOne data showed that the majority of referrals were from
social care, GPs, then family and Community Specialist Nursing.
 Reason for referrals were as follows:
Reason for Referral
No of Referrals
Short Term Condition (STC) - Health
598
Long Term Condition (LTC) - Health
186
Not recorded
128
Social / Welfare
106
Mobility
60
Dementia
55
Carer Breakdown
46
Social/Welfare Check
41
Falls
26
Social Care Package
25
Mental Health
20
Medication
16
Not Eating/Drinking
16
Other
13
Equipment/adaptation
8
End of Life
6
Discharge from hospital in previous 72hrs
2
Equipment/Aids - OT
1
GP declined to visit
1
Safeguarding
1
Total
1,355
%
44.1%
13.7%
9.4%
7.8%
4.4%
4.1%
3.4%
3.0%
1.9%
1.8%
1.5%
1.2%
1.2%
1.0%
0.6%
0.4%
0.1%
0.1%
0.1%
0.1%
100%
 57% of referrals seem to be health related, this could account for
why there are fewer joint visits being undertaken.
© 2014 Merra Ltd. All rights reserved
10
Findings from data and information related to RRAS – visits related to referrals
Visits
Of the 1,355 records provided, 478 (35%) contained data for the visit date and time, September 2013 onwards.
Out of the 478 records, 413 (86%) were shown as visited within the same day. 48 records (10%) were
visited within the following day and the remaining were visited within a number of days, as shown below:
Patients visited
Within same day
Next day
Later
Total
No
413
48
17
478
17
%
86%
10%
4%
100%
48
Within same day
Next day
Later
413
Of those visited within the day (413 patients), 85% of patients were seen within 2 hours with 233 (56%)
seen within the hour and a further 116 (28%) were seen within 1 to 2 hours. The table below shows the distribution.
Same day visits
Less than 1 hour
1 to 2 hours
2 to 3 hours
3 to 5 hours
Greater than 5 hours
Total
No
233
116
30
27
7
413
%
56%
28%
7%
7%
2%
100%
Majority of referrals
received & deemed
appropriate are
actioned quickly
(1-2 hours)
27 7
30
Less than 1 hour
1 to 2 hours
2 to 3 hours
116
233
3 to 5 hours
Greater than 5 hours
© 2014 Merra Ltd. All rights reserved
11
Findings from data and information related to RRAS – assessments
 Approximately 80% of referrals received result in an assessment being undertaken by a member of the team. The decision as to which
practitioner will visit the service user and complete this assessment is based on the details from the referral and additional information
Assessments undertaken by:
accessed from the two IT systems.
Joint visits are low in
comparison to Health.
These need to be
increased to support
the teams original
focus.
Assessed by
Nurse Practitioner
Social Worker
Healthcare Assistant
MDT
Support Planner
Other
Total
From Referral to Assessment, proportion
Date data not Same day Next day Beyond 1
recorded*
day
7.9%
4.1%
0.4%
0.4%
7.0%
3.1%
0.7%
0.3%
28.0%
23.4%
0.9%
0.4%
0.1%
9.4%
4.9%
1.3%
0.4%
5.0%
1.3%
1.1%
0.1%
57.3%
36.9%
4.3%
1.5%
No of
% of
assessments Assessments
590
53%
178
16%
142
13%
124
11%
84
8%
1
0%
1,119
100%
*Date of assessment data has only been recorded since September 2013
 As from the previous page, the majority of referrals seem to be health related which could explain these results. Of the ones where date has
been recorded, the HCA complete, the was assessment took place on the same day.
 The busiest time for the RRAS based on the data provided seems to 09:00 - 12:00 which could be related to the way other services work, e.g.
difficulty in contacting GP practices, etc. There are very few calls from 19:00 onwards. This information may support the discussion on the
need for a seven day working.
Referrals Received by day and time of day
Operating times
– most intensive
periods appears
to be from
09:00 - 12:00
Day of Week
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Not recorded
Total
% of Day
Pre 08:00 08:00-09:00 09:00-10:00 10:00-11:00 11:00-12:00 12:00-13:00 13:00-14:00 14:00-15:00 15:00-16:00 16:00-17:00 17:00-18:00 18:00-19:00 19:00-20:00 20:00-21:00
1
3
1
1
43
28
33
32
31
21
8
45
31
34
31
41
11
6
33
19
25
32
31
10
12
33
16
23
26
29
8
5
27
29
24
18
40
6
5
18
24
32
15
25
3
8
18
26
32
32
21
4
1
27
15
32
19
24
4
3
12
13
17
12
13
5
8
8
1
3
2
1
1
4
2
2
1
196
14%
199
15%
162
12%
140
10%
149
11%
125
9%
134
10%
124
9%
67
5%
25
2%
10
1%
3
0%
1
3
3
2
1
7
1%
9
1%
Not
recorded
5
5
0%
Total
% week
264
214
265
228
263
67
49
5
1,355
19%
16%
20%
17%
19%
5%
4%
0%
NB: Most intensive period appears to be from 09:00 to 12:00.
