Report to the Cabinet Member for Adult Community Services
Report submitted by: Executive Director of Adult Services, Health and
Wellbeing
Date: 10 March 2014
Part I
Electoral Division affected:
All in Lancaster (and Fylde
and Wyre secondary)
The Future of the North Lancashire Intermediate Residential Dementia Care
Unit
Contact for further information:
Sarah Coulson, 07775221221, Adult Services, Health and Wellbeing Directorate
sarah.coulson@lancashire.gov.uk
Executive Summary
The North Lancashire Intermediate Residential Dementia Care pilot has supported
adults with dementia from across North Lancashire to recover from a bout of illness
in a safe and appropriate environment and has facilitated a safe return home, thus
easing the pressures of inappropriate placements on mainstream hospital and
residential care services. The service is delivered by an integrated health and
social care staff team. As demonstrated in this report, the service has performed
very well against the projected outcomes however has not, to date, been able to
demonstrate the necessary cost efficiency to the County Council's domiciliary and
residential care budgets.
Recommendation
The Cabinet Member for Adult and Community Services is recommended to
approve an extension to the pilot of 12 months, at a cost of £300,040, in order to
carry out further detailed analysis of the outcomes and cost efficiencies to the
domiciliary and residential care budgets to inform the long term viability of the
service.
Background and Advice
Approval to a pilot for a North Lancashire Intermediate Residential Dementia Care
Unit was given in April 2012, after it was agreed that specialist dementia
intermediate care provision was needed in the area.
The pilot is utilising ten existing beds within the Dolphinlee residential home in
Lancaster and has been refurbished to provide a safe and appropriate environment
for adults with dementia. It mixes traditional rehabilitation staff with a team of
physical therapists (one occupational therapist, one physiotherapist and one
technical instructor) to support physical and mobility needs, all of whom are trained
in the provision of specialist care for people with dementia. The Unit also has access
to GP and district nursing care to address any non-urgent or threatening medical
needs, as well as more intensive mental health support through the Intermediate
Support Team (IST); meaning that a host of support can be given to health and
social rehabilitative needs to ensure the best possible chance of maintaining
independence following discharge. The pilot is also incorporating new, partnership
initiatives to provide a holistic, innovative service: work has been on-going to embed
the use of the Portrait system in the Unit, as well as implementing a volunteer
"befriending" service provided by Age UK to support people on discharge home.
In line with the agreed staged approach to implementation, the unit started taking
referrals on 1 August 2012 and was running up to its 10-bed capacity by 1 October
of that year. Since that time there have been 89 admissions to the unit (who would
otherwise have gone to residential care) and of the 79 discharges, only 17 (21.5%)
were discharged into residential care.
Indeed, it was expected that, in line with similar services, the Unit would discharge
67% of people into community-based settings; in this period, the Unit has exceeded
this target, with 78.5% of people (62) being discharged into environments other than
residential care. The majority of these people (49 people, 61% of all discharges)
were discharged to their home with a package of care, whilst 1 person was
discharged home without any formalised support at all. Ten of the 79 discharges
were back to hospital, with only 17 (21.5%) being discharged to residential care.
From the outset, it was estimated that the Unit would see a 77% utilisation rate:
during this period, it has averaged 68% utilisation, though usage had picked up to
over 80% in the latter two months.
Lasting impact
In order to fully examine the lasting impact and sustainability of the independence
gained through the pilot, a shorter period of admissions and discharges between 1
November 2012 and 30 June 2013 was analysed. A 12-week evaluation period
followed each discharge so that an analysis of the sustainability of the independent
living arrangements following discharge could be carried out.
During that period, 53 people went through the unit, of which;
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29 people (58%) were discharged directly home (1 with no package of care);
5 people (9%) required an additional period of rehabilitation either before
being allowed home or very soon after being discharged home;
26 people (49%) were still at home after 2 weeks;
23 people (43%) were still at home after 6 weeks; and
21 people (40%) were still at home after 12 weeks.
Of those people discharged home but no longer there at the end of the 12-week
evaluation period:
 1 person's health deteriorated and was admitted to hospital;
 4 people were admitted to residential care; and
 2 people had died.
Financial impact
The actual cost incurred to the Directorate during the analysis period was
£359,472.01: £225,030.00 on the unit itself and £134,442.01 on follow-up care and
support.
Based on the assumption asserted in the original business case that the people
accessing the service would, without this provision, have gone directly to permanent
residential care, the cost of that support over the same period would have been
£280,547.52.
This equates to an additional cost to the Directorate, over the analysis period, of
£78,924.49.
