Annie Coppel, Implementation Consultant – North West 15 October 2014.
Improving care and support for people with frailty...2018/03/02 · NORTH Annie Coppel Associate...
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Transcript of Improving care and support for people with frailty...2018/03/02 · NORTH Annie Coppel Associate...
Deborah O’CallaghanAssociate Director – Midlands and EastSector lead for public health22nd February 2018
Improving care and support for people with frailty
• What does NICE say about frailty?
• Using NICE Quality Standards to improve care
• Practical support and finding what you need
• Any questions
Overview
Martin Vernon, NCD Older People (Feb 2017)
What are NICE guidance and quality standards?
Evidence Guidance Quality
Standards
A NICE quality standard is a concise set of statements designed to drive and measure priority quality improvements.
A set of systematically developed recommendations to guide decisions for a particular area of care or health issue
Research studies - experimental and observational, quantitative and qualitative, process evaluations, descriptions of experience, case studies
• Older people with social care needs and multiple long-term conditions (2015) NICE guideline NG22
• Department of Health (2014) Better care for people with 2 or more long term conditions
• Department of Health (2014) Care Act 2014
• Department of Health (2014) Care and support statutory guidance
• Department of Health (2014) Carers strategy: the second national action plan 2014–2016
• NHS England (2014) Safe, compassionate care for frail older people using an integrated care pathway: practical guidance for commissioners, providers and nursing, medical and allied health professional leaders
• Department of Health (2013) Integrated care: our shared commitment
Evidence sources
• Multimorbidity• Social care for older people with multiple long-term conditions• Falls in older people• Pressure ulcers• Delirium (includes risk assessment and prevention)• Sepsis• Dementia: support in health and social care• Medicines optimisation• Nutrition support in adults• Transition between inpatient hospital settings and community or care home settings for
adults with social care needs (see quality statement 2 on comprehensive geriatric assessment)
• End of life care for adults
Key quality standards: Frailty -interventions
• Mental wellbeing and independence for older people (addresses mood, physical activity and social isolation)
• Mental wellbeing of older people in care homes (physical and mental wellbeing, sensory impairment and sense of identity)
• Dementia: independence and wellbeing (includes home safety, physical activity, physical, social and emotional wellbeing)
• Preventing excess winter deaths and illness associated with cold homes• Foot care• Alcohol use disorders: diagnosis and management• Smoking: supporting people to stop and Smoking: harm reduction• Falls in older people• Nutrition support in adults• Medicines optimisation and Managing medicines in care homes (addresses polypharmacy)
Key quality standards: Frailty - prevention
For more info on how to use quality standards…
https://www.nice.org.uk/standards-and-indicators/how-to-use-quality-standards
Finding what you need
• Integrated Care Clinical Pharmacist for Frail Older People: Case Management and Enhanced Rapid Response
• Peer Support Meetings for Pharmacists Undertaking Medication Reviews for Older People in Care Homes and Domiciliary Settings
• Medicines Optimisation for Older People in Care Homes and the Intermediate Care Setting: Developing and Reproducing new Models of Care
• Neighbourhood Integrated Medicines Optimisation Team: Improving medicines use at home
• Patient Led Clinical Medicines Reviews
• The Alive! approach to providing meaningful activities for older people living in care, particularly those living with dementia
• Improving the mental and social wellbeing of the elderly in residential care – a case study from Mellifont Abbey Residential Care Home
• Patient information leaflets about preventing falls in hospital and the use of bedrails
• Multifactorial interventions can reduce harm from falls in Acute Hospital settings
• Care Home Support Team (CHST) - Reducing Falls
• Community based Falls Prevention in Older People
• Moving on, The Lunch Club experience
• The role of Private domiciliary care for dementia care
• Derby Dementia Support Service
Frailty: (some) shared learning examples
If you still can’t find what you’re looking for…
Any questions?
