Sutton Homes of Care Vanguard Programme

Transcription

1 Sutton Homes of Care Vanguard Programme End of Life Care Clinical Network Conference 22 February 2017 Dr Clare O Sullivan: Clinical Lead for End of Life Care and Sutton Vanguard Programme Corinne Campion: Clinical Nurse Specialist, Supportive Care Home Team, The Royal Marsden

2 Five Year Forward View Published 2014; set vision for Vanguards Sutton awarded 1 of 55 Vanguards; 1 of 6 Enhanced Health in Care Home Vanguards Annual Value propositions; funding released subject to conditions 2

3 Overview: The population of Sutton 81 Care Homes 594 residents in NHS Funded 203, Care Home Beds Nursing Home placements Residents in Sutton aged aged 85+ Health funded home care packages Fully funded nursing home placements 10 M 1770 A&E presentations from Care Homes 1034 Emergency Admissions 1.1M 275 people were eligible to receive Funded Nursing Care 3

4 Our Care Home Residents Perceptions vs reality 4

5 Our Partners Sponsored by: The National Institute for Health and Care Excellence (NICE) All our Care Homes in Sutton Working in collaboration with: NHS England New Care Model Programme SWL Collaborative Commissioning Care Quality Commission Health Education South London Health Innovation Network Academic Health Science Networks Other Care Home Vanguards 5

6 Integrated Care Care Staff Education and Development Quality Assurance and Safety Sutton Homes of Care: The programme Our vision is to have vibrant, high-quality care homes in Sutton delivering care that embraces the national nursing values of patient care Care, Compassion, Competence, Communication, Courage and Commitment (the 6Cs ). NEW MODEL OF CARE The vision is implemented through the three pillars 6

7 The Challenge for Care Homes Independent organisations Recruitment and Retention Negative attitudes Barriers to engagement Terms and conditions are not standardised Most Frail and vulnerable members of society What happens if a care home closes? Myths and limitations of NHS support not in their own home Large number of beds but limited statutory controls 7

8 What we have achieved (1/2) Impact on NHS Care: 9% reduction in ambulance call outs and conveyances 18% reduction in A&E attendances and 9% reduction in unplanned admissions 4 days reduction in length of stay in hospital (results from preliminary evaluation of Hospital Transfer Pathway) Reduction of 100k in medicines costs from Sept 15 to Sept16 through resident medication reviews Impact on Clinical Quality 10% reduction in pressure ulcer rates and 15% reduction in falls rates (AQP data) Reduction in UTI rates following introduction of resource packs (AQP data) 8

9 What we have achieved (2/2) Genuine partnership and collaborative working enabling enhanced communication and more joined-up services Bi monthly care home forums for care home mangers Positive impact on care home staff work roles Engagement with residents and families Contribute to Dementia Diagnosis Rates Collaborative working with other five care home vanguards: Embedding EHCH Framework into practice National and International Publications; Award finalists Presentations at Pan-London and National conferences; Visits from NICE, DOH, Ministers and Dignitaries 9

10 How we achieved this Quality Assurance and Safety Pillar Joint Intelligence Group Quality Dashboard Policy for safe medicines supply and administration 10

11 How we achieved this Care Staff Education and Training Pillar Training / Education E-learning packages Classroom based training Bespoke interventions from link staff Student nurse mentorship training underway Dementia support (DeAR-GP, Barbara s Story, Music Mirrors,This Is Me) Summary of resources Concerned About A Resident poster Priorities For Care of the Dying Person poster Red bag poster and film Quick Guides (reference cards, posters and film Care Home Forums 11

12 How we achieved this Integrated Care Pillar Health and Wellbeing Reviews In nursing homes: Link GP pilot In residential homes: Link nurses and champions Care Home Support Team Link nurses Supportive Care Home Team (EOLC) Care Home Pharmacist: Medicines Optimisation Dementia Support Workers The Hospital Transfer Pathway Red bag initiative Residents with a red bag have 4 days less in hospital than those without a red bag

