Integrated Care Collaboration between Somerset Care Yeovil District Hospital. Oct 2015-present

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1 Integrated Care Collaboration between Somerset Care Yeovil District Hospital Oct 2015-present

2 Outline Introduction YDH/Somerset Care collaboration Care Hotels in NL

3 Outline Introduction YDH/Somerset Care collaboration Care Hotels in NL

4 Somerset Care Not-for-Profit Home care, Supported living, Care homes, Training

5 Somerset Care Not-for-Profit Care homes, Home care, Supported living, Training

6 Somerset Care Not-for-Profit Home care, Supported living, Care homes, Training 72m turnover, c employees 7 domiciliary care bases 5 in Somerset, 1 in Wilts, 1 in Hants/Surrey 16K hours per week, 1000 staff, >2700 customers Income split LA:self-funding 78:22 2 LD bases 5K hours per week supported living Somerset, Dorset, Wilts 28 care homes, 1522 beds, residential, dementia, nursing 27 in Somerset, 1 on IOW Income split LA:self-funding 40:60

7 Home care YLMS/Realise Specialist care

9 Vision To lead the market in high quality, evidence-based lifestyle support and care, through research, innovation and outstanding customer focus

11 Mission To enhance quality of life and promote independence of older and disabled people

17 Outline Introduction YDH/Somerset Care collaboration Care Hotels in NL

21 Aims of Collaboration Improve patient flow at YDH Reduce unnecessary length of stay at YDH Enable appropriate reablement Maximise patient clinical outcomes Reduce cost of ongoing care

23 Criteria for admission Documented confirmation by Consultant of Medically Fit For Discharge status Patient signed up to intensive reablement days Discharge destination is usual place of residence Demonstrate ability to actively engage with rehabilitation (physically and mentally) Evidenced potential for rehabilitation

24 Criteria for admission Holistic therapy requirements identified 18 years Discharge summary completed /medications ready/treatment Escalation Plan in place Ongoing care plans completed for patients with specialist involvement Emergency escalation plan agreed to avoid readmission to YDH

26 Exclusions Stroke patients Chest pain within last 24 hours Intravenous therapy No fixed abode 72 hours post Myocardial Infarction Medically unstable Dorset GP

27 Number of admissions 600 admissions Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Apr-17 Jun-17 Aug-17 Oct-17

28 Length of Stay Days Average 11.63

29 Home First

30 Length of Stay Days Home First Average Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Apr-17 Jun-17 Aug-17 Oct-17

32 Discharge destination 95% discharged home Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 Discharge Home Returned to YDH

33 Discharge destination 91% discharged home Home First Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Apr-17 Jun-17 Aug-17 Oct-17 Discharge Home Returned to YDH

35 Clinical Outcomes Goal Attainment Scaling (GAS) Scores Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Apr-17 Jun-17 Aug-17 Oct-17 Overachieved Achieved Underachieved

36 Clinical Outcomes Goal Attainment Scaling (GAS) Scores Over-achieved Achieved Under-achieved

38 Costs

39 Cost of Delays Opportunity cost associated with the time it takes for patients to be assessed and a long term care plan put in place YDH estimates that there is on average a delay of c days between a patient being medically fit and having their long term plan of care (POC) confirmed and put in place

41 Cost of Plan of Care Delays Home First 35, , , , , , , Feb-16 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Apr-17 Jun-17 Aug-17 Oct-17

42 Costs Cost of bed in acute hospital 400 per night, 2800 per week Cost of bed in community hospital 285 per night, 2000 per week Cost of bed in brand new purpose built nursing care home 117 per night, 825 per week Nursing care home cost 2-3x lower than hospital Better environment, more intensive rehabilitation, better outcomes

43 Cost savings 42% of patients required a reduction in their predicted care packages upon discharge from Cookson's Court Downstream saving to the local authority of c. 1.6 million p.a. in home care costs Resulted in reduced elective cancellations, and income protection of an estimated 1.9m in 17/18

45 Feedback The world is a better place because of people like you Wonderful staff, highly efficient, compassionate and very caring No praise is high enough A total credit to the service Dad returned home with renewed confidence Thank you for the advice and help you have given to us all. We will be able to care for Mum so much better now

46 Feedback Thank you for your professionalism, friendliness and kindness You deserve a medal for your 100% fantastic service The care and support given to Mum has been amazing So grateful for your service Highly efficient, compassionate and caring therapists Cannot praise therapy staff highly enough and long may the service continue The therapy staff were amazing and nothing was too much trouble The staff were always willing- thank you for everything There are no words to express my gratitude, thank you with all my heart. I ve been born again

48 Case Study 73 year old lady admitted to YDH 31 st May 2016 Fell from steps, bilateral inversion, unable to weight bear Diagnosis L #5thMT and R #2,3,4 th MT and #distal phalanx of greater hallux Slow progress in mobility and function; mobilising with WZF short distances only, assistance of 2 people for transfers. Unable to complete personal care activities Felt that wasn t being communicated with spoken to PALS, felt that was just thrown into a corner of a bay and left Orthopaedic team felt too unrealistic to mobilise without frame or complete steps therefore aiming home in microenvironment with QDS double up PoC personal care Admitted to CC 16 th June 2016

49 Case Study Within 3/7 independent with toileting throughout 24hours, independent using shower, independent with 1xWS, independent completing steps Within 4/7 able to carry hot drink whilst mobilising, independent outside with stick, able to complete full flight of stairs Discharged home 21 st June with no PoC Feedback: I did not think I d be able to do this for months I cannot thank the therapists enough for their encouragement and treatment they are a credit to the NHS I feel so privileged to have been able to come here, I just wish I could thank you all personally

51 Conclusion Collaboration and integration of services does not require a change in organisational form or complex rearrangement of budgets, it depends on relationships between people at different levels in the collaborating organisations

53 Outline Introduction YDH/Somerset Care collaboration Care Hotels in NL

54 Care Hotels The Netherlands

55 Bernhoven hospital

56 Health and Care Healthcare in NL paid for by insurance 100 euros per adult per month After hospital treatment, patients are moved asap for rehabilition to Care Hotels for up to 44 days Cost of bed in care hotel is ½ that of hospital bed

57 Udens Duyn, Uden, NL

58 Care Hotel, Uden 76 beds, 12 for regular guests 4 th floor - highest dependency of need 3 rd floor physiotherapy room and gym 2 nd floor regular guest rooms 1 st floor lowest dependency of need, lounges, dining room, activity room, library, hair-dressing salon

59 Care Hotel, Uden

60 Dr Jane Townson Chief Executive, Somerset Care Group

HomeFirst. Most importantly, we patients prefer and hope to be at home not in hospital, so I think this service is the way of the future.

HomeFirst. Most importantly, we patients prefer and hope to be at home not in hospital, so I think this service is the way of the future. Most importantly, we patients prefer and hope to be at home not in hospital, so I think this service is the way of the future. HomeFirst I felt I was looked after at home much better than I would have