NORTH
Annie CoppelAssociate Director
Angela ParkinRegional Technical Adviser(and Northern Ireland) [email protected]
Rachel ReidImplementation Facilitator
MIDLANDS & EAST
Deborah O’Callaghan Associate [email protected]
Gill EddyRegional Technical Adviser (and Wales)[email protected]
Joanne McCormackImplementation [email protected]
Michelle LiddyRegional Technical [email protected]
LONDON
Jane MooreImplementation [email protected]
SOUTH
Chris ConnellAssociate Director [email protected]
Zoe GirdisRegional Technical Adviser(and Channel Islands) [email protected]
Jade FortuneImplementation Facilitator(South East) [email protected]
VacancyImplementation Facilitator (SouthWest) [email protected]
NORTHERN IRELAND
Lesley EdgarImplementation [email protected]
NICE Field Team and Technical Advisers
Integrated care for frail elderly patients in CamdenDr Stuart Mackay-Thomas, Clinical Lead for Integrated Adult Care,
Camden CCGPartner, Hampstead Group Practice
Introduction
Historic background to the frailty and complex care work in CamdenMulti-disciplinary Hub for complex careUniversal Offer (LES) including care homesNeighbourhood (CHIN) working
Camden Whole System Working Model
Com
mun
ity
Cent
reH
ome
Scho
olO
utre
ach
Hub
e.g. H
ive
Wider Determinants of health-education, housing employment, social isolationPreventionSocial CareSocial CapitalSelf-management
GP Practice- Prevention- Core GP
contract- LTC- Home visit- Outreach to
community- Some
unscheduled care
GP Practice/Community
Planned:- Core GP- LTC + specialist clinics
+ outreach- Frailty MDT- Palliative Care- Mental Health Team
- Children’s team
- Therapist/MSK- Maternity- Range of specialist
clinics, e.g. dermatology, gynaecology, ophthalmology
- Self-care/management- Care navigators- Social care- Diagnostics (simple)- Pharmacist/therapistsUnplanned:- Unscheduled/? Care- 8-8- Home-visiting serviceBack office functions:- Admin, rotas, secretarial etc.
‘Hub’/CHIN
Chronic Disease
Management- Community LTC Hub +
admin
Hospital/Mental Health
Secondary/local hospital
Planned Care
- Advice + guidance- Diagnostics- ‘One-stop clinics’- Planned admission
Un-planned admission
Tertiary/specialist/Mental health- Advice + guidance- Support to 2ndry care + GP- Care plans/treatment
specialist- Review of specialist
patients
- Community nursing
- MH services- Children’s services- (Community and
GP links)- Social care- Voluntary sector- ETOH/drugs
Community Services/Social Care/Voluntary Sector- Community nursing support- Rapid response- Crisis team- In-reach/ out-reach/
community/ social care/ voluntary sector
- ‘Step up/step down’ bedsGP Front End
Practice- Core GP (registered
list Camden +)- Walk in emergency- 8-8 access
Unscheduled Care- Urgent treatment
centre- 8-10pm- Minor injury
A&E- Diagnostics- Urgent front
end clinics- CDU- AMU- Ambulatory
care- Emergency
care
Unplanned Care
Neighbourhood
GP Federation
Community/GP Front End
IT/CIDR
Prevention + Self-managementCommunity/GP
Accountable Care Entity (ACE)
‘spoke’
- Diagnostics/ ambulatory care
- GP OOH/111
- Prevention/LTC- Re-direction- Admin GP federation
- CCAS- GPIT- GP website/training +
education- PharmacyCamden Whole System
Working ModelLocal Care Strategy. Jan 2017
Frailty / complex care timeline
2010 – Virtual ward pilot2011 – set up of multidisciplinary “frailty Hub”
- Camden Integrated Care Service (CICS)2013 – Frailty LCS2016 – Locality MDTs trialled2017 – Universal offer LCS2018 – Neighbourhood MDTs planned
Camden Local Care Strategy
“Health and care services will work together with local people to provide co-ordinated, proactive, accessible, good quality care in order to improve the health and wellbeing of people in Camden”
ie a whole system model of care which allows providers to work together
Key elements of model
Communities – ie public health, local authority, health providers and voluntary sectorNeighbourhoods of general practice – 50-80000 patients
Care Closer to Home Integrated Networks (CHINs) – see aboveSpecialist acute and mental health in-reach to the communityIncreased communication between staff – using Camden Integrated Digital Record (CIDR)
How is this model planned?