Weekend working for nursing started 7th September
Weekend working for social started 2nd November
© 2014 Merra Ltd. All rights reserved
12
Findings from data and information related to RRAS – GP practice (1/2)
 Approximately 15 GP practices appear to account for 50% of all referrals received. GP information was only routinely recorded from May
2013 onwards, which may account for the high % of where practice not recorded.
Referrals by registered Practice of service user, regardless of referral source, by month
Practice
Apr May
Jun
Practice not recorded
104
114
114
1
1
Dr Headon, Crammavill Street - F81192
Dr Leighton, High Street, Aveley - F81010
Dr Yasin, Darrenth Lane, South Ockendon - F81632
Dr N J Tresidder & Partners, Southend Road, Stanford-le-Hope - F81153
Dr Mohile, Brentwood Road, Chadwell St Mary - F81084
Dr Bellworthy, Daiglen Drive, South Ockendon - F81197
Dr Colburn's Surgery, Rowley Road, Orsett - F81137
Dr Davies - MainPear Tree Close, S. Ockendon F81134
Dr Dilip Sabnis, Chadwell St Mary - F81698
Dr Deveraja, The Sorrells, Stanford-le-Hope - F81697
Dr Abela, Chafford Hundred Medical Centre - F81113
Dr Bansal, Balfour Road, Grays - F81155
Dr Yadava, East Thurrock Road, Grays - F81211
Dr P. K Mukhopadyay, Calcutta Road, Tilbury - F81719
Dr Abeywardene, Orsett Road, Grays - F81219
Total Top 15 Practices
Jul
Aug
Sep
Oct Nov
Not
recorded
Total
% Total
336
24.8%
6.7%
6.1%
5.6%
4.1%
3.6%
3.1%
2.7%
2.7%
2.7%
2.7%
2.6%
2.4%
2.2%
2.1%
1.8%
50.8%
3
1
15
13
18
13
13
10
6
1
3
91
82
76
55
49
42
37
36
36
36
35
32
30
28
24
689
11
1
18
1
3
24
19
19
17
11
1
6
5
8
8
5
4
7
6
5
8
129
Other practices
4
6
6
67
55
53
63
74
2
330
24.4%
Total Referrals
119
138
144
196
158
153
206
236
5
1355
100.0%
7
1
1
6
2
1
1
3
1
1
1
1
3
3
2
1
2
3
5
1
18
15
8
10
4
4
6
11
2
6
4
7
4
3
1
103
11
13
7
3
11
7
3
7
9
5
7
7
3
4
3
100
12
7
12
4
8
6
3
140
25
19
10
12
19
14
13
3
5
7
6
6
8
9
5
161
1
1
% Cum
6.7%
12.8%
18.4%
22.4%
26.1%
29.2%
31.9%
34.5%
37.2%
39.9%
42.4%
44.8%
47.0%
49.1%
50.8%
15 GP practices
account for 50%
of referral
received
Further analysis
required
 Further analysis is required from this information, such as size of practice, age profile, % of >65 yrs and 85+ yrs, for this to have any meaning.
Such analysis was not part of the scope of the evaluation review. This information should then be compared with service users attending
acute to see if there is a similar trend and if the current pathway of care needs to be reviewed and optimised.
© 2014 Merra Ltd. All rights reserved
13
Findings from data and information related to RRAS – GP practice (2/2)
 Repeat referrals do occur with the RRAS, the numbers are not significantly high
(+5), however from the service user review (see later slides), these service users
are the more complex and already have involvement with other practitioners.
There seems to be a breakdown of pathways or care. These are also the same
types of service users that seem to decline support or care.
Repeated Referrals
Referrals per service No of service
user
users
8
1
7
2
6
3
5
11
4
26
3
62
2
169
1
632
Total service users
906
Repeated Referrals (2012/2013
%
0%
0%
0%
1%
3%
7%
19%
70%
100%
Referrals per
service user
8
7
6
5
4
3
2
1
Total service users
No of service
users
1
1
2
5
13
37
121
475
655
There seems
to be a link
between high
user & repeat
referrals in
terms
registered GP
practice.
Further data
and analysis
required.
 Service users only seen once does not mean that the crisis situation was resolved
completely. The service user review from this cohort showed that the ones that
were documented as been seen only once had been seen before by the service.
 The balance between number of repeat referrals to manage the current crisis and
provide resilience for future crisis is difficult to comment on.
