Evaluation of Adapting for Change - Learning Points
The Adapting for Change ( AfC) Initiative, consisting of five pilot sites, developed and tested ways of improving the housing adaptations process. It ran from the Autumn of 2014 and came to a formal conclusion at the end of March 2017.
This summary presents some of the key learning to emerge from an independent process evaluation of AfC. The focus is on how the experiences of one or more of the test sites can potentially help inform the improvement of the housing adaptations process in other areas.
These learning points have been developed taking account of the views and experiences of those involved in the AfC programme. This includes a number of key individuals whose commitment to driving positive change, combined with a very significant investment of time and energy, has been instrumental to the progress made across the test sites.
The Adapting for Change Initiative
The role of housing adaptations in supporting independent living is well known. In 2011, an Independent Adaptations Working Group ( AWG) was set up by the Scottish Government to review practice and delivery. The AWG published their report in November 2012, which recommended that fundamental changes were needed. Recommendations focused on strategic leadership; person-centred services; a broader, outcomes-focused approach; and partnership governance arrangements.
Accepting the AWG's recommendation to pilot suggested changes, the Scottish Government with support from the Improvement Hub ( ihub), launched the AfC Initiative in Autumn 2014.
The focus of activity in each of the AfC test sites was as follows:
Aberdeen aimed to improve partnership working and promote a person-centred approach with a delivery model which was easy to navigate and understand.
Falkirk aimed to develop a new service model for adaptations, which was outcome focused, and provided a common approach across all tenures.
Fife aimed to test approaches to address key issues around service and support and consider new ways to better deliver outcomes across the partnership.
Lochaber planned specifically to redesign the existing Care and Repair service to deliver a local, tenure-neutral route to aids, adaptations and equipment.
Scottish Borders aimed to further develop the Care and Repair service to establish a one-stop-shop approach for adaptations.
The 2016 -17 independent process evaluation focused on 'real life' implementation, and assessed whether, and how, the activities at the five AfC test sites had led to fundamental changes in the delivery and funding arrangements of housing adaptations. The specific objectives were to:
- Understand the 'real-life' implementation and delivery of the AWG recommendations;
- Explore the extent to which the different approaches achieved the overall recommendations;
- Assess how implementation compares to the approach outlined in the Working Group recommendations; and
- Assess the role of different factors which helped or hindered implementation and delivery.
The study involved: desk-based analysis and document review; interviews with key stakeholders, primarily within the test sites; interviews with current or former users of adaptations services; and observation, including attending a learning event for test sites organised by the ihub.
The full research report can be found on the Scottish Government's website at: http://www.gov.scot/Publications The findings from the report will be used by the Scottish Government to inform consultation with stakeholders and the development of guidance.
Key learning points
Highlighting the role of prevention in the Housing Contribution Statement
The Housing Contribution Statement ( HCS) has the potential to be a powerful vehicle for setting out the vital role preventative services can play. In particular, it can be used to increase the understanding of the potential of housing services, including how they can collaborate with health and social care to improve outcomes. Features of this approach might include:
- Involving a wide range of key stakeholders from the public, independent and third sectors in the development of the HCS, with stakeholders then viewing the HCS as a 'partnership statement of intent'.
- Emphasising the vital role adaptations services can play in early intervention and prevention.
Rather than being seen simply as a requirement, the HCS can then be used as a means for key partners to come together and articulate the adaptions-related case for change to the Integrated Joint Board and beyond.
Developing accessible information and advice services
Ensuring that information and advice is readily available to both members of the public and to a range of professionals has been central to much of the work taken forward under AfC. The key learning has included that:
- A single access point or one-stop-shop approach offers real potential to provide an easily accessible source of early information and advice. Critically, it also creates a range of other opportunities, including having early conversations about housing options and exploring the potential of smaller works services or self-assessment.
- Information needs to be available in a range of formats and be accessible to those who prefer to access information electronically but also to those who do not. The provision of digital information accessible to people with dementia may also be worth considering.
- Clear branding of information materials can be helpful, particularly if associated with the one-stop-shop approach. It is also important to provide clear contact details that people can use if they want to access further information or advice.
Working together to map and redesign the pathways through services
Considering the pathways which people take through adaptations services has been a clear focus across the test sites. The key learning has included that:
- Involving a range of staff from across health, social care, housing and the third sector can help break down barriers, with people better placed to understand each other's roles and responsibilities. Holding multi-agency workshops, with those involved in mapping and (re)designing service journeys for people with a range of needs, can help create enthusiasm for, and commitment to, the change process. It can also help build a consensus around the importance of developing and delivering person-centred services.
- It is important to look at the range of ways people can access the system, including how this may be influenced by tenure. Identifying the range of possible 'entry points' into the system provides the starting point for agreeing the arrangements for referring people on to other services if appropriate.
- Minimising the number of 'hand-overs' between different agencies and eliminating any unnecessary waiting times is key. This might include looking at which processes can run concurrently – for example the processes associated with putting funding in place and the work planning stages.
- It is important not to 'design out' flexibility and personal choice; the focus needs to be on how the system supports and responds to the choices people make, rather than the existing structures or pressures on the organisations delivering the service.
Much of the other key learning from the AfC initiative is also connected with pathway and process mapping and redesign.
Creating joint approaches to complex cases and timely discharge from hospital
Ensuring that the adaptation-related pathways are firmly embedded within other key pathways, including those supporting timely and well-managed hospital discharge or telecare services, has been fundamental to the redesign work at some AfC sites. Their experience suggests that:
- It is important to look at how community and hospital-based Occupational Therapy ( OT) services can work together to support early action and remove any unnecessary duplication of assessments.
- Establishing a complex care panel to support shared decision making around the package of services required, including adaptations services, can help with avoiding unnecessary hospital admissions or allow people to leave hospital as soon as they are ready to do so.
Making best use of OT expertise, including specialist housing expertise
The pathways work provides a mechanism for ensuring that the specialist assessment skills within OT services are put to best use. Key learning includes:
- Smaller works services can allow for 'triaging' of small, straightforward work. This not only allows for rapid, early intervention focused responses, but can also help reduce waiting times for those who do not need a full OT assessment.
- If self-assessment forms any part of the overall package of services, it will be important to ensure that the self-assessment process triggers a referral for a full OT assessment when appropriate.
- An approach based on the most complex assessments being carried out by those with particular knowledge and expertise in adaptations could be considered. Embedding a specialist housing OT role within a one-stop-shop service could be one option.
Next steps for the AfC test sites
Although the formal AfC initiative period has now come to an end, the change process is continuing. A brief summary of the work to date and future plans for each of the test sites is set out below.
Aberdeen's experience highlights the benefits of bringing representatives from across a range of organisations involved in adaptations and housing together. They are clear that achieving strategic buy-in, and particularly creating links into the strategic planning of Health and Social Care Integration, has been key to taking forward some of their bigger areas of work.
The Project Board has agreed a cross-tenure Single Major Adaptation Pathway and further work will be looking at procurement and making other links and developing other partnerships. Another major focus has been Delayed Discharge. They have carried out a Delayed Discharge Audit, and other connected work is ongoing. Their Project Board is now looking at ways of ensuring that the joint-working approach can be maintained and built on after the official AfC period comes to an end.
Falkirk aimed to develop a new service model for adaptations, which was outcome focused, and provided a common approach across all tenures. They have established a multi-agency steering group, including housing, social work, health and local RSLs. The group has developed a process map of the customer journey, developed definitions of adaptations and standard specifications for different types of work, produced a common referral form and piloted a 'complex cases' panel.
Going forward, Falkirk are finalising leaflets for tenants and owners and working with the ihub to develop training packages and performance management tools. There are plans to begin rolling out training and implementing the new systems. A new project manager was appointed in January 2017 and will be focusing on taking the AfC package of work forward.
Fife have placed a considerable emphasis on fully understanding their local challenges, and developing subsequent, shared solutions to improve the delivery of adaptations. This focus on a single pathway is currently being developed into an adaptations policy articulating expectation, standards and accountabilities across all partners. Several 'tests of change' are in place to tackle local issues, and learning from these will inform the pathways development.
There is an acknowledgement that the Adapting for Change principles firstly require senior support, then they need to influence the health and social care agenda. To this end, a proposal is being finalised to establish a formally integrated adaptations team with single management, to deliver and support this function across the partnership and with accountability to the Integrated Joint Board.
Lochaber have developed a tenure-neutral one-stop-shop, Be@Home, based in Lochaber Care and Repair. A single pathway, designed by local agencies, provides service users with access to a menu of solutions including aids and equipment, handyperson services, adaptations and housing options advice. An OT has been seconded from the NHS and is helping to connect Be@Home to the local integrated team. The OT also developed a framework which supports Handyperson staff to assess to OT Assistant level.
The Project Board plans to continue their work after the formal AfC test period comes to an end. Partners in Skye & Lochalsh have expressed an interest in developing existing Handyperson and housing adaptations services using the Be@Home model. A report on the Be@Home test model will be presented to NHS Highland's Adult Services Commissioning Group, seeking recommendations for the future for the Be@Home model in Highland.
Scottish Borders aimed to further develop the Care and Repair service to establish a one-stop-shop approach to which individuals could self-refer. The assessment responsibility for adaptations would be transferred from the social work locality team OTs to the Care and Repair OTs. An OT post was seconded from the Council to assess and manage adaptations, initially in three of the Council's five areas. Moving forward, there are plans to roll out the pilot to two other areas.
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