High Impact Change A: Building the foundations of at-scale implementation

The following outlines a step-by-step approach to achieving OHC implementation at scale, emphasising the critical role of leadership at all levels, incorporating population demographics analysis, mapping of the existing care landscape, and utilising a jointly developed risk assessment framework as a key enabler.

Leadership at both system and provider levels is crucial… without clear portfolio ownership, initiatives may not be sustained."

Without strong evidence, it’s difficult to persuade stakeholders and commissioners."

Phase 1. Securing leadership commitment and baseline analysis (foundation for scale)

• Identify champions: Pinpoint influential leaders within the system who are passionate about people’s empowerment, workforce well-being, and efficient resource utilisation. These champions should represent key organisations like hospitals, community health services, local authorities, and commissioning bodies. For example: Identify a Chief Nurse in a hospital, a Director of Social Services in the local authority, a lead GP in a primary care network, and a senior commissioner in the ICB.
• Population demographics analysis: Conduct a thorough analysis of the local population demographics, including age distribution, prevalence of chronic conditions, levels of frailty, and social determinants of health. This data will inform the targeting of OHC interventions and the development of tailored training programmes. For example: The analysis might reveal a higher-than-average population of older adults with mobility limitations in a specific region, prompting the system to prioritise OHC implementation in care homes and domiciliary care services in that area.
• Map out the "as-is" position: Conduct a comprehensive mapping exercise to understand the current landscape of care delivery within the system, including:
  
  • Current scale of double-handed care: Quantify the prevalence of double-handed care packages in various settings (hospitals, care homes, domiciliary care).
  • Service provision: Identify existing OHC initiatives, training programmes and equipment availability. Identify pathways which can benefit from OHC implementation, such as discharge to assess, deconditioning in hospitals wards and Emergency Departments.
  • Existing risk assessment processes: Analyse existing risk assessment processes across different care settings, identifying inconsistencies and gaps. For example: The mapping exercise might reveal that 60 percent of domiciliary care packages in a particular area involve double-handed care, and that only 20 percent of staff have received OHC-specific training

Build a compelling case

• 1. Synthesise the 'as-is' mapping data: Compile all data from the mapping exercise into the local template. This should quantify themcurrent state of OHC practices across the system, identifying key areas for improvement and potential cost savings. For example: It highlights that, Double-handed care packages cost the system £5 million annually. Falls in care homes result in 500 hospital admissions annually, costing the system £1 million.
• 2. Select pilot sites: Choose a few strategically selected pilot sites within the system representing different care settings (hospital wards, care homes, domiciliary care services). The as-is mapping could also support site selection. These sites should have supportive leadership, motivated staff, and a willingness to embrace change. For example: Select a geriatric ward in the hospital including discharge pathway, a care home with a history of innovation, and relevant domiciliary care provider(s) known for its strong training programmes.
• 3. Estimate investment required for the pilot: Develop a detailed budget for the pilot phase, including the following costs:
  
  • equipment: Purchase of appropriate assistive devices (e.g., in-bed sheets with handles, manual and mechanical standing products, gantry hoists and/or celling track system) for the pilot sites, if required.
  • staffing: Allocate staff time for OHC training and implementation and potentially any additional staff to support the pilot including building therapy assessment capacity in the community.
  • training: Delivery of comprehensive OHC training to staff at the pilot sites (including internal and external training costs).
  • data collection and analysis: Resources for collecting and analysing data to evaluate the effectiveness of the pilot.
  • project management: Staff time and resources for managing the pilot project.
  • for example The estimated investment for the pilot, encompassing a hospital ward, care home, and domiciliary care agency, is £135,000, broken down as, Equipment: £30,000, Staffing (Backfill and Project Management): £50,000, Training: £40,000, Data Collection & Analysis: £15,000.
• 4. Project expected benefits and return on investment (ROI): Project the expected benefits of OHC implementation based on the synthesised "as-is" data and the specific context of the system. Quantify these benefits in terms of cost savings, improved outcomes for people, and enhanced staff well-being. Estimate the time required to achieve a return on investment (ROI).
  