 Service users who are placed in interim care beds are often registered with
another GP practice during their stay.
No of service users with repeated referral by practice registered with
NB Service users may be regsistered with more than 1 Practice during this period
Practice
Practice not recorded
Dr Headon, Crammavill Street - F81192
Dr Leighton, High Street, Aveley - F81010
Dr Yasin, Darrenth Lane, South Ockendon - F81632
Dr Colburn's Surgery, Rowley Road, Orsett - F81137
Dr Mohile, Brentwood Road, Chadwell St Mary - F81084
Dr Dilip Sabnis, Chadwell St Mary - F81698
Dr Bellworthy, Daiglen Drive, South Ockendon - F81197
Dr N J Tresidder & Partners, Southend Road, Stanford-le-Hope - F81153
Dr Colburn's Surgery - BranchKing Edward Drive, Grays
Dr Abela, Chafford Hundred Medical Centre - F81113
Dr Abeywardene, Orsett Road, Grays - F81219
Dr Davies - MainPear Tree Close, S. Ockendon F81134
Dr Deveraja, The Sorrells, Stanford-le-Hope - F81697
Dr P. K Mukhopadyay, Calcutta Road, Tilbury - F81719
Dr Dey, Derry Avenue, South Ockendon - F81669
Dr Joseph, New Road, Grays - F81218
Dr Leighton - BranchDarrenth Lane, South Ockendon
Dr Sunthralingam, London Road, Tilbury - F81110
Dr Khan, Coronation Avenue, East Tilbury - F81691
Dr Masson, Milton Road, Grays - F81641
Dr Shehadeh, Grays (PMS) - F81643
Dr Shehadeh, Quebec Road, Tilbury - F81206
Dr Sidana, Bridge Road, Grays, F81659
Dr Yadava, East Thurrock Road, Grays - F81211
Purfleet Care Centre, Tank Hill, Purfleet, Y00033
Dr Cheung, Fobbing Road, Corringham - F81644
Dr Roy, Southend Road, Stanford-le-Hope - F81088
Dr S.J Jones, Giffords Cross, Corringham
Dr SidanaBridge Rd, Grays F81623
Thurrock Health Centre, High Street - Y02807
Dr Saha, Montreal, Tilbury - F81734
Dr Shehadeh, Grays (GMS) - F81659
Dr Abeywardene, Wharf Road, Stanford-le-Hope
Dr Bansal, Balfour Road, Grays - F81155
Dr Deshpande, Wharf Road, Stanford-le-Hope - F81177
Total
© 2014 Merra Ltd. All rights reserved
No
94
26
23
18
12
12
11
10
10
9
8
8
8
7
7
6
6
6
6
5
5
5
5
5
5
5
4
4
4
4
4
3
3
2
2
2
354
14
Findings from data and information related to RRAS – admission avoidance
 Social care residential service avoided as part of RRAS – has been captured
manually by practitioners as shown below:
Details of AT referrals *
Total referrals made
Inappropriate referrals
Deceased
Went into residential care
Service user moved for extra care
AT removed
Total still using AT
Social Care Residential Service potentially avoided
Service
Homecare Agency
Older Person Residential (Standard)
Not recorded
Homecare
Dementia Residential
Emergency Respite Care
OP Nursing
Older Person Nursing
Older Person Residential (High Dependency)
Older Person (Dementia unit)
Total
No of Referrals
314
501
270
201
20
14
13
9
7
6
1,355
%
23.2%
37.0%
19.9%
14.8%
1.5%
1.0%
1.0%
0.7%
0.5%
0.4%
100%
 Referral to Assistive Technology - AT was used by a number
of service users during the timeline reviewed.
No
106
2
11
10
1
1
81
Assumptions
made on
social care
residential
* Timeline of report 1st April to December 2013
service
potentially
 AT may have been introduced to services at a later stage in
avoided
their conditions which may not be appropriate as successful
seem very
usage of this equipment especially when a behavioural
subjective
change is required e.g. for medication dispensers.
 The most commonly supplied AT equipment to these service
users was pendant alarm, falls detector and medication
dispenser.
 This information appears to use subjective opinions based on the service user
care delivered even though a high proportion of referrals seen and assessed
were for health.
 Further review of this information is required before any analysis or comment
can be made.
 Agreed criteria for this data entry needs to be developed and agreed together
with commissioners.
© 2014 Merra Ltd. All rights reserved
15
Summary - service user review
Data and information
 20 service users (5% of a total of 521 referral, 392 service users) were
reviewed using their IAS numbers from 2nd December 2012 to
31st January 2014.
 Detailed review of each service user was undertaken using both social
care (IAS) and health (SystmOne) records (see appendix 1 for further
details).
 Based on performance information of the 521 referrals received in
December and January:
297 referral used the service once
129 were repeats users (25% out of 521) of which 67 were referred
twice, 22 referred 3 times and 6 service users referred 4 times.
Service user review
 Information collated from the two systems (SystmOne and IAS)
appeared to be incomplete at times and SystmOne did not capture the
social situation of the service users especially where family members
were involved in their care.
 16 out of the 20 were repeat users of the service even though a
proportion only seen once was chosen.
 19 were known to social care, with a mixture of interim and
permanent care packages commissioned.
 Service user information:
 Main reasons for referrals were health related with 15 out of the 20
for short term health and 4 for long term health reasons.
 End outcome of service users at time of the review (26th of
February):
17 service users were at home (1 in original care home)
2 deceased
1 in residential care home
 Overall, following the service user review, 18 of the service users
seen by the service were considered to have been appropriate use
of the service, 1 was seen due to gaps in existing services and 1 was
considered an inappropriate referral.
 Benefits of RRAS to service users for overall care during time period
reviewed were:
Managed crisis in service user home treatment complete (6)
Managed crisis in community on-going including community hospital (5)
Acute admission avoidance (4)
Managed at home, more time needed for permanent solution (4)
One service user was inappropriately referred
Gender: 10 female and 10 Male
Age: 51-94 years of age
 The primary source of referrals:
GP 7, NELFT 5, social services 3, family/friend 2 and
others were either self, OOH or care agencies.
© 2014 Merra Ltd. All rights reserved
16
Feedback collated from stakeholder engagement (1/3)
Approximately 26 individuals were interviewed during this evaluation,
these included members of the RRAS, teams linked to RRAS e.g. MDT, JRT
and SEEDS, plus 5 GP practices. A set framework of questions was
developed and agreed and used as part of this process.
What works well with current set up for RRAS
Summary of the feedback:

 Location
 Immediate response, assessment, diagnosis and provision of treatment
 Nursing side, highly skilled can do most of things the GP would do during a home
Perceived roles and functions of the RRAS
 Provision of urgent assessment for both social and health care






Crisis intervention and management, preventing future crisis
Supporting the unplanned care agenda
Admission avoidance to acute
Promote independence and keep service user at home
Provide a holistic approach in managing crisis
Ensure appropriate care packages are delivered to avoid future crisis, minimise
the need for nursing and residential care homes
 Mitigate risk, right care, right place at the right time
 Deal with short term needs and onward referral to relevant services, though
can’t see how this can result in admission avoidance unless follow up takes
place
 Support other OOH providers in supporting crisis management as the team
have a better understanding of social input required and sometimes know the
service users more than the doctors
Other comments
 Name may not describe what the service does, not clear from posters and
confusion with other admission avoidance schemes
 Not sure when to contact the team and when to contact others e.g. SPA
 Location supports integration and joint working in the community
 Service is not there to save GPs workload or to ‘off load patients’ to another
service, but danger of that sort abuse – could be reason why it seems a popular
service
 Sometimes focus is not clear, more so recently, ‘goal posts’ keep changing






visit and more due to close working with social care
More value for money in terms of resolving crisis compared with a GP visit. GPs
are looking for a medical problem, therefore not always best placed to deal with
other issues such as social care needs, assessing needs for equipment etc.
Having direct and rapid access to community facilities, which prevent admissions
to acute e.g. community step up beds
Seems to work ok as it is, skill mix ok
From GP perspective always get feedback from outcome of referral which
supports long term management of service user, do not get this from other
community services
First community service that is ‘truly seamless’, others are more fragmented
Skill set of nurses are advanced so support diagnostic assessment and acute
treatment, a lot of interventions can be delivered in one visit e.g. bloods,
prescribing
Joint visits and assessment, skill mix of staff from Social and Health
Other comments
 Fantastic service, supports keeping service users out of hospital
 Really supportive service, happy to support this from commissioning side
 Makes GPs work load easier as sometimes service user are seen a number of
times by the GP already, good to have a joint approach with the team to solve
the crisis situation, MDT approach
© 2014 Merra Ltd. All rights reserved
17
Feedback collated from stakeholder engagement (2/3)
Main changes to RRAS over time
The following changes were described:
 Longer working hours based on demand
 Weekend working due to demand
 Improved communication and understanding of social care
 Service has improved with time
 Perception - there are less joint visits & assessments when compared to
when the service first started, this was the unique part of the team set up
 Increased awareness of the team and what it does, however, there can be
overlap with other services and what they do at times
 Formal joining of the health part of the team
 Operating hours have increased but not sure if there is a demand for the
service and if the exact times were thought through
Other comments
GP who use the service often were not aware of the operating hours.
Some GPs felt the weekend working did not impact them as the surgeries are
closed.
