Collaboration Between Health and Social Care. Ruth Holt Director of Nursing/Independent Care Sector Regional Lead, NHS England (North) September 2017

Transcription

1 Collaboration Between Health and Social Care Ruth Holt Director of Nursing/Independent Care Sector Regional Lead, NHS England (North) September 2017

2 Collaboration why now? Changing demographics Ageing population Changing expectations - family Hospital is not the right place for many people Loss of independence PJ Paralysis! Isolation Infections, falls Shared challenges Quality, workforce, finance

3 The vital ingredient for patients 10 days in hospital (acute or community) leads to the equivalent of 10 years ageing in the muscles of people over 80 Gill et al (2004). studied the association between bed rest and functional decline over 18 months. They found a relationship between the amount of time spent in bed rest and the magnitude of functional decline in instrumental activities of daily living, mobility, physical activity, and social activity. Kortebein P, Symons TB, Ferrando A, et al. Functional impact of 10 days of bed rest in healthy older adults. J Gerontol A Biol Sci Med Sci. 2008;63:

4 When we think about solutions we must focus on the residents whose health and wellbeing we are trying to improve. We should never lose sight of that in the face of our focus on systems, processes, money and targets. The Kings Fund, 2016

5 Regional Care Sector Board Regional Management Board Chair: Richard Barker, Regional Director, NHS England (North) Care Sector Board Chair: Margaret Kitching, Chief Nurse, NHS England (North) Operational Groups Chairs: Directors of Nursing, NHS England Sub Regions Task and Finish Groups Defined within the annual programme of work

6 Vanguard sites Enhanced Health in Care Homes 6

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8 Social care fundamentally important

9 Our commitments

10 Case studies

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12 Closing the three gaps

13 Hospital or Home? Collaboration to support discharge from hospital Collaboration to prevent admission to hospital GP alignment to care homes MDT inreach for specialist skills End of life care Dementia care Joined up commissioning

14 Enhanced Health in Care Homes (EHCH) care model Care element 1. Enhanced primary care support for care home residents Sub-element (further detail on each sub-element in annex) Access to consistent, named GP Medicines reviews Hydration and nutrition support Out of hours/emergency support 2. MDT in-reach support Specialist clinical advice for those with complex needs Navigating the system (single point of access to advice) 3. Re-ablement and rehabilitation to promote independence 4. High quality end of life care and dementia care 5. Joined up commissioning between health and social care 6. Workforce 7. Data, IT and technology Rehabilitation and reablement services Community engagement End of life care Dementia care Shared contractual mechanisms Co-production with providers and networked care homes Access to appropriate housing Training and development for care staff Co-ordinated workforce planning Linked health & social care data Access to care record and secure Better use of technology

15 Workforce of the future Coordinated workforce planning Joint appointments care sector/nhs? Advanced skills Rotational posts Address recruitment issues in the care sector/nhs Greater understanding of different sectors Learning together Teaching Care Homes Student Placements Greater job satisfaction

16 Closing the three gaps

17 Improving wound care programme A bespoke evidence based educational resource Initially developed by NHS, CCG and Care Sector Colleagues Aims to increase knowledge and awareness of pressure ulcer avoidance amongst carers Positive results through increased prevention/early awareness resulting in reduced harm and unnecessary hospital admissions

18 Scale of the issue The elderly in care homes are particularly vulnerable, often with poor mobility/comorbidities and at increased risk of developing pressure ulcers 20% of residents in residential and nursing homes will develop pressure ulcers (NPSA; 2010) 60% at risk (Callaghan; 2014) Safeguarding issue- avoidable v s non avoidable PU remains highest harm 4.2% (NHS Safety Thermometer 15/16)

19 Training Resource

20 Closing the three gaps

21 Quick Guides 1. Quick Guide: Improving hospital discharge to the care sector 2. Quick Guide: Better use of care at home 3. Quick Guide: Clinical input into care homes 4. Quick Guide: Sharing patient information 5. Quick Guide: Technology in care homes 6. Quick Guide: Identifying local care home placements 7. Quick Guide: Supporting patients choices to avoid long hospital stays 8. Managing care home closures 9. Quick Guide: Discharging to Assess 10. Quick Guide: Health and Housing

22 Live Care Home Bed State Improving Relationships & Delivery Through Digital Solutions. Pilot areas live in May 17 Rolling out across the north of England Free to implement

23 Concept A new model for bed state communication between Care Home s, Local Authorities & Acute Care Trusts. Collaborate & Navigate Benefits 1 2 Streamlined Real-Time Processing. Insight Driven Reporting 1 2 Care home inputs capacity & available bed demographics. Health Trusts & Local Authorities search available capacity based on specific parameters. Improved Patient Choice & Experience

24 Our values

25 Moving forward What is right for people using services? What is right for the different professions? What is right for health and social care? Can they be aligned? What do people using health and care say they want? Care sector forums need our support

26 When we think about solutions we must focus on the residents whose health and wellbeing we are trying to improve. We should never lose sight of that in the face of our focus on systems, processes, money and targets. (The Kings Fund, 2016) The future has to be different by collaborating we will create a better future

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28 If you had 1000 days left to live how many If would you choose choose to spend in hospital? to spend in hospital? If you had 1000 days left to live how many would you

29 If you had 1000 days left to live how many would you choose to spend in hospital?

30 Thank you!