Improving Outcomes for Frail Older People

Transcription

1 Improving Outcomes for Frail Older People Presented by Elizabeth Saunders

2 What we were asked to do The Health and Wellbeing Board in March 2013 requested an update on the improved outcomes being achieved for frail older people with a clear summary of the next steps, key milestones and delivery mechanisms.

3 So what did we do? Workshop held to clarify what we have currently across the systems Explored what was happening, what was working well and what wasn t Reviewed work areas and suggested future priorities Designed a way of reporting to HWB Board what success looks like

4 And what else has happened? Joint Health and Social Care Review (Community Bed Review) signed up to and plan of work being developed to implement recommendations Joint Expression of interest to be a Pioneer in Integrated Health and Social Care and proposals for take this forward

5 What success looks like for frail older people My carer/family have their needs recognised and are given support to care for me. I am supported to understand my choices and to set and achieve my goals. I have as much control of planning my care and support as I want. I have one first point of contact. They understand both me and my condition(s). I can go to them with questions at any time. Taken together, my care and support help me live the life I want to the best of my ability. I have information, and support to use it, that helps me manage my condition(s). I am as involved in discussions & decisions about my care, support and treatment as I want to be. My care is co-ordinated I receive services and responses that are proportional to my needs. I know who to contact when I have a concern and the issue will be dealt with at that point or signposted. I am treated with dignity, respect, and cultural sensitivity. I have the information and support to use it, that I need to make decisions and choices about my care and support.

6 What Success looks like for frail older people I feel Safe. I am independent and as mobile as possible I receive high quality care that is centred around my needs. Those that support me (my carers, family, neighbours) receive support and positive outcome and are seen as individuals. I don t feel like I am being a burden. I trust and have confidence in professionals caring or making decisions around my care. I have pride in myself and feel like I matter. I have a rewarding social life and feel part of my community. People see me as a whole person and understand my individual circumstances, health conditions and life story (ie likes, dislikes, history). I am involved in communication and conversations about me I can make informed choices and am involved in decisions around my care I now have a sense of purpose and have something to look forward to.

7 The Pathway What s going well Health Checks Warm Homes Healthy People Stop smoking services Fall prevention Case management/community Matrons Mindings Project Direct Payments Project Step up Step down service in South (Greenacre) Care home framework Prevention and early intervention Dementia Quality Mark Council s Reablement Service Ageing Well Programme Urgent Homecare and Falls Response Service (UHFRS) Self directed support (personal budgets) Village Care Schemes Dementia Peer support Extra Care Dukeminster development Dementia community activities Singing for the Brain

8 What s working? Tender started for Framework Agreement for Care Home Services giving greater customer choice and efficiencies Village Care Scheme 98% coverage at present with 100% target by Reduction in isolation and improved health and wellbeing Pilot Targeted Prevention Project 40/60 had avoided hospital admissions or care home placements in Chiltern Vale First new 80 bedded Council owned Extra Care Sheltered Housing Scheme due to open in Comprehensive Reablement Service. 50% require no further support. Social Worker in A&E/Acute Assessment Unit 67 people diverted from hospital (72% of those assessed) Short Stay Medical Unit South 70% people return home Step up Step Down (South) 65% people return home, 75% still at home after 12 months Urgent Falls Home Response Service 100 people per month avoided hospital admission

9 So what? It s amazing to think that in a village our size There are all these people who need a bit of Help, and all these people who are willing to Help, and none of us would have ever found Each other without the care scheme Quote from volunteer with CaddingtonCare Case Study 1: A lady, also a carer for her elderly mother who Lived a few streets away was hoping to go on Holiday but was concerned for her mother s Safety and welfare whilst she was away. The care scheme volunteers assessed her Level of care and arranged a plan whereby Her mother rang the care scheme s phone Everyday to confirm that she was ok. The Mother enjoyed the daily phone chats. Village Care Scheme During the last quarter we have been transporting a resident to visit her husband in Bedford Hospital. She has used the scheme a few times in the past but is now very dependent on them. She has no family an is disabled due to arthritis of her hips. It became clear that one volunteer for this was not enough so they organised for couples to undertake transport. Case Study 2: A couple were a bit uncertain as to whether They should carry out their dream of moving To the country to a beautiful but fairly remote Village. They had no transport of their own And both had medical problems. However, They were advised about the existence of the Village s local care scheme and got in touch. They contacted the group who gave Reassurance that they could rely on the Group for the occasions that they might need A lift. They are now very much part of the Rural community.

10 So what? Computer Classes Most residents go onto buy their own computer, ing friends/family, sharing photos and even do their banking and pay bills online. Village Care Scheme Coffee and Chat mornings Held weekly with around 30 residents, mostly In their late 80 s attend. 11 sessions held April to June. Exercise Classes Held once a week. Average of 11 residents attend. Fitter residents less likely to fall; new friendships and increased communication. Walking Group Monthly walk from 3-5 miles with refreshments/lunch at the end. Gentle exercise; new friendships and increased communication.