Throughout this pilot, North Lancashire Clinical Commissioning Group (CCG) has
contributed to cover the costs of the therapy staff on the unit. Without this
contribution, the additional cost to the Directorate over the evaluation period would
have been £177,322.99.
Performance against outcomes
Anticipated outcome
Timely discharge from hospital
Delayed or reduced admissions to long term
care
Performance
81% of referrals from hospital discharge
teams
89 admissions to the unit (who would have
gone to residential care)
Of the 79 discharges, only 17 (21.5%) were
discharged into residential care.
Effective rehabilitation and improved levels of
functioning/quality of life for the person with
dementia and their carer
Increased independence, with the person being
able to remain living in their own home in the
community for longer
49 people (61% of all discharges) were
discharged home
Of the 53 people included in the detailed
analysis, 31 (58.5%) were not able to
maintain independent living at home.
Of the 34 people (67%) discharged home1
during the detailed analysis period, 21
(61.8%) of them were still at home after 12
weeks
49 people (61% of discharges) were
discharged home;
Of the 34 people (67%) discharged home2
during the detailed analysis period, 21
(61.8%) of them were still at home after 12
weeks
29 people discharged directly home, 5 people requiring an additional period of rehabilitation before
being discharged home.
2
29 people discharged directly home, 5 people requiring an additional period of rehabilitation before
being discharged home.
1
Cost efficiencies for the County Council on
domiciliary and residential care for people with
dementia
Reduced avoidable hospital admission
Of the 53 people included in the detailed
analysis, 21 (40%) were maintaining
independence at home after 12 weeks
Over the analysis period, the costs incurred
to the County Council exceeded the savings
to domiciliary and residential care by
£78,924.49 3
Four referrals were received into the unit
directly from GPs
10 of 79 (12.7%) people discharged from
the unit were discharged to hospital
Only 1 person discharged home was
subsequently admitted to hospital.
Cost efficiencies for the Health economy on
acute hospital admissions and lengths of stay
81% of referrals were from hospital
discharge teams
56% of people were assessed within 2 days
of referral, 82% within 5 days.
The pilot is due to come to an end on 31 March 2014. From the table above, it is
evident that there have been some positive outcomes, as well as some questions
raised concerning the financial viability of the service. It is therefore proposed that
the pilot be extended for 12 months, to enable further analysis to be conducted on:
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The situations of those people accessing the unit since the analysis period;
The situations of those people not included in the analysis but who have now had
long enough at home to be appropriately analysed, including the scale and
longevity of cost benefits;
The circumstances that have caused people who were discharged home to be
readmitted to a residential or acute hospital setting; and
A comparison of performance against similar provision in other parts of the
County.
This will ensure that the reasons behind the loss of independence in those people
not successfully living at home following a period of support at Dolphinlee are
understood. The pathway model can then be fully evaluated to see whether any
changes can be made to increase the number of people successfully maintaining
independence after a stay at Dolphinlee.
A twelve-month extension to the pilot will allow sufficient time to carry out the
analysis, as well as a period of service redesign or decommissioning if necessary. It
will also retain the capacity in the unit over the critical winter period, which could be
lost in a shorter extension.
The cost of this extension to the pilot will be £431,238. North Lancashire CCG has
confirmed that it will make available £131,198 from its budgets to support this, with
3
Would have been £177,322.99 without North Lancashire CCG covering the costs associated with the
therapy staff for the duration of the pilot.
the County Council therefore needing to fund £300,040 for the 12 month pilot
extension.
Consultations
North Lancashire CCG Commissioners and Personal Social Care value the service
as an important part of the Transitional Care Pathway and are supportive of this
proposal.
Implications:
This item has the following implications, as indicated
Financial
The Council's contribution of £300,040 to allow the pilot to be extended for a 12
month period will be funded from uncommitted balances available to the Directorate.
Continuation of the service after this period will be dependent on the outcome of the
detailed analysis to be undertaken, as detailed in the body of the report, with
ultimately a recurrent funding source needing to be identified based on the cost
benefits for both adult social care and health services.
Risk management
With an extension to the pilot rather than a full-term contract, it is possible that there
will be some loss of staff due to them seeking permanent roles. In order to mitigate
this risk, it is essential that the proposal to prolong the pilot is communicated to
teams as soon as possible.
List of Background Papers
Paper
Date
Contact/Directorate/Tel
Report to the Cabinet Member
for Adult and Community
Services – 'Proposals for a
Pilot Project to Establish a
Specialist Residential
Rehabilitation Service for
Older People with Dementia in
North Lancashire'
12 April 2012
Dave Gorman, Office of the
Chief Executive, (01772)
534261
Reason for inclusion in Part II, if appropriate
N/A