  • for example based on the estimated savings from reduced double-handed care, and fewer hospital admissions, the project is expected to generate the following benefits within the pilot sites: Reduced Double-Handed Care Costs: £100,000 per year, Reduced Hospital Admission Costs: £50,000 per year, Total Annual Savings: £150,000.
  • ROI: The pilot investment of £150,000 is expected to be recovered within 11 months, with ongoing annual savings of £170,000 thereafter. The system should start seeing significant return on investment towards the end of the first year.
• 5. Engage Leadership Early: Organise meetings with key leaders to present the OHC vision, share data, and address their concerns. Emphasise the culture change required through leadership commitment. For Example: Hospital CEOs, Director of Social Services, System CEO are briefed on the benefits of embedding OHC across the system and how the system can get the return on investment in better people and staff outcomes as well as cost savings.
• 6. Establish a System-Wide Steering Committee: Form a multi-disciplinary committee comprising representatives from all key stakeholder organisations. This committee will oversee the OHC implementation process, ensuring alignment and accountability across the system. Ensure occupational Therapists (Ots) are actively involved and leading the development of the risk assessment framework, along with other stakeholders. For Example: The committee should include the identified champions, as well as representatives from nursing, therapy services, social work, commissioning, provider representatives and patient advocacy groups
• 7. Secure formal endorsement: Obtain formal endorsement of the OHC initiative from the governing bodies of all key stakeholder organisations. This signals a commitment to allocate resources, support implementation efforts, and hold individuals accountable for achieving OHC goals. For Example: The hospital board, the local authority council, and the ICB governing body should all formally approve the OHC pilot and allocate funding for training, equipment, and staffing as outlined in the business case.

Phase 2. Develop and implement a risk assessment framework and pilot (testing for scale)

• 1. Develop a risk assessment framework: The Steering Committee (with significant OT leadership) develops a standardised, evidence-based risk assessment framework for OHC implementation. This framework should be applicable across all care settings within the system, ensuring consistency in assessment and decision-making. Key elements:
• 2. Standardised risk assessment framework: Develop a standardised risk assessment framework through a systematic and collaborative approach. The approach should:
  
  • clearly define the scope: What specific areas of optimal care will the framework cover (e.g., moving and handling, falls prevention, motivation and engagement)?
  • set clear objectives: What do you hope to achieve with the framework (e.g., improve consistency in decision-making, reduce adverse events, promote person-centred care)?
  • identify target users: Who will be using the framework (e.g., social workers, care providers guiding care workers, occupational therapists)?
  • evidence-based practice: Conduct a thorough review of relevant literature, including national guidelines, research studies, and existing risk assessment tools.
  • identify best practices: Identify examples of successful risk assessment frameworks used in other areas.
  • select assessment domains and factors: Identify all relevant domains and factors that should be included in the risk assessment (e.g., function, mobility, cognitive function, physical health, environmental factors, social support). Clearly identify the separate sections for acute and community, subject to discharge process (if a discharge to assess process is in place, minimum review and assessment required to enable discharge with full holistic assessment in the community).
  • adopt/develop the assessment tool: Adopt an existing or design the risk assessment tool to be clear, concise, and easy to use by the target audience. Use a standardised format to ensure consistency in data collection and interpretation. Choose format options such as checklists, rating scales, and narrative sections to capture relevant information. Ensure the framework includes questions or sections to capture the individual's preferences, goals, and values related to their care.
  • develop clear guidance and definitions: Provide clear and detailed instructions on how to use the assessment tool. Define all key terms and concepts to ensure consistent interpretation. Include examples and case studies to illustrate how the framework should be applied in different situations.
  • implementation and training: Develop a comprehensive training programme for all target users. Use a variety of training methods, such as workshops, online modules, and on-the-job training. Focus on practical application of the framework and provide opportunities for hands-on practice.
  • monitoring and evaluation: Establish mechanisms for collecting data on the use of the framework and its impact. Identify key performance indicators (KPIs) to track progress. Regularly evaluate the effectiveness of the framework in achieving its objectives. Identify areas for improvement and make necessary adjustments.
• 3. Implement standardised protocols (including risk assessment): Implement standardised OHC protocols incorporating the newly developed risk assessment framework at the pilot sites. The risk assessment should be the foundation for all care planning and decision-making related to OHC. Ensure consistent use of the risk assessment framework across all settings. For example: All individuals admitted to the pilot sites would undergo the standardised OHC risk assessment within 24 to 72 hours, if medically appropriate. The results of the assessment would be used to develop a personalised care plan, including specific OHC interventions and equipment recommendations.
• 4. Provide targeted training (including risk assessment): Deliver comprehensive OHC training to staff at the pilot sites, with a strong emphasis on the use and interpretation of the risk assessment framework. Ensure staff are competent in identifying risks, developing appropriate care plans, and using assistive devices safely. For example: Training sessions would include practical exercises on completing the risk assessment tool, analysing the results, and developing OHC care plans based on the individual's risk profile.
• 5. Collect data and evaluate outcomes: Collect data on KPIs at the pilot sites, such as falls rates, staff injuries, patient satisfaction scores, resource utilisation, percentage of people maintaining mobility and function during inpatient stay, and adherence to the risk assessment framework. Analyse the data to evaluate the effectiveness of OHC implementation and the impact of the risk assessment process. For example: Track the percentage of people who receive a completed OHC risk assessment within 24 hours of admission and the percentage of care plans that are consistent with the results of the risk assessment.
• 6. Refine and adapt: Based on the data and feedback from the pilot sites, refine and adapt the OHC protocols, training programmes, equipment provision strategies, and the joint risk assessment framework itself. For example: If the data shows that staff are struggling to accurately assess a particular risk factor, revise the training materials and provide additional support. If the framework doesn't adequately capture specific person’s needs, revise it to include additional assessment domains.