Challenges going forward
 Increasing demand of service and not having the capacity to manage this
 Loss of focus and diluting the service due to recent changes
 Working with other OOH providers and not confusing service users and





referrers on what each one is set out to deliver
Data inputting and demonstrating robust information/evidence of what the
team has delivered over time
Managing the expectations of the frail elderly as they do not want to go to
hospital or care homes, even though the need for this support is warranted
at times
Two IT systems – not talking to each other and GPs who do not share,
results in delays in providing appropriate care and providing feedback
As a health economy not having the funding to keep the service going
Onward referrals to other services not being able to manage with demand
and respond in a timely manner
Best practices used by team




Joint working and assessment
Multidisciplinary approach to crisis intervention and management
Communication in terms of providing feedback to GPs following referrals
Response times and ability to visit and act quickly, responding and doing all
the necessary on-ward referrals required as they have a better
understanding and priority access to the relevant services
 Increase in knowledge of both health and social for team
 Location of team both health and social working together
 Providing a joined-up service around the patient and not the other way
around
 Being able to do most tasks in one visit e.g. prescribe, take bloods
Other comments
Some of the services linked to the team were fully aware of how RRAS operates
but felt there needed to be improved links and expectations of each other for the
interests of the service user.
GPs found the links and urgent access the teams of added value, the ‘RRAS can get
things done quicker’.
Key Services
 A range of services were listed by each individual when interviewed, the
range depended on whether they were from a social or health background
RRAS meeting service user needs
This question was asked to all 26 individuals. One felt they could not answer this
question as they were not close to the service users to understand their needs and
whether they were met by the service. Scale used was 1-5 (1 = not very well and
5 = very well).
 All chose 4 to 5 with the exception of one, who chose 3
Other comments
The majority felt the RRAS does meet the service users needs and does manage
the crisis situation well but funding is a concern in terms of meeting the demands
of the service.
© 2014 Merra Ltd. All rights reserved
18
Feedback collated from stakeholder engagement (3/3)
Main gaps in services for service users
 Mental health services was considered to be a significant gap when dealing
with service users in crisis situations. Particularly in the acute stage when
diagnosing a condition that could be mental health and requires an urgent
opinion.
 Services for the elderly to deal with being on their own and lonely requires a
a different type of solution, perhaps from the voluntary sector. There has
been support from certain local libraries which can provide support groups
e.g. coffee mornings. Key was knowing what is out there, understanding
this and then actively promoting this to service users.
Improvements
 More joint working and assessments
 Improving the office space came from a number of people both within and
external to the team. There was limited work space and a number of
computers were ‘out of order’
 Better IT system in terms of working for both health and social
 Improving the data collection process for the team, making this easier
 Formalising links with other services to improve longer term management
 Response from other community providers needs to be more rapid due to
crisis situation as at times this is seems to be too slow
 Having a bank or quick access to carers that can respond immediately
 RRAS needs to see more service users as the data is showing that there is
capacity to see and do more
Other comments
Some of the GPs felt the team worked well as it is but required more staff. When
challenged, this was more of a perception that more staff will be required as
demand increases rather than current shortfalls.
Main interventions
 Assessments for health and social
 Assessing, ordering and supplying emergency equipment and ensuring this
is working appropriately with follow up
 Diagnosing, delivering acute treatment via prescribing and re-assessment
when required
Onward referral to support long term management of condition
Arranging emergency care packages for critical and substantial needs
Supporting other community teams in situations which are borderline crisis
Fast track CHC assessment, especially for end of life
MCA when service users are not making rational decisions and resulting in
potential harm
Other comments
Response to this question depended on peoples understanding of the team at an
operational level which did vary.





Community focussed or traditional model
Most of those questioned felt that the model of care delivered via RRAS was a
community focused solution. Some felt it was a mixture of community and
traditional type of service.
Other comments
‘There is not a traditional model to compare with as caring for >85 yrs in the
community is new. Previously these types of service users were managed long
term in community hospitals or care homes. The model of care that is right is still
unknown, growing concern especially as there are staff who may not have the upto-date skills to manage the service users effectively in the community.
General comments
On the whole the RRAS is very well received service by all involved directly or
indirectly with the exception of service users who were not surveyed.
 Approximately 30 compliments from service users or family members have
been received from the start of the service.
 There has been 1 complaint to date.
© 2014 Merra Ltd. All rights reserved
19
Overall conclusions
Meeting original goals
The scope for evaluation was to review whether the current set up for the RRAS
delivers what was originally agreed and formalised. Data, opinions captured via
structured interviews and service user review all indicate that the team does deliver
what was envisioned at the services inception in April 2012.
RRAS does respond to health and social care crisis calls when received and triaged.