13 The Royal Marsden Supportive Care Home Team Royal Marsden Palliative Care Corinne Campion Ash Kassaye Louisa Stone Susie Sutherland Change Presentation title and date in Footer dd.mm.yyyy 13

14 The Royal Marsden End of Life Care model for care homes in Sutton Specialist palliative care Education Clinical Rounds GP Palliative Care Meetings

15 15 The Royal Marsden Nursing Home Key Performance Indicators Key performance indicators ( KPI s) % of residents dying in PPD No data 84.2% ( n=101) % of residents being offered Advance Care Plans 29.6%( n=132) 70.8% ( n=276 ) % of residents with CMC record 27.6% ( n=123) 58.6% ( n= 232) 159 teaching sessions- 402 Attendees

16 16 The Royal Marsden Residential Care Home Pilot Key Performance Indicators (Oct15-Oct16) Key performance indicators ( KPI s) Oct 2015 Dec 2016 % of residents dying in PPD No previous data 82% ( n=14) % of residents being offered Advance Care Plans 17.1% (n=18) 79% ( n=94) % of residents with CMC record 17.1% (n=18) 31.9% ( n=25) 78 teaching sessions- 190 Attendees

17 17 The Royal Marsden Recent CQC report Inequalities in EOLC People with a learning disability are likely to be identified as approaching the end of life late This can lead to problems in coordinating end of life care and providing support to the person and family Palliative care staff have a lack of knowledge around learning disabilities Communication was identified as a significant barrier to good care. Difficulty in assessing pain

18 18 The Royal Marsden Learning Disability Homes Development of model of care based on nursing home model Development of teaching programme specific to learning disability Development of confidence questionnaire KPI s around PPD,ACP and CMC and pain assessments Attendance at relevant GP practice GSF meetings Regular meetings with St Raphael s Hospice, local acute hospital and continuing health care Clinical Rounds Education GP Palliative Care Meetings Short film on YouTube: We are Living well but Dying Matters (2:26 to 4:38)

19 19 The Royal Marsden Resources

20 Enhanced Health in Care Homes Framework (1/2) Published in September 2016 using outcomes of the 6 Care Home Vanguards From April 2017 will be included in CCG assurance processes 20

21 Enhanced Health in Care Homes Framework (2/2) Care Element Vanguard Interventions RAG 1. Enhanced primary care (access to GPs, medicine reviews; hydration & Health and Wellbeing Rounds; Hospital primary nutrition support; access to urgent care when needed and efficient care Transfer Pathway (Red Bag); Care Home care transfer) Pharmacist; Care Home Dietician; CAAR 2. Multi-disciplinary teams (MDTs) and coordinated health and social care to support those with most complex needs. This could include new roles (for example Care Coordinator) to help professionals, individuals and carers to better navigate the system 3. Reablement and rehabilitation and the development of community assets to support individuals resilience and independence 4. High quality dementia and EOLC (access to specialist dementia services and support; proactive identification of care home residents requiring EOLC; support to die in place of choice; care staff supported with appropriate knowledge and skills re. dementia and palliative care) 5. Joined-up commissioning and collaboration between health and social care (co-production, access to appropriate housing, shared contractual mechanisms) 6. Workforce development (training for social care provider staff; joint workforce planning) 7. Data, IT and better use of technology (linked data sets; access to shared care records; secure ; telehealth, telemedicine and telecare). poster; Link Nurses Care Coordinators in care homes; Care Home support team (CHST) - link nurses and End of Life Care nurses; Champions in residential home pilot; Voluntary Sector initiatives Intermediate Care beds in care homes Silver Letters End of Life nurses and dementia support workers (part of CHST); London Borough of Sutton s Challenging Behaviour Team; DeAR GP Care Home Forums; Cake, Cuppa, Chat; Joint Intelligence Group (JIG); AQP in nursing homes for CHC E-learning modules; Resource packages; Training from CHST); Care Home Forums Quality Dashboard; JIG; Secure NHS ; Mapping of IT in care homes; Sutton CCG s Integrated Digital Care Record 17/18 plans 21

22 Sutton Homes of Care Great care is a partnership Equity Equality Empowerment More information is on our website: 22