Local Care Strategy Delivery Board:
Camden CCGSecondary care providersLocal AuthorityCommunity providers (eg CNWL and C&I)Voluntary sectorPatients and carers
Frail and elderly
Large part of a group of patients that require co-ordinated care between multiple professionals including:
Primary careSecondary careAdult social careMental healthCommunity nursing and therapyVoluntary sector
Camden’s model for those with complex needs
localGP and
Integrated Primary Care
team
centralHub MDT
Hospital
Social services
Mental health services
Voluntary sector
Hub MDTWeekly Multidisciplinary
meeting• GPs• Geriatrician / secondary care• Complex care nurses• Social workers• Psychiatrist• Camden Carers• Age UK Camden• Palliative care• Pharmacist
Communication at the Hub
• Medical record in EMIS community – main screen• Each service accesses their record during meeting• Administrator holds email list, takes referrals and distributes the
summaries afterwards
14-Feb-2018 Case conference (South Camden Centre for Health) SHELDON, Jonathan (Dr)
Problem CKD stage 3A with proteinuria (First)
Problem Osteoporosis (First)
Problem Atrial fibrillation (First)
Problem [X]Dementia in Alzheimer's disease (Review)
Problem CVA unspecified (Review)
Problem Insulin treated Type 2 diabetes mellitus (Review)
History Presented by Christine Salmon. Lack of capacity. Often fluctuates but currently has
a suspected UTI.
Has diagnosis of dementia. Non concordant with carers and DN visits. Not allowing
them into the property. Stopped shopping for himself, no food or not enough food
at home. Mice infestation.
DN team reluctant to visit as of late, as his home is very neglected and dirty. Takes
meds and insulin. Not allowing catheter care. Christine Salmon raised three adult
safeguards with ASC in the past few months. Is known to memory services.
Plan
Martin Hampton to visit client's home early next week, to take photos of the
property and the living conditions, assess personal neglect. DN team to continue
going in as per care plan twice daily.
To be discussed at the Hub in 2 weeks.
Who refers to the Hub?
Outcomes in those managed by the Hub – A & E
Outcomes of those managed by the Hub -admissions
Days spent at home by those managed at the Hub
Does it save money though?
Universal Offer – complex care component
Local Enhanced Service (LCS) that remunerates GPs to visit frail (or complex) patients, perform comprehensive geriatric assessment, and agree care plans with patients and carers.Frail or complex patients are identified by:
Electronic frailty index (eFI)Rockwood Clinical frailty scale
Frailty register numbers
Care homes
Enhanced service for GPs to visit care homes in Camden weekly (around 600 residents)Monthly MDT with geriatrician and TREAT nurseYearly quality improvement project / audit
Neighbourhoods and CHINs
Smaller MDTs manage similar patients to the Hub but located in GP practices rather than in South Camden Centre for Health, with a slightly smaller group of professionals
Initial trial in 2016 – limited GP involvement
Due to relaunch under Neighbourhood guise imminently
Demarcation of District Nursing
zones
WEST
NW3
NW5
Neighbourhood areas overlaid on District Nursing zones
CHE(W)
NW3
NW5
CHE(S)
SOUTH
NW3 Neighbourhood Frailty pilot
• Frailty doctor of the day• 4 week pilot in May 2017• Covering 6 practices in emergent NW3 neighbourhood• Referrals from hospitals, GPs, palliative care, rapids• Telephone number given to LAS and 111 as well as adult social care• GP met with rapids, district nurses and went into TREAT clinic and the
wards
Findings
InsightThe number of patients seen 85 with 111
contactsThis equates to ~5/day, with some seen multiple times
Pts avoided some sort of Hospital admission
49 of contacts (~44%)
Whilst this was the Drs opinion, this is still a good indicator that the right pts were being referred
How many interventions had Palliative Care (PC) input
8pts 11 contacts (~10% of pts seen)
*Across NW3 practices there are ~190 on PC registers. Extrapolating for a whole year this could mean ~50% of PC patients would benefit from additional GP input at the point hospital intervention is considered.
Pts directly referred from RFH (most from TREAT)
35 contacts (~30% of pts seen)
Re-enforces the point of collaborative working and supporting the drive of ‘Care Closer to home’
What proportion of our Frail pts were seen
~10% in a month
**Across NW3 practices for 2016-17 there are ~850 on our Avoiding Unplanned Admissions registers. Opportunity for a large number to benefit in a year
So what next?
Develop Neighbourhood working using neighbourhood MDTs
Implement shared communication structure (?EMIS) and outcome measures between providers
Measure patient and carer reported outcomes
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Care Home Strategy WorkshopThursday 26 October 2017 at 2pm at Avenue House
Name of presenter: Dr Jonathan Lubin, NHS Barnet CCG GP Board MemberDate: 26th October 2017
Working together with the Barnet population to improve health and well being
Care Home Vision
Working together with the Barnet population to improve health and well being
We recognise the need for a shared vision of care in Care Homes to help us develop a strategy to be shared, endorsed and followed by Barnet CCG and London Borough of Barnet.
The strategy would benefit from being supported by NCL and the NCL STP to try to ensure that the strategy can be funded and supported.
The prizes are:
• Better care for residents• Care homes with a sustainable future• Care home staff with better jobs• A reduction in avoidable admissions to hospital from care homes• More residents dying in the place they choose• Residents and their families/loved ones feeling that the support they
need is in the care home
Care Home Vision – From Vanguards
Working together with the Barnet population to improve health and well being
What works in care homes?
• Access to a consistent named GP• Medicine reviews• Hydration and nutrition support• Access to urgent care when needed in and out of hours• Expert advice for those with complex needs• End of life care• Dementia care• Joined up commissioning between health and social care• Workforce development• Harnessing data and technology
Care Home Vision from Vanguards
Working together with the Barnet population to improve health and well being
Access to a consistent named GP
This has been shown in vanguards to simplify care delivery. There should be weekly rounds to provide reviewing and planning of the care of residents.
Care home MDT
The evidence is the weekly round should be carried out with other members of the MDT that is Registered nurse, pharmacist, and social care and specialist nurses. The individual members of the MDT should be working with Care home staff, residents and families to provide care on a day to day basis and for reviews and longer term planning.
Care Home Vision from Vanguards
Working together with the Barnet population to improve health and well being
Medicine reviews
These reduces drug interactions and likelihood of iatrogenic illness leading to hospital admission.
They also lead to a reduction in costs of drugs, dressings and appliances.The reviews should be at least every 12 months, ideally every 6 months and done by doctor, nurses and pharmacist.
Care homes providers should demonstrate they have effective medicines policies that reduce unnecessary harm, reduces medication errors, optimises choice and use of medicines and reduces waste.
There should be audit evidence that the medicines policy is effective.
Working together with the Barnet population to improve health and well being
Hydration and nutrition support
Residents care plans should include regular reviews of:• Hydration• Nutrition • Oral health
Residents should have access to:
• Specialist dietetics• Speech and language therapist assessments of swallowing
Care homes should have a nutrition policy in place with a single person overseeing implementation and audit.
• Train care home staff to recognise dehydration• Cards with signs of dehydration for use by staff• Use technology to observe individuals ability to feed and drink to assess
care needs and intervene
Care Home Vision from Vanguards
Working together with the Barnet population to improve health and well being
Access to urgent care when needed in and out of hours
• Streamline health and care teams for in and out of hours care.
• The teams include in hours GP, out of hours GP, NHS 111, rapid response health and care teams and LAS
• Consider using the teams with a lead provider to liaise with care home staff and or paramedics to assess and plan best care for the patient
• Care home residents should be able to have IV antibiotics and fluids in the care home to help reduce the need for admission.
• Consider mobile US service to diagnose faecal impaction, enable flatus tubes to decompress sigmoid volvulus in care homes.
Care Home Vision from Vanguards
A Care Homes Vision to consider
Working together with the Barnet population to improve health and well being
All care in the home
•Including IV fluids and IV antibiotics•Care in hospital only if it cannot be provided in the home such as acute surgery
Telehealth
•Residents to have monitoring by telehealth to pick up early changes in health to enable early treatment and reducing risks of care needs escalating•Monitoring of mobility to reduce falls risks and to pick up signs of change in health
A Care Homes Vision to consider
Working together with the Barnet population to improve health and well being
Telemedicine
• Telemedicine to support consultations with residents in the care home by consultants, GP’s, specialist nurses, and therapists
• All care workers working to top of their license
• Ongoing training for all staff
• Some nurses to be trained to nurse practitioner level to enable examination of patients, diagnosis and prescribing. Supported by GP’s and consultants.
• Training paid for by reduced costs of admission.
• Ongoing training for staff
Working together with the Barnet population to improve health and well being
Care home nurse practitioners to enable examining and prescribing (for instance of) of antibiotics for chest, urine, and simple infections.
Prevention• Continuing of significant seven• Use other prevention as evidence develops
Residential home HCA training
• Train and develop care workers to be able to assess residents and be more confident in managing patients and dealing with emergencies
Care planning
• Expect that all care home residents will have advanced care pans and DNAR discussions.
• We will develop a process to manage care needs of patients and families that are unable to engage to ensure that residents best interests are managed.
A Care Homes Vision to consider
A Care Homes Vision to consider
Working together with the Barnet population to improve health and well being
GP support
• This will be initially attached to care homes from a single service and will adapt to become more advisory, supportive and supervisory as care home nursing from within care homes and from community services develops.
Consultant support
• To support care home staff, GP’s and community staff. Access via telemedicine and in the home if needed, but this will be exceptional.
OPAS
• A unit to oversee unwell residents from home, care homes and GP services. To be sited at FMH. To take over the care of much of the service at BGH currently run by TREAT.
A Care Homes Vision to consider
Working together with the Barnet population to improve health and well being
End of life care in care homes
• To be expanded to ensure that resident needs can be met in a timely manner so that residents do not suffer at the end of life and the need for hospital or hospice admission is reduced as far as reasonable.
AI ISO13482 standard for close human robot interaction
• Care homes costs will lead to the need for increased productivity and this will push the introduction of Robotic care home interaction.
Care Home Vision – Tasks
Working together with the Barnet population to improve health and well being
Care for both Nursing and residential care homes:
• GP’s
• Options:
• Single practice for each home• CHIN provides GP practice to manage care homes in the CHIN
area• Federation/other entity provides a coordinated GP service for
care homes• Care home/elderly frail practice operating from FMH
Working together with the Barnet population to improve health and well being
GP role
• Support Care home BILT
• Involvement in weekly MDT in care home
• Assessment of complex medical needs of residents in weekly ward round• Involvement in working with care home staff and relatives on behalf of
residents
• Out of hours cover
• Telemedicine cover
• Supporting care home specialist nurses and other care home staff
• Liaising with care of elderly consultant for advice
Care Home Vision – Tasks
Care Home Vision – Tasks
Working together with the Barnet population to improve health and well being
Specialist nurse role
• Member of MDT• Day to day assessment and treatment of care home residents
face to face or by telemedicine• Monitoring of care home residents at distance by technology• Intervention when technology indicates early changes in health• Working with care home staff to support relatives of care home
residents• Prescribing nurses• Supporting care home staff by teaching and support when
needed• Liaising with GP’s• Liaising with care of elderly consultant for advice
Care Home Vision – Tasks
Working together with the Barnet population to improve health and well being
Care home Nurse
• Day to day management of nursing and medical needs of residents• Supporting care workers and health care assistants• Liaising with GP, BILT, specialist nurses, clinics and family• Overseeing medication given by HCA to residents• Later: Prescribing for UTI and chest infections• Examination of residents including chest, cardiovascular and abdominal
examinations supported by telemedicine• Wound care and overseeing wound care• Monitoring health of residents on telehealth in care home• Assessing swallowing and managing the findings• Carrying out ECG on residents
Care Home Vision – Tasks
Working together with the Barnet population to improve health and well being
Care home health care assistants
• Medicines rounds• Wound care• Preventative role ensuring residents are drinking and bowels are functioning• Testing urine for infection• Phlebotomy• Blood glucose testing• Management of PEG and ostomies• ECG’s • Vaccinations
Speech and language therapist
• Assessing swallowing• Food advice for those with abnormal swallow
Care Home Vision
Working together with the Barnet population to improve health and well being
Tissue viability nurse
• Assessing wounds by telemedicine• Part of MDT when needed• Advice to care home nurses, specialist nurses and HCA’s
Dietician
• Management of MUST scores• Assessment of diet• Assessment of outcomes of diets• Specialist advice on diets
Care Home Vision
Working together with the Barnet population to improve health and well being
Physiotherapists
• Assessment of function • Assessment of future ability• Management to prevent contractures• Fall reduction care and planning• Prevention of immobility
Care of Elderly consultant
• Specialist input• Support of care home GP’s and nursing staff• Support of assessments of residents need of admission • Support to MDT• Leading TREAT assessments• Support of IV care
Care Home Vision – Tasks
Working together with the Barnet population to improve health and well being
Palliative support team
• Consultant led palliative care team• Support and provision of end of life and palliative care• Support for DNAR agreements• Support and training of care home staff to enable syringe driver
access • Rapid response telemedicine, advice and prescribing of end of life
care and palliative medicines
Social worker team
• Support of staff in issues with relatives• Meet social work needs of residents• Best interest opinions within 2 hours• Arranging and liaising over continuing care
Care Home Vision – Tasks
Working together with the Barnet population to improve health and well being
Occupational therapists
• Assessment of residents needs• Working with team to maximise functional ability of residents• Ensuring that residents have best method of obtaining and using fluids• Assessments of machinery etc to meet needs of residents• Assessment and provision of wheelchairs
Psychogeriatricians
• Assessments of mental health• Treatment of mental health• Telephone advice to care home staff and GP’s• Attendance at MDT by telemedicine when needed
Care home robots• Transfers of patients• Giving medicines?• Helping to feed and give drinks• What do you want them to do?
Care Home Vision
Working together with the Barnet population to improve health and well being
75 plus- Home visiting Service
Joint Clinical Leads for Central CHIN Haringey Dr Sheena Patel and Dr Mei Mei Till
AIM
• Moderately Frail patients >75 years on more than 10 medications- have a full assessment- Medication review- Connected with Local services
Each practice within the CHIN will:
• Run a search: patients >75, on 10+ drugs• Compare this with those identified as moderately frail• Add/subtract patients using GP knowledge and judgment
Team delivering service
• Community matron• Prescribing Pharmacist• Care Navigator • GP – advisor, NOT seeing patients
WORKING WITH THE HARINGEY INTEGRATED LOCALITY TEAM
Home Assessment
• Falls and environment check• Dietary review• Long Term conditions checks• Supported Self care• Social isolation and signposting/referral• Depression and Dementia Screen• Identify possible self-neglect, safe-guarding issues
Followed by:
• Care plans and consultation: recorded directly into the patient’s primary care record (EMIS web), Read coded• Medication reviews: mainly remote, some face to face• Care navigator: health, social, community, voluntary • Weekly MDT meetings • NOT case management• Advice on patients and pathways from GP, teleconference
What are the measured outcomes?
• Completed comprehensive annual reviews and chronic disease case finding• Referrals to community and voluntary sectors• Costing outcomes for Medication changes • Changes in e-FI• Health promotion- smoking, diet, exercise, alcohol, vaccinations• Advanced care planning – community DNAR forms
So far…
• The service has just started 6/2/18 – 15 patients have been seen in one of the practices.
CASE 1: 83 year old pastor
• Not attended surgery• Outstanding annual Hypertension and Diabetic reviews• DH: Metformin 500mg BD, Glicazide 80mg OD • Medication review: Diabetic medication was not optimised,
measuring blood glucose in appropriately throughout the day, hypoglycaemic agent
Interventions:
- Optimisation of Meformin, Glicazide stopped- Test strips and lancets removed- Health care promotion: Diabetes self care monitoring - Referral to GP gym - Completion of care plans- Community Referrals made direct from the consultation (on behalf of
the practice)- Monitoring investigations – blood tests, urine
CASE 2: 80 year old, lives alone
• Info gathered from HV: - Sleeps on a sofa - No hot water in the house for 2 years - Financial concerns- Safety concerns- smoking with home oxygen! - No community support
• Medication review: non-compliance • Medical review: Poor BP control, COPD review overdue (poor control), Pre-
diabetic, Recurrent leg swelling and ulceration• Bloods not up to date for DOAC monitoring
Interventions:
• Increased eFI from 0.25 (moderately frail) to 0.33 (severely frail)
• Referral to Haringey Locality Team
Learning points so far…
• Addressing Polypharmacy• Invaluable information gathered in patient’s own setting• Updating GP records and patients care plans• Great interest in GP gyms• Community service navigation • Assessing safety issues• MDT learning
Health & Wellbeing Partnership
Haringey & IslingtonFRAILTY
Health & Wellbeing Vision
Born well, live well, age well
What is the intended impact on their health and wellbeing?Help older people live and age well:1. Improved living environment and stronger communities to support wellbeing
and independence2. Prevention of crisis through early identification of risk, and enhanced
integration across health and social care , MH housing and third sector3. Reduce frequency and duration of crisis through robust frailty services when
required
Medical care is only 11% of the opportunityClinical care is the main focus of our health systems, but only accounts for 11% of overall health.
The real opportunity 68% lies beyond science and medical care
Individual behaviour accounts for 36%
Collectively these factors can be used to improve health within the clinical, population, and public health spaces
Source: www.goinvo.com/features/determinants-of-health/
Person perspective
• Outcomes older residents from Haringey and Enfield wanted:
• co-ordinated the care around the patient/resident• ability to sustain health• preserve independence• maximise the time spent at their place of residence • reduce mortality
• I Statements in Islington include:
• I want to be treated as a whole person and for you to recognise how disempowering being ill is• I want my care to be co-ordinated • I want to feel supported by my community and get the most out of services available locally• I want to feel respected and to feel safe.
Broad collaboration
Working Together
§ Sharing evidence and innovation- efrailty index, Comprehensive Geriatric Assessment in different settings
§ Commitment to place based care - working CHINs - North Islington, West and Central Haringey
§ Strong patient engagement- Good neighbour schemes to address isolation
§ Importance of working with housing: showing importance of housing assets/skills/staffing in supported housing in Haringey
§ Falls workstream- mapping services, working with LAS.
§ Acute care pathway
§ Intermediate Care strategy
Proposed population approach for older people Move to earlier intervention
Next steps:1. Developing place based systems
CHINSHow do locality teams develop?Matching workforce to needsThe roles of specialist community teams How social care and health partners have equal ownership?
2. Common acute care model across hospitalsMaximising admission avoidance with prehospital care, ED interface, CGA as standard, early supported discharge
3. Activating community to identify and support mild to moderate frail to promote wellbeing, independence, reduce isolation and prevent crisis
North CHINFrailty Project Update
Dr Ajay Bassi (Dr Lucia Manfredi)
Frailty Project • Moderate Frailty• 9 North Islington practices• Proactive care• Evidence based interventions
• Holistic geriatric assessment• Medication Reviews• Falls Assessments
• Current partners are:• 9 GP practices• Whittington Health• Age UK Islington• Islington GP Federation
• Established a CHIN Frailty register• GP rapid screening using eFI and Rockwood Clinical Frailty Score
• A list of ’not sure’s
• Searchable from a central location
• Established a CHIN Frailty team• Physio (WH)
• Pharmacist (WH)
• Navigator (AgeUK-I)
Where we are now:
• What are the numbers?
• Moderate Frailty: 458• Not sure of frailty status: 217
The Frailty Register
• Moderate Frailty:• Telephone assessment using own tool• Face to Face holistic assessment• Identification of needs• Applying interventions
• Completing the register (Not Sures):• Telephone screening tool• HV assessment if likely to be frail• Added to register if appropriate
• Establishing the pathway ongoing
Current work:
• Moderately frail:• 38 telephone assessments• 25 home visits
• “Not Sure”:• 7 telephone assessments• 2 home visits
• Referrals:• 23 onward referrals• 7 referrals to AgeUKI navigator• 8 Falls Assessments (by team)• 9 Medication reviews (by team)
Activity So Far:
• Social services• Community Dentist• Age UK Islington• Audiology• Podiatry• TCES- Medical Equipment Service• District Nursing
• REACH- Physiotherapy and OT community services• Falls Groups• SALT
Onward referrals to date
Case examples
• Hypertension, Chronic Kidney Disease, Glaucoma, Sight Impaired.• Lives with Wife, independent all ADLs• GP screening: Moderately frail• Telephone screening: Mildly frail but falls • HV:
• Holistic assessment found:• Significant postural BP drop• Poor hearing• Sight impairment• Undiagnosed cognitive impairment• High alcohol intake
Mr B- 87M
• Interventions:• Medications amended and reviewed• Onward referrals- Audiology, Podiatry, ECG and Dexa scan…• Equipment arranged• Offered memory service referral• Joint repeat visit with navigator:
• Taxi card• Recheck blood pressures • Referral to AgeUK-I for ongoing support
• Re-coded as Severely Frail
Mr B- 87M
• Heart Failure, Diabetes, Arthritis, recent heart attack
• Limited mobility:• Walks with roller frame• Outdoors with scooter
• Generally managing with ADLs• Son helps with some meals• Has pendant alarm• No falls
Mrs GA – 69F
• GP rapid screening: Moderately frail• Telephone screening: agreed with this• Seen on home visit by physio
Issues:Increased falls risk and Social Isolation. • No hand rails –• No access to outside space. • Broken Intercom.
Mrs GA
• Referring to social services• Islington Council to repair the intercom
Outcome:Reduced fall risk and maintained the patients independence, gaining access to the community and being able to socialise
• Information Governance• IT and operational issues: Still waiting for laptops,
mobiles or a direct telephone number for Frailty CHIN team. • Coding• Team capacity!• Comms and branding • Sharing responsibility and establishing lines of
accountability across organisations• Making sure it is safe and effective• Discovering lots of complex patient need
Challenges
Doing lots of this…
• This is hard• Lots of unmet need in Islington• Never enough time
• We can work across organisations to deliver one service• This type of proactive service can add value
What we have learnt?
• More hands: Frailty Nurse• Skills gap identified
• More interventions
• Data, data, data• Collection• Analysis: does this work
The future
Enfield’s Care Closer to Home Integrated
Network on Frail Elderly
www.enfield.gov.uk
Integrated Locality Team – Frail and Elderly
Phase I of the development of the ILTs brought together health and social care services as a “virtual team” to case manage and support GPs in their practices without any organisational changes. The model manages and care plans for appropriate very high risk patients aged 50 and over using a multi-disciplinary team (MDT) approach underpinned by risk stratification and clinical judgement. MDT meetings are held to review ‘very high risk’ patients this occurs on a monthly basis in the four localities in Enfield.
Phase I brought about a trusted relationships between GPs and community health & social care teams, acute providers and commissioners were more eager to move to a jointly managed, co-located ILT, with a widened scope to include all categories of need and risk that community teams work with. A key ambition for Phase II is the alignment of ILTs with the wider Strategic Transformation Plan and the Care Closer to Home Integrated Networks model (CHIN).
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The Care Homes Assessment Team (CHAT) is a nurse-led team who support individual patients in care home and who also help develop the nursing capability off care home staff. The CHAT work closely with GPs to support patients in care homes.
CHAT holds routine clinics within the homes to help manage residents’ cases, with the regularity of these clinics dependent on risk assessment of the homes’ quality of care including its hospitalisation rates. CHAT also has an urgent visiting service for patients where their condition is causing concern.
The Care Home Assessment Team are vital partners in reducing A&E attendance from care providers; they have a strong and collegiate relationship with care homes and are part of the Trusted Assessor implementation locally, creating a relationship where providers feel confident and safe to seek advice
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Care Home Assessment Team (CHAT)
Enfield Delivery Programme Group Membership: Key stakeholder includes: ECCG Governing Body Clinical Lead, Primary Care Lead, ECCG, BEH-MHT, LBE, Public Health, Health Watch and Acute Sector
Responsibility: Strategic Overview of the CHINs Programme; Strategic development, monitoring progress and outcomes across the four locality CHINs
Enfield CHINs PROGRAMME GOVERNANCE & INFRASTRUCTURE
Locality CHINs Delivery Group Membership: CHINs GP Leads, Health, Social Care, VCS, Primary Care, Public Health, Health Watch and Locality Service Manager.
Responsibility: Develop and Implement CHINs delivery plan; Deliver the CHINs outcome for all populationMonthly Activity & Finance Reporting
CHINs QIPP Steering Group Membership: Programme SRO, Director of Commissioning, Director of Recovery, Head of Care Closer to Home, Commissioning Managers, Transformation Managers, Primary CareResponsibility: QIPP delivery;
CHINs Financial & Activity Impact
Meetings currently held fortnightly
NEL Commissioning Support Unit, Enfield CCG Financial Management & Planning Team & Public Health
Local Community Forum – Service User Expert Group
Joint Health & Social Care Commissioning Board
Health and Well Being Board
Enfield’s CHINs DevelopmentPhase I - Virtual MDT
- Running for 2 years- Reviewed
Phase II - Joint role/ further recruitment- Develop locality teams/services- Co-locate
Phase III* - Service re-design- Embed practices- Learning & Development (on-going)
* Approach not yet agreed
Progress to date...PRIMARY CARE MANAGEMENT• Joint Assessment, care
planning & delivery• Support for Care Home
Residents (CHAT)
RAPID RESPONSE• Helping people return
home post-hospital• Planning & managing crises
at home or end of life (CCRT
DIAGNOSTICS & TREATMENT• Older People’s
Assessment Unit• Memory Service for
people with dementia
IDENTIFYING PATIENTS• Sharing information
between professionals• Identifying high risk
patients on GP lists• Single Point of Entry
Demographics in LocalityNorth East
South EastSouth West
North West
• Core team co-located • Additional services aligned
to the SE area team: Hospital Discharge; Review
•Core team co-located •Additional services aligned to the SW area team: Hospital Discharge; MASH
• Core team co-located and managed by the NE ILT SM
• Additional services aligned to the NE area team: ICT; Enablement; Magnolia
• Core team co-located and managed by the NW ILT SM
• Additional services aligned to the NW area team: CHAT; SPA / Access; Matrons
North West ILT Service Manager (Nurse)
North East ILT Service Manager
(Therapist)
South East ILT Service Manager
(SW)
South West ILT Service Manager
(OT)
Proposed Extended ILT Structure
Core teams consist of Social Workers, District Nurses and Community Matrons
Our Plans for 2018-19• Develop further an operational CC2H Delivery Group• Establish clear shared goals with key stakeholders• Co-design improved packages of care for Enfield patients• Focus on clinical priorities per locality• Health SPA for the borough• MDT process redesign• Learning & development planning
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