83% of total referrals received result in an assessment, the majority of which are
undertaken by health. It appears that only a small proportion are joint assessments
with both health and social representatives. This is not in line with the goals of the
service and needs to be addressed.
10-20% of referrals are considered inappropriate and either referred back to the
referrer or re-directed. The majority of visits take place within the same day of
referral (usually within 1-2 hours).
Demand and operating hours
The demand for the RRAS service has increased over time and there are concerns by
some referrers that capacity will not match demand for the service.
Internally, there are perceptions that the team need to see more service users as
there is capacity to do more based on the current data. This would be addressed
through capacity planning.
The most intensive period for receiving referrals is between 09:00 - 12:00. There are
few referrals from 19:00 onwards. Based on the data available there does not appear
to be justification for a 24 hour RRAS.
To optimise the operating hours and days a demand vs capacity model analysis is
required. This would also support the workforce management and future demands,
especially with the demographic trends predicted, e.g. 85+ yrs increasing to 106% by
2030, increase in people with 3 or more Long Term Conditions and in increase people
requiring care by 61% by 2032. 1,2
Service perception
The RRAS does appear to be a community focussed solution to crisis management and
it is perceived this way by the majority of stakeholders surveyed.
It is well received by those who refer to It and work with it.
Understanding of the service, its operating hours and association with social care
needs to be improved.
Evidence to demonstrate service effectiveness
Robust evidence, as with many other organisations, on proving that RRAS avoids
admissions to acute and emergency residential placement is not available. With some
consideration of the types of users of the service, it may be possible to obtain this
information and it should be actively sought with the right support and further
analysis of the available data.
The service has evolved over time in terms of operating hours and days which will
hinder comparisons being made in terms of data. This should not deter robust
evidence being gathered to support further developments of the unplanned care
pathway and securing on-going investment for the RRAS, particularly with the change
in reablement funding in 2015.
Observations and limitations
It appears that there are many joint discussions about service users between health
and social elements of the team and that relevant opinions are sought for complex
referrals. However, these may not be formalised, or captured in service user records
and therefore do not support long term management of the crisis. If the referrals
were managed jointly from the start this would result in improved management of the
crisis and support the key goals of the service.
Joint working is not supported by the two having different paperwork that needs to
be completed to different timescales. This should be addressed to facilitate better
joint working.
The time constraints and funding available for the service evaluation limited what was
reviewed and most importantly direct feedback was not sought from service users. It
is possible that this would be of limited use and does not detract from the evaluation
performed. The overall approach taken with the limited time has produced a robust
evaluation of the RRAS. It would be possible to improve the evaluation by increasing
the percentage of service users reviewed and engaging with other stakeholders not
involved.
The RRAS on its own, via the interventions delivered for crisis management, cannot
prove that it avoids admissions to acute or emergency residential care in long term
but can for the short term, as shown by the recent service user review. By working
together with other admission avoidance type services, the accumulative effect of
interventions may be able to achieve this long term. The difficulty will be definitively
proving this.
1 King’s Fund 2013, 2 Department of Health 2012,
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20
Recommendations following evaluation (1/2)
Robust evidence
 Agree the final details for a ‘minimum data set’, that matches what the team delivers. For example, the list for GP practices was not correct which hinders
prompt reporting of this information. Agree if this should include GP practice name only or also have branch details, if the service user is registered there. If
both are required clarify the purpose for this information being collated. Decide what should be recorded if the service user is placed in interim care which
requires a change in GP practice.
 Consider creating a customised database for the team to support data entry, speed the process, reduce duplication, support ease of use, and standardise the
process. This would allow the possibility of live information being analysed and relevant actions undertaken, overall supporting commissioning requests and the
strategic pathway for unplanned care.
 Minimise the use of “other” during data entry and group certain fields to simplify reports and understanding.
 A robust review of service users seen during a defined time period should be undertaken as the sample reviewed in this evaluation identified some potential
trends. For example, repeat referrals were for very complex service users with a number of professionals already involved in their on-going care, who perhaps
should not have been referred to RRAS. The pathway to manage these types of service users needs to be explored and reviewed again.
 When service users were seen only once the data recorded states once but they are seen a number of times so a recording issues. This should be reviewed to see
whether a correlation exists, longer involvement of RRAS is required or a revision of the care pathway is required as using the review this could not be established
with the same reviewed.
Team dynamics
 Re-energise or re-vitalise the RRAS team as a number of structural changes have taken place which may have impacted or influenced the focus and ways of
working for the team. The sense of urgency in demonstrating value needs to be understood in order to support on-going funding for the team post 2015. 2014 is
a crucial year for the success of the team and also meeting even larger service demands via the unplanned care pathway due to further efficiencies that need to
be made in the acute and social care.
