Developing proactive and enabling sheltered housing services that avoid unnecessary hospital admissions Christine McMillan and Prof. Glenda Cook Roy Marston, Jo Rose & Dr Cathy Bailey 27 th January 2014 KTP funded by TSB, ESRC & DH The project aimed to: Increase supply of desirable homes Decent Homes / DDA standards High quality, spacious, modern apartments Choice, independence and well-being Help people remain in own homes Early intervention and avoidance of unnecessary hospital admission Reduce fuel poverty Contribute to local economy / jobs 1
The Project will deliver: 26 quality sheltered housing schemes (10 new build and 16 refurbs) 922 apartments (350 new and 572 refurbs) Including over 90 two bed apartments 2 year 10 month construction period 28 year contract for cleaning, repairs & grounds maintenance Alongside the building programme service development is being facilitated through a KTP programme 2
KTP key Objectives Quality of life and optimal well-being Maximum control over own life Ageing in place through lifetime homes Innovative housing with support and care Prevention of ill health and enabling recovery Supporting self management of chronic disease Service development grounded in tenants perspective of personal wellbeing and evaluation Service development model Interagency working:ecp & AART pilot Tele-health pilot Interventions Skilled workforce Prevention and enablement Wellbeing resources NTC Sports & Leisure Move It Programme Nutritional Wellbeing Contact the Elderly Elderflowers Well-being database 3
Optimising well-being maintaining community connections and relationships Keeping active Practical, emotional and spiritual coping Why develop the partnership with community health services? North Tyneside is higher than national prevalence in many areas CHD, cancer, renal disease Chronic disease Falls Dementia Population need Bereavement Stroke Sensory impairment 4
Hospital Admissions 2012 Emergency Genito-Urinary Admissions 2012 5
ECP pilot (3 schemes) Referral criteria: (including minor injuries; sprains/strains; assessment following a fall; coughs/cold/sore throat; UTI; COPD: sticky eye) Referral: direct from SHO between 7am-7pm ECP pilot: Case study Female, 88 years old had a fall 2 weeks previously She did not want to see her GP; SHO concerned about untreated skin flap that appeared to be infected ECP contacted by SHO Response within one-half hours Assessed wound cleaned, dressed until would healed; antibiotics prescribed Both tenant and family appreciated treatment at home 6
AART pilot (3 schemes) Referral criteria (including in need of MDT assessment; will no longer than 2/3 weeks require intensive support at home; clinically assessed to be medically supported at home Case study Male, 88 years old who experienced a persistent cough, decreasing mobility & hearing problems. AART member comprehensive assessment reviewed medication Advised SHO/activities co-ordinator on appropriate intervention (access to Move-it programme; audiology review) provided reassurance and advice to patient about respiratory and mobility problems. http://www.youtube.com/watch?v=r9jevkpwv JY Telehealth Project Telehealth equipment sends medical readings directly to a Community Nurse 7
Telehealth Case Study Mr A, 79, lives alone, COPD (10 years), diabetic, oxygen dependent, short of breath on movement and visually impaired Community Nurse (CM) devised daily monitoring plan, training Mr A to measure BP and pulse oximetre (helps monitor oxygen needs) Sheltered Housing Officer (SHO) set up equipment and gave initial user support to Mr A Mr A, CM and SHO working together to tailor telehealth to Mr A s needs Benefits to date Mr A I think you get a bit bothered with the breathing when you move around and it s a bit of a habit to take the oxygen this (telehealth )tells me I don t need it as much as I think CM Beyond pilot would like to explore capturing long term trends; says telehealth here to stay and good to engage SHO Training and peer support improved confidence setting up technology; problem solving with Mr A rewarding With Mr A, CM and SHO developing shared protocols/strategies for ongoing training, support, response Challenge Issues with broadband provision and service take time to address What needs to happen next to make this model replicable, sustainable or mainstream? Integrated working between the sheltered housing service, ECP and AART team has been rolled out from the 3 pilot sites across the service What factors enabled this service model to work Commitment to develop a partnership Effective communication between teams and across sectors Understanding KPI s and service targets Identifying how integrated working could address those targets Clear referral criteