Impact and celebration event - the change challenge by NHS East and North Herts CCG
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Transcript of Impact and celebration event - the change challenge by NHS East and North Herts CCG
The Change Challenge
‘Develop integrated physical, mental health and social care pathways to prevent inappropriate
hospital admissions’
Impact & Benefits• Improved relationships between Health
& Social Care• Protected time for learning &
Development• Skills and competencies to take forward
large scale change• More confidence in using tools &
techniques• More confidence in questioning
challenging data and use of metrics• Tangible resultant outcomes for
patients:– ESD, Homefirst, Better Care Fund
Highs & LowsEnjoyable
Relationships developed
Positive relationship with key NHSIQ facilitators
Tools and techniques, e.g. SPC
Time commitment
Staff changes
Role of elected Members?
How to engage providers?
To ensure 60% of people
who have expressed preferred place of death
achieve it by 2019
Find out where they want to die Find out where patients and carers know their preferred place of care for death
Ensure resources are available delivered to support different choices of PPD
Get ACP/PPD in place
Share ACP/PPD
Culture where people expect to discuss death to PPD / culture of death being demedicalised
Identify resources needed and commissioning contracts
AIM PRIMARY DRIVERS
SECONDARY DRIVERS
IN
TE
RV
EN
TI
ON
S
Social services contact with older people – death wish 50% of SC manager interactions include discussion ACP by October 14
ACP talk and agree plans with those with LTCs
Advanced care planning: GPs / hospital / community / nursing homes
Develop support for families in helping them agree ACP / PPD
GP contact with older people – death wishSingle assessment – advanced care plans. Consent - DNAR
Develop a consistent way of recording ACPPlace of residence i.e. patient’s home – clear about ACPs
Staff education on how to do DNAR
Apps or IT programs available to make online choices
Train staff in discussion / recording of ACP (HCP / SCP / residential nursing home staff)Funeral plan – incorporate ACP / PPD / death wishes into pre-payment plans
Funeral directors learn how they talk - ACP/PPD/death wishes – training?
Collate responses
Carer support and training for carers of patients who are palliative
Peer support development
Amber project
Public education: value of ACP / PPD
AIHVS
Create entry on patient record / social care file
Ensure each provider ensures everyone in organisation knows the client’s ACP 100% of patients with ACP have them avail in the notes
Agree a process for sharing ACP/PPD with providers % admissions from NH for EoLC
Good death for patient and family – who gets to decide? Post-death
What support do families get after the death?
Engage with carers
Living will
Perceptions about death in society / from films / as failure / dramatic & unpleasant
Power of attorney
Develop community services to support EoL care at home Care home 1° care
project
Holistic assessment unitA&E navigator
NH contract for 1° care to encourage high quality ACP/PPD - KPIs
Acute medical consultant triage
Create capacity to fulfil expectation
Standalone unit – hospice and hospital
Nursing home staff to avoid admissions for EoL patients
Staff in care homes are trained and not risk averse
How do we enable/commission hospital to provide approp. EoL care?
Ambulance Trust – avoid admissions
Voluntary sector roles
Keep a shared register move to share ACP / PPD
Develop hospice services for those choosing them on PPD
Dedicated block capacity for fast track care
Comms. strategy
Ensure all staff in partner organisations have awareness of how to do a DNAR
50% SC records with ACP for O75s asked if they knew about ACP and want to start the processAcute care
colleagues to engage with supporting good deathsNo. of funeral directors participating in the project / who has bought a funeral plan in the last 5 yrs
90% of NH pts with PPD at home achieve wish 12/12
No. of admissions by Nursing Homes by condition per quarter
Register of shared ACP / PPD
Balancing measure: 1. reduce bed
occupancy for EoL patients
2. Increase home care costs
What was most useful about the programme?
Relationships across health and social care
Joint understanding of health and social care commissioning
Underpins ambitious Better Care Fund of c.£120m
If you knew then, what you know now, what would you do
differently?• Think differently about elected
member engagement• Spend time earlier on shared health
and social care issues• Understand need to co-design with
NHSIQ and be flexible
What are your personal insights, reflections and learning?
• Relationships drive integrated care• Successful transformation of care built
on effective relationships across health and social care system
• The importance of quality, facilitated, time-out to plan and deliver change