In this pilot project, care managers agreed outcomes and an appropriate budget for each home care service user and let the provider negotiate the details with the user, with sufficient autonomy to respond flexibly to needs and preferences. The care plan and assessment summary set out the outcomes that the provider was expected to achieve. The service user plan set out the activities to be carried out to achieve these
outcomes and the estimated number of hours required. Seventy service users were included in the pilot: 19 per cent received maintenance-based outcomes services and 81 per cent received change outcomes services. Local evaluation of the pilot found higher levels of user satisfaction than in a recent national user experience survey and increased job satisfaction was reported by front-line home care staff. Only eight per cent of care packages exceeded the original budget. A number of learning points were identified, including:
• providers need an appropriate infrastructure to be able to construct, cost and adapt service user plans as necessary • care managers must be confident that providers can match
activities to outcomes and will monitor users regularly. Good communication between providers and care managers was essential
• revisions to paperwork and financial processes were needed to improve communication and reduce paperwork
• new contracts should include performance management frameworks defining the council’s and provider’s respective responsibilities for monitoring; frameworks should incorporate key performance indicators.
Case study sites involved in outcomes-based commissioning of inde- pendent home care services agreed they involve transferring power and responsibility from commissioners to providers and users. This required significant levels of trust between purchasers and providers; open com- munication channels; and appropriate administrative and financial management systems.
Although these new approaches to commissioning could result in less choice of provider for service users, members of the User Advisory Group did not consider this a problem. They were concerned at the transfer of home care services from in-house to independent agencies as they felt that this gave them less control over the quality, reliability and costs of services. The costs of home care services were also perceived to be a barrier for some older people. Moreover, if home care services were to be provided by independent agencies, Advisory Group members did
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not want the responsibility of choosing an agency themselves; indeed, they considered choice to be meaningless without access to information and support.
One case study site had experience of commissioning low-level preventive services from local voluntary groups. In this locality, Age Concern was contracted to organise a volunteer shopping and home de- livery service. Age Concern had enhanced its basic service by producing lists of local shops that will deliver and by offering advice on internet shopping. In another part of the locality, Age Concern provided a short- term volunteer service to fill gaps in statutory services for older people at risk of hospital admission (for example, help with laundry and shopping or looking after pets).
2.3.3 Outcomes-focused services
2.3.3.1 Intermediate care and ‘reablement’ services
Early discussions in several case study sites led the research team to focus on intermediate care and reablement services, as staff thought these showed greatest progress in outcomes-focused approaches. These services have a very clear focus on change outcomes.
Typically, reablement services aim to promote independence by iden- tifying and working towards outcomes that were important to each individual. Domiciliary reablement services were thought to give added encouragement to a holistic approach. For example, initial referrals iden- tified goals that users wished to achieve and these are refined during an initial assessment visit from the team’s occupational therapist. Goals might relate to personal care, daily living activities such as shopping or leisure interests – ‘We try to tailor things very much to what the client says’. Subsequently a detailed picture of the user and her/his desired out- comes was compiled; this was shared with rehabilitation assistants who visited regularly. In one site, users could request visits at times to fit their daily routines (the service could be offered seven days a week between 7am and 10pm). Visits were arranged a week in advance and a timetable sent to users every Friday so they know who to expect and when.
Outcomes could include, for example, going shopping or attending art classes. Helping to restore confidence in whatever areas of life are important to users was central. In one area, progress was measured using
the Canadian Occupational Performance Measure that is both person- centred and outcomes-focused. It asks about a user’s lifestyle and what is important to them; identifies the top five things they want to do; asks how satisfied users are currently with their ability to do these things; and then asks again after a period of intervention. Smiley faces can be used for people with cognitive impairments and interpreters for people who do not speak English.
2.3.3.2 Day care
One locality was reviewing its output-based contracts for voluntary sec- tor day care services, to see if new incentives to focus on user outcomes could be introduced. In another day centre for older people with mental health problems, a six-week assessment period allowed staff to identify users’ individual interests; each user was then assigned a key worker who shared their interests, so the focus on outcomes was as natural as possible. However, no examples were found of day services that addressed outcomes that could be met other than by attendance at a day centre. 2.3.3.3 Residential and nursing home care
A Quality Development Scheme (QDS) had been developed by one locality for its 40 nursing and residential homes, to encourage standards above the CSCI minimum. Homes receiving the QDS Award received an additional payment for each local authority-funded resident and a mar- keting advantage as they were clearly flagged up on the local authority’s website. In addition, residential care staff could attend outcomes training run by social services, although staffing constraints restricted take-up.
2.3.4 Monitoring and evaluation
The most frequent and systematic monitoring of user outcomes appeared to occur in relation to the change outcomes that were the focus of in- termediate care and reablement services. For example, clinical outcome tools were often used; weekly reviews and six-weekly reviews of users were routinely conducted; and questionnaires obtained feedback from users at the end of their first week in a rehabilitation unit and again on discharge.
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In contrast, little evidence was found of routine monitoring of main- tenance and prevention outcomes among long-term users of home care services. One authority was considering how to include user outcomes in its new arrangements for monitoring home care providers, but had not yet done so. In another case study site that had a long-standing commitment to outcomes-focused assessment and care management, information from outcomes-focused assessment documents was not available electronically and could therefore not be aggregated and used as part of the monitoring and contracting arrangements with independ- ent providers. Managers here noted that as outcomes were not a national priority or performance target, organisational resources to develop ap- propriate computer information systems were a low priority. However, in another authority centralised contracting for independent home care services enabled the feedback from annual reviews of service users to be incorporated into strategic planning.
In relation to monitoring outcomes in residential homes, managers identified multiple opportunities to obtain feedback from users: