Fylde & Wyre CCG New Interim Care Home Service Amanda Lomas F&W CCG Commissioner
Care Homes Model Overview Background Four new care home models piloted on the Fylde coast. One in BCCG area, three in Fylde and Wyre. In summary, these models all centre on improving the triage and assessment of patients, increasing home staff s access to advice/support from healthcare professionals and medical optimisation.
Care Home Service 3
Introduction Aim of the presentation Alison Ricchiuti- Operation Manager Michelle Dicks- Deputy Manager, Alexandra Nursing Home
Background Wyre Integrated Neighbourhood (WIN) 6 practices, Thornton, Poulton, Over Wyre All practices wanted to develop services for care home patient with ambitions of extending this service out to household patients and recognised an underserviced population 25 homes, Cohort of 415 residents Primary Care not set up to service Chronic Disease Management in residential care Currently reactive service
Why? Ageing population, increasing burden of illness Dementia 1 in 5 >80 yrs, set to double in next 30 years. Complex health and social care needs and fragmented services. Residential Home 24 months avg. life expectancy High rates of unplanned admissions distressing & costly
Aims Improve health care for residents. Improve patient experience & Quality of life. Improve communication. Improve medicines management. Patient centred anticipatory care. Building on collaborative working with care homes. Identify learning needs and skills gaps for teaching and training. Reduce hospital inappropriate admissions.
Neighbourhood engagement 2014/15 - Two very successful formal engagement events involving care home managers, practices and CCG and wider stakeholders ( mental health, social services Age UK Dementia UK, Trinity etc.)prior to service going live Informal feedback Formal Questionnaires
Stakeholders Care Home Staff WIN Team Practices Mental Heath Third Sector Patient OOH Services Social Services Family Community Services
Feedback following engagement Sharing of information. A greater understanding of the barriers to effective communications for optimum care between practices and care homes. Communication across the board identified inconsistences between practices e.g Medications. Discharge information. Local champions from care homes that took part in the original pre 2014 pilot to promote uptake across all the care homes.
Meet the team
WIN care home team Service commenced in December 2015 Initially challenges with recruitment and staffing capacity Initial "hump" of workload in 1st round of assessments and care planning Initial assessment, 3 mthly review now 6 monthly Individual holistic care Co-ordination plans New residents within 14 days Within 72 hrs of hospital discharge Chronic Disease Management Medication review Advance care planning /end of life Care home staff training NOT an acute service
New resident visit Harry is scheduled for a visit in 6 months time to review his health plan Home inform of Harry s admission to the care home. Care home Team visit Speak with Harry Care staff and Family Care Coordination plan shared with GP and FCMS Assess holistically Chronic disease 6- CIT review, check MaRR against GP records.encourage discussion around advanced care planning. Care co-ordination plan produced given to home and asked to call appropriated numbers, EpaCCs recorded Pharmacist review sometimes face to face
Admission to hospital Lessons learned Harry admitted Service makes contact with the Hospital & works with the home to reduce LOS Admission discussed at MDT with clinical lead to identify if considered avoidable or not. Outcome shared with home Action plan completed and Care Coordination plan reviewed and shared with GP and FCMS Pharmacist will review medications checked Assessment and discussion with the resident, home and family as to why the resident went in and RCA form filled in. Marr Comparison made. Team contact the home following day of discharge and visit within 72 hours
GSF ward rounds Care home team will update FCMS and GP Care home team call Care Home to arrange a monthly meeting Care staff and link care home team nurse go through all the residents in the home Actions identified discussed jointly for resident who have moved along the coding scale including med review Discuss DNARCPR protocols and Just In case Advanced care planning discussion will be confirmed including if the resident has a shared EpACCs Each resident will be discussed as to where they sit on the GSF prognosis scale
GSF ward rounds Lead nurse identified for each home Each resident s discussed monthly in a virtual ward round Just in case drugs DNACPR protocol Named link in each practice and information shared across Common and consistent processes and clinical coding across all practices. Medication reviews Involvement in practice palliative care meetings Involvement of Trinity and EOL care home group
Pharmacist interventions Medication reviews Visit home, review MARs, carers concerns, suitable patients to review with them. Look at indication, suitability, dosage, formulation, usage, risk scores of prescribed medications. Best practice prescribing, following local and national guidance. Advise GPs on suggestions, implement with agreement and notify homes. 72hr discharge and new patient reviews. Dealing with specific queries that come in from homes that may otherwise be directed to GP. Support & advice for team. Neighbourhood given pharmacist authority to make cost effective changes to certain medications where appropriate.
Two years on 91% Med reviews completed (March 17) Admissions reduction of 74% 100% 100% PPC/ PPD and DNARCPR discussed New residents seen within two weeks Care plans completed. 89 15-16 = 250 16-17 = 161 Total cost savings 280,901 Of which 68,818 medication savings Length of stay reduction by 1,118 days 15-16 (2,916 days) 16-17 (1,798 days)
Two years on Care Home feedback Primrose Bank would like to thank care home team for all their hard work and support. Gave us a bunch of flowers. Just wanted to take some time out to thank you and the WIN team on behalf of Pilling Nursing home for all your help and support during our ongoing development since opening. Worth their weight in gold Alexandra Nursing Home. Family feedback Thank you for getting my Mum home sooner post discharge and checking everything has been OK. You ve been a great support. Thank you for your kindness and support in helping us make Mum s last few days comfortable and in the right place. You went above and beyond to ensure, Mum got the best care and for that we ll be forever grateful.
Initial reflection on the new service Alexandra Nursing Home: Initial Barriers Staff trust nervous about who the team were and constructive comments not taken easily Vision unclear not communicated Short term increased work load care plan writing and collection of resident information weights ect. My own previous experience of care plans and no explanations given How did you overcome them? Reflection and recognition of lack of services out there to support Vision became clear Building relationships Easy access to other MDT Quicker and smoother response Able to bounce ideas of each other having a mutual respect Preventing unnecessary admissions and placement breakdown
Case study Chris 81years old. History of Frailty, dementia, stroke and diabetes. Chris had been very independent up until 2011 when he suffered memory loss. Diagnosed in 2011 with Dementia. Family struggling to cope 2015-16. Admitted to Rest home section of the Nursing Home following an admission from a fall and fracture 2016. Wandered frequently and high risk of falls. Home and wife would always be feeding him finger foods. WIN Team when visiting would witness him singing Let it go Disney classic from Frozen and that he would often dance. He would sometimes be mischievous and creep up behind you whilst having conversations with others but was like a gentle giant.
Case study Home WIN 5/2016 Home Informed WIN new resident 5/2016 Chris seen on initial chronic disease review and care plan completed. Discussed need for advanced care planning with home and offer of support 7/2016 Home discussed with family and requested DNARCPR along with PPC/ PPD 4/2017 GSF ward round +continued care 5/2017 GSF Ward round + continued care 7/2016 Care plan updated following Advanced care planning 11/2016 Joanna pharmacist med review 5/2017 Chronic disease review and advise around fortification 5/2017 Fall in home and admission 5/2017 Visit by WIN Identification of drug changes when comparing MaR against discharge letter Referral made to falls team and Dietician. Green months years prognosis EPaCCS notified 6/2017 GSF ward round and continue monthly 9/17 Fall in home and admission 9/17 Care home identify EOL weeks (Yellow) and inform WIN and GP 10/17 Care home confident in looking after Chris in EOL 9/10/17 Chris died peacefully in the home 6/2017 Med review following admission. Updated EMIS records of changes 9/17 Visit by WIN discussion around deterioration EOL and falls to highlight with safeguard team Care plan completed 9/17 WIN update EPaCCS and change care plan. Request 4 core meds 10/17 Continue to support home with EOL 10/10 WIN and surgery informed
Lessons learned 1. Inconsistencies surrounding completion of DNRCPR s 2. RCA s MDT 3. Understanding of common themes in admissions i.e falls 4. Managing family expectations - important to involve family 5. Safeguarding can increase LOS 6. Sometimes gaps in key skills and competences ( such as wound and EoLC) in nursing homes 7. Acute hospitals understanding of frail patients once admitted 8. Advanced care planning and using consistent sharing processes. 9. What can be achieved through a shared vision and desire to collaborate for a common goal.
Success Provides a conduit to support better communication Shared Vision Neighbourhood and care home relationships and trust. Increased EOL recognition Quality of care for residents and families Team professional satisfaction and neighbourhood pride in achievement Further possibilities in streamlining neighbourhood protocols to improve quality and flow Chronic disease protocols Wound care protocols for ordering Shared protocols in covert medications Common homely remedies agreement
Success A future service across the Fylde and Wyre based on national evidence and local success.
Thank you!
Fylde & Wyre CCG Interim Care Home Service 2 Interim Care Home Teams between 1 st November 2017 31 st March 2019 Fylde - (Kirkham & Wesham and Lytham Neighbourhood) Interim Workforce ( Nov 2017 Mar 2019) Nurse Practitioners Health Care Assistants Pharmacist GP Neighbourhood Support Integrated Falls Service Enhanced Primary Care (EPC) Future Integrated Neighbourhood Team District Nursing Community Matron Therapy Services Mental Health Services Social Services Extensivist Service (ECS) Wyre (Fleetwood and WIN)
Future Vision Integrated Neighbourhoods Patients and professionals refer into a neighbourhood hub including care homes. Triage Assess Signpost Community consultants Patient activation Care coordination Primary care Therapy Community nursing Mental health Social care Diagnostics and specialist acute care Wellbeing support 1 Improved outcomes and experiences of care for patients 2 Better utilisation of the local health and care workforce 3 Improved utilisation and sustainability of local services
Interventions include: Medication reviews and optimisation Care planning Advanced care planning GSF Nurse Ward Rounds Dementia screening Post discharge review within 72 hours Urgent clinical triage via telehealth MDT
Virtual Care Homes MDT GP Neighbourhood Support Pharmacist Nurse Practitioners Integrated Neighbourhood Team Health Care Assistants Community Matron MDT Social services Integrated Falls Service Therapy Services Mental Health Services District Nursing In-Reach Geriatrician
Technology Utilisation 2017/18 secured funding via vanguard programme to provide telecare in all care homes across the Fylde Coast. The IT project teams have worked alongside the Care Home team to roll this out and provide support. Care Homes will link to: Fylde & Wyre Care Home Teams Out of hours services (Care Coordination) Primary Care ongoing roll-out during 2017. Working with other Community Services (Dietetics and SaLT).
Care Home Connect Update 100% engagement with 69 care homes in Fylde & Wyre CCG. Care Homes refused service: 25% (17/69) Initial surveys completed: 100% (52/52) Broadband commissioned: 79% (41/52) Wi-Fi commissioning complete: 62% (32/52) ipads deployed and training complete: 48% (25/52) The process is to: Engage Visit and explain the project further Survey any existing network Complete installations Issue ipad and training Sign and return MoU
Directory of Services Now launched across the Fylde coast: www.fyidirectory.co.uk Provides a comprehensive resource for patients and professionals to access health, social and third/voluntary sector service information. Fylde coast care homes listed on the site enabling families to review. Please take a look at your own listings you can manage these yourself!