11 So what? Ministerial Visit to Step up Step down Dunstable August 2013 Mrs R had come from hospital she had not slept for several nights due to it being so noisy, she was exhausted. Once within this reablement bed Mrs R said she had slept much better and it was very peaceful and she was getting the reablement she needed to move back home Independently. Mr E letting people know how good these type of beds are and he wouldn t have coped without his stay in this kind of service. Mrs C showing how well she s getting on since her arrival. Both the Physio and OT really helped her gain skills and confidence.

12 So what? Mrs S was admitted to the Short Stay Medical Unit following a fall at home, she then went into reablement where staff worked on building her confidence to return home. Mrs S soon went home with 4 calls per day to build further confidence and after 12 days was confident enough to be self caring. Feedback: Mrs S found it very beneficial being in the reablement bed as she regained her confidence after her fall and enjoyed her stay there. Mr H was admitted from hospital after a leg amputation below the knee. Previously He d lived independently. After three weeks in reablement he was able to return Home (now in a ground floor flat) and confident to be self caring. Feedback: Mr H commented that the staff had helped him gain confidence to live independently and his advice for others would be don t think about it, just go to reablement Mrs B was admitted to reablement after a stay in hospital. She was in bed unable to weight bear. She was soon able to join in group exercises and soon was able to walk 7 or more steps unaided. After three weeks she was able to return home with carers calling four times a day, this lasted a further four week. Now Mrs B is self caring and returns to the reablement unit only to visit friends she made whilst there. Feedback: Mrs B benefitted from physio and occupational therapist and was informed and included in any changes to therapy.

13 So what about Reablement? Mrs H has reduced mobility and requested assistance with personal care and meal preparation. Due to muscle weakness she needed to rebuild her strength and confidence. A referral for telecare was done, a trolley to assist her in transferring food and drink and a shower chair was ordered. Initially assessment started with 4 calls daily, 14 hours per week. With the reablement she was receiving this was reduced over a month and Mrs H is now self caring. Mrs E was utilising the reablement services and receiving morning and lunchtime calls. After 4 weeks it was apparent that Mrs E was becoming more independent and confident at her personal care and making food and drink for herself that it was agreed that she would go self caring with the support of her family. Mrs R was referred to the reablement team after a hospital admission for breaking her arm. Mrs R s reablement started with 4 calls per day, 14 hours per week and after 5 weeks of support Mrs R has been able to reduce her hours down to 10.5 hours per week with community physiotherapists helping with her mobility on a regular basis.

14 Prevention Joint approach to prevention developed Signed up to by the Council and BCCG Joint programme to embed preventive approach Joint post to drive forward

15 The Pathway Needs more Work Alcohol reduction services Flu vaccinations Stroke Early identification and treatments Vision and hearing screening Paying for Care service Short Stay Medical Unit (SSMU) Development of new Extra Care Housing schemes Generic advocacy services review Village Agent Scheme

16 The Pathway Need Higher Priority Physical activity initiatives Effective crisis management Reablement / Rehabilitation services Residential and nursing care homes admittance Risk stratification tools Making Every Contact Count (MECC) Community nursing teams Joint social work & nursing assessments Community Geriatrician model in primary care Care Coordinators Integrated urgent care pathway Step up Step down service in North Telecare Remodelling Biggleswade Hospital Information Strategy Joint Commissioning framework for beds Dementia Care in hospitals Older Peoples Day Centre Review Joint strategy for dementia? Expansion of Extra care Housing Programme Dementia Pre diagnosis support Dementia Post diagnosis support Supported Housing Strategy Dementia Access to psychological therapies Dementia support care pathway implementation

17 What we have learned.. Changing landscape of staff and programmes Different agendas, timescales and leaders Limited joint structures Barriers around information sharing Lack of understanding of investments across the whole system

18 What we have learned.. Need to capture people s experiences better Focus on service orientated and organisational projects Lack of people centred approaches

19 The Whole System at the Moment Accident & Emergency Not joined up yet Elective Surgery Assessment GP Services Urgent Home Care Acute Services Health Rehab / Enablement Ur ge nt Emergency Surgery Emergency Medicine Ambulance Services l Co o lab Ca re Rapid Intervention Short Stay Medical Unit Assessment Beds Reablement eh tiv ra & S Day Procedures Health Visitors Pa thw ay 3rd Sector Suppliers Carer Support Information & Advice Individual Healthy Living Infrastructure Self Care Leisure Village Care Schemes Family Support Co lla bo r Dentist Meals Service Residential Care at iv e Respite He alt h End of Life Care Mental Health Pharmacy Optometry Out-patient Services Community Nursing ia oc & So Diagnostics c ia lc ar e Therapy Cancer Treatment Palliative Care Geriatrics Day Care Domiciliary care Assessment Beds s Step Up/ ay Down hw t Pa Short Notice re Respite l Ca lth ea Local Services Mental Health Treatment Pa th w ay s

20 Being Bold More focus on the Whole System Develop people rather than organisational care pathways Taking risks Truly integrated programmes of work

21 What improvements are needed for the whole system? Planned Care Community and Social Capital Early Intervention and Prevention Integrated Governance and performance management Integrated Commissioning arrangements Urgent Care