 Formalise links with other teams. There seem to be informal relationships with certain teams, which works well for some and not so well for others. As the team
is dependent on other community providers taking over the long term management of the crisis, these links need to be robust and streamlined and clearly
documented.
 Increase the number of joint assessments. This is understood by the team, however, this has not been happening at practice level. This could be partly due to a
perceived health dominance in the team, e.g. more health staff and majority of referrals being documented as health related at the point of referral. Consider
regular case reviews during team meetings of the more complex referrals and those with repeat referrals.
 The impact of the social care element needs to be clearly demonstrated, especially since the team was developed following a successful social care pilot. The
perception outside the team was that there used to be more joint assessments and visits undertaken in the beginning and this has reduced over time. This may
be due to new social workers joining the team.
 The current process of referrals for service users already known to social care prior to referral is to redirect to the locality rather dealing with the crisis through
RRAS. The process needs to be reviewed and updated to support increasing joint visits and assessments and understanding of social care within and external to
the team.
 An audit of records should be undertaken as two service user’s information had discrepancies in the IAS system. One had no notification of death and the other
had a different service user’s document attached to the records.
© 2014 Merra Ltd. All rights reserved
21
Recommendations following evaluation (2/2)
Raising awareness of RRAS
 Operational processes need to be developed as they are not clear from current information available. These include hours of working, days of working, timelines
for visits, and discharging from RRAS. The draft process within this document was developed to support understanding of the service and to perform the
evaluation.
 Service specification: during the evaluation the only available document was the draft format. This needs to be reviewed updated and finalised.
 Increase the awareness of the social care interventions, especially for health. Increasing joint visits will support this.
 Other avenues need to be explored as well including updating the current poster and leaflet and involving GPs and service users in doing this.
 The evaluation found that some GPs are unaware of the interventions delivered and legal framework for social care. Education of this group is important
specifically when some service users or families decline support and then end up in further crisis situations following on from the original referral.
 Share evaluation findings with commissioners to further explore the data and map out the unplanned care pathway, in particular for the complex service users
and repeat referrals (referred 3 or more times).
 Simplify the unplanned care pathway where similar practitioners are involved e.g. MDT and feedback from GPs. There seems to be duplication of the process and
lack of understanding on the differences between the two services when the same service user was discussed either pre or post referral.
 Pathway development – during the evaluation it become apparent there was an evaluation of the JRT team taking place. There had been some discussions on the
pathways of the two teams and whether this could be redefined or more joint working in terms of long term management of service users to mitigate further
crisis. This area should be explored further.
 Review repeat referrals more widely to support partnership working. It was seen when reviewing service users with repeat referrals that they are people who
have already had a number of other professionals intervening but the crisis situation keeps occurring. Interventions will rarely be implemented in isolation. A
combination of interventions intended to reduce admissions could have a cumulative effect and although each may have little effect individually, there may be
greater benefit overall than the combined effects of single interventions.
Pathway
 It would be worth considering whether some service users are referred too late into the RRAS pathway or discharged too early, missing opportunities to prevent
hospital and residential care admissions. Further analysis is required to see if a certain cohort of service users should be held by the team for longer or a formal
follow-up process developed.
Note: The recommendations described may have already been identified and be in the process of being addressed by the CCG, RRAS team and should be considered in that context.
© 2014 Merra Ltd. All rights reserved
22
Appendices
1.
Service user review covering the period 2nd of December 2013 – 26th February 2014.
2.
Glossary
3.
Acknowledgements & list of stakeholders interviewed
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23
Appendix 1: summarised service user review
20 service users (5% of all service users) were reviewed using the IAS numbers covering the period 2nd of December 2013 – 26th February 2014 details
shown below.