Phase 3: System-wide rollout (achieving scale)

• 1. Pilot evaluation and scaling up case: Evaluate the qualitative and quantitative results of the pilot. Estimate the investment required to scale up OHC implementation across the entire system. Project the long-term benefits and the estimated ROI return period.
• For example: The estimated investment to scale OHC implementation across the entire system (all hospitals, care homes, and domiciliary care agencies) is £1 million, broken down as follows: Equipment: £300,000 Staffing (backfill and project management): £400,000Training: £200,000 Data Collection & Analysis: £50,000 ongoing support and training: £50,000
• Projected benefits across the whole system: Better people satisfaction and outcomes, Reduced double-handed care costs: £2,000,000 per year, Reduced staff injury costs: £200,000 per year, reduced hospital admission costs: £300,000 per year total annual savings: £2,500,000
• 2. ROI: The system-wide investment of £1 million is expected to be recovered within 12 months, with ongoing annual savings of £2.5 million thereafter. By the first half of the following year, the system can anticipate significant benefits from OHC implementation. Furthermore, the cascade impact of OHC includes delayed admissions in residential settings as people live more independent lives for longer.
• 3. Develop a phased implementation plan: Create a phased implementation plan for rolling out OHC across the entire system, prioritising areas with the greatest need and the highest potential for impact. For example: Start by implementing OHC in all hospital wards and domiciliary care providers, where high percentage of need is prevalent.
• 4. Secure funding and resources: Secure the necessary funding and resources to support the system-wide OHC rollout, including funding for training, equipment, staffing, and data collection.
• 5. Market mobilisation: A systematic approach to embedding OHC in provider delivery: Market mobilisation is a critical enabler for the widespread and sustainable adoption of Optimal Handed Care (OHC) across a health and care system. It involves proactively engaging with a diverse range of providers, including domiciliary care agencies, care homes, and voluntary organisations, to encourage them to embrace OHC principles in their service delivery.
  
  • A systematic and comprehensive approach to market mobilisation is essential to ensure OHC becomes embedded in provider delivery. This requires moving beyond simple contractual obligations and fostering a true partnership based on shared values and mutual support.
  • identify stakeholders: Begin by identifying all relevant providers within the system, including those currently delivering care services and potential new entrants.
  • awareness campaigns: Conduct targeted awareness campaigns to highlight the benefits of OHC for people, staff, and the overall system. Emphasise OHC as more than just a cost-saving measure, focusing on its role in promoting independence, dignity, and improved outcomes.
  • disseminate information: Share clear, concise information about OHC principles, best practices, and available resources through workshops, webinars, newsletters, and online portals.
  • showcase success stories: Present case studies and examples of providers who have successfully implemented OHC, demonstrating its positive impact and addressing potential concerns.
  • address misconceptions: Proactively address any misconceptions about OHC, particularly the notion that it compromises safety or quality of care. For example, the system could organise a Q&A session with a panel of experts (including occupational therapists and experienced carers) to address common concerns about OHC.
  • collaborative dialogue: Establish open and honest communication channels with providers, creating a space for dialogue, feedback, and shared problem-solving. For example, the system could establish a "Provider Forum" that meets quarterly to discuss OHC implementation, share challenges, and discuss solutions. This forum would include representatives from domiciliary care agencies, care homes, voluntary organisations, and the system.
  • co-design solutions: Involve providers in the design and development of OHC initiatives, ensuring that their perspectives and expertise are considered.
  • mutual respect: Foster a culture of mutual respect and trust between commissioners and providers, recognising their respective roles and contributions.
  • "Train the Trainer" initiatives: Implement "train the trainer" programmes across the system to empower staff and providers to develop internal expertise and cascade knowledge throughout their organisations. Establish appropriate space/room with equipment for training, accessible to all stakeholders for training and embedding OHC.
  • peer support networks: Facilitate peer support networks where care workers can share best practices, learn from each other, and access ongoing support.
  • establish key performance indicators (KPIs): Define specific KPIs to track the progress of OHC implementation. For example, percentage of people receiving OHC, percentage of people moved from double handed care to OHC, number of care hours released back into the system, percentage of people achieving independence, percentage reduction in hospital admissions and impact on discharge delays.
  • performance reviews: Conduct regular performance reviews with providers, assessing their progress towards achieving OHC goals and providing feedback on areas for improvement.
  • regular communication: Maintain regular communication with providers, keeping them informed of new developments, best practices, and available resources.
  • celebrate successes: Recognise and celebrate the successes of providers who are implementing OHC, promoting their achievements and inspiring others to follow suit.
• 6. Establish a support network: Create a support network to assist organisations in implementing OHC, providing access to training, resources, and expertise. This network could include OHC champions, experienced practitioners, and online resources. The support network should include experts in the risk assessment framework who can provide guidance to organisations on its implementation and use. For example: Establish an "OHC Help Desk" staffed by OHC experts who can answer questions, provide technical assistance, and connect organisations with relevant resources. OR consider an online portal with Q&A facility powered by Artificial Intelligence (AI).
• 7. Communicate and engage: Communicate the OHC rollout plan to all stakeholders, emphasising the benefits of OHC and the importance of their participation. Provide opportunities for feedback and address any concerns. Emphasise the importance of using the risk assessment framework to ensure a person’s safety and well-being.
• 8. Monitor and evaluate: Continuously monitor and evaluate the implementation of OHC across the system, tracking key performance indicators (KPIs) and identifying areas for improvement. Use the data to inform ongoing adjustments and ensure that OHC is delivering the desired outcomes at scale. Ensure that the risk assessment framework is being used consistently and effectively across all care settings. For example: Track the number of related admissions reported across the entire system before and after OHC implementation, as well as the number of staff sick days related to musculoskeletal injuries. Track the percentage of care plans that are based on the results of the risk assessment and the number of adverse events (e.g., falls, pressure ulcers) that occur despite the implementation of OHC.

By embracing this leadership-driven, data-informed, and phased approach, and critically by integrating a jointly developed and consistently applied risk assessment framework, systems can successfully implement OHC at scale, transforming care delivery and improving the lives of people, carers, and staff across the system. The consistent use of this framework throughout the process will be a key enabler for ensuring safety of people receiving care, promoting informed decision-making, and driving continuous improvement.

Case studies