No
Age
Sex
Known to
social care
Repeat
yes / no
No of repeats
Primary source of
referral
Primary reason for
referral
End outcome of service user
as of 26th Feb
Appropriate
use of RRAS
Benefit of RRAS input
1
91
Female
Yes
Yes
4
Short term health
GP
Service user home
Yes
Managed at home, more time needed for permanent solution
2
76
Female
No
Yes
3
Short term health
Self
Deceased
Yes
Managed crisis in community on-going inc CH
3
92
Male
Yes
Yes
4
Short term health
GP
Service user home
Yes
Managed at home, more time needed for permanent solution
4
67
Male
Yes
Yes
3
Short term health
GP
Residential care home
Yes
Acute admission avoidance
5
51
Male
Yes
Yes
Yes
Short term health
Social services
Service user home
Yes
Managed crisis in community on-going inc CH
6
85
Female
Yes
Yes
5
Long term health
OOH doctors
Service user home
Gap in health
Managed crisis in community on-going inc CH
7
87
Female
Yes
No
N/A
Short term health
GP
Service user home
No
N/A
8
87
Female
Yes
Yes
3
Long term health
GP
Service user home
Yes
Managed crisis in community on-going inc CH
9
94
Female
Yes
Yes
4
Short term health
Family/friend
Service user home
Yes
Managed at home, more time needed for permanent solution
10
83
Male
Yes
No
N/A
Social /welfare
check
NELFT
Service user home
Yes
Managed at home, more time needed for permanent solution
11
91
Male
Yes
Yes
2
Long term health
GP
Service user home
Yes
Managed crisis in patient home treatment complete
12
66
Male
Yes
Yes
2
Short term health
NELFT
Service user home
Yes
Managed crisis in patient home treatment complete
13
84
Male
Yes
Yes
3
Short term health
Social services
Service user home
Yes
Managed crisis in patient home treatment complete
14
88
Male
Yes
Yes
3
Short term health
NELFT
Service user home
Yes
Managed crisis in patient home treatment complete
15
87
Female
Yes
No
N/A
Short term health
NELFT
Service user home
Yes
Managed crisis in community on-going inc CH
16
79
Male
Yes
Yes
3
Long term health
NELFT
Service user home
Yes
Acute admission avoidance
17
93
Female
Yes
Yes
2
Short term health
GP
Service user home
Yes
Acute admission avoidance
18
91
Female
Yes
No
N/A
Short term health
Care provider
Residential care home
Yes
Managed crisis in patient (care) home treatment complete
19
87
Male
Yes
Yes
2
Short term health
Social services
Service user home
Yes
Acute admission avoidance
20
81
Female
Yes
Yes
2
Short term health
Family/friend
Deceased
Yes
Managed crisis in patient home treatment complete
© 2014 Merra Ltd. All rights reserved
24
Appendix 2: Glossary
AT
Assistive Technology
CCG
Clinical Commissioning Groups
CM
Community Matrons
CST
Community Solutions Team
EDT
Emergency Duty Team
EoL
End of Life
GP
General Practitioner
ICT
Integrated Community Teams
JRT
Joint Reablement Team
LTC
Long Term Condition
MCA
Mental Capacity Assessment
MDT
Multi-Disciplinary Team
NELFT
North East London NHS Foundation Trust
OOH
Out Of Hours
OPMH
Older People Mental Health
PCT
Primary Care Trust
RRAS
Rapid Response Assessment Service
SEEDS
South Essex Emergency Doctors Service
SPA
Single Point of Access
STC
Short Term Condition
UTI
Urinary Tract Infection
Service users – are referred in health as patients, in this document as service users
© 2014 Merra Ltd. All rights reserved
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Appendix 3: Acknowledgements & list of stakeholders interviewed
The following teams and individuals were interviewed as part of this evaluation review, their contribution was invaluable and greatly appreciated.
Team or
Organisation
RRAS team
Names of individuals interviewed
Thurrock Council
Dawn Wakeling, Deputy Manager, Business Lead for Adult Services
Ann Laing, Contract Compliance Intelligence Officer
Maralyn Sibbons –Lead for RRAS for Social Care
Michelle Taylor, Telecare Specialist Practitioner
Joint Reablement Team, Tina Jordon & Sandy Beck
North East
London
Foundation Trust
Gary Townsend, Head of Unplanned Care – South West Essex
Community Services
Bernice Morgan, MDT Coordinator Thurrock locality
Thurrock Clinical
Commissioning
Group
SEEDS
Philip Clark, Commissioning Manager
Thurrock GP
Practices
Hospital social
worker team
Nicky Newnes (Nurse)
Jane Richards (Nurse)
Kim Clayton-Moore (Nurse)
Richard Lartey (Health Care Assistant)
Trudy MarfoAmponsah (Deputy Manager & Social Worker)
Doreen Eshun (Social Worker)
Brenda Jones (Support Planner and Occupational Therapy Assistant)
Pat Barrett (Admin Support)
Lindsay O’Connor (Admin Support)
Jo Harvey – Operational Manager
Dr P Martin from Dr Headon practice
Dr Yasin, Darrenth Lane
Dr Bellworthy & Jackie Griffin from Daiglen Drive, South Ockendon Dr Yadava & Marilyn Brady-Spires from East Thurrock Road, Grays
Dr Cheung, Fobbing Road, Corringham
Bianca Peel, Deputy Manager Hospital Social Worker Team
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26
Merra Ltd is an independent consultancy specialising in
advisory engagements in healthcare. We support all levels
of NHS organisations and private sector providers to
assess, redesign, improve and manage the provision of
services and care.
Contact:
Sudeep Dhillon
sudeep.dhillon@merra.co.uk
07971 156265
© 2014 Merra Ltd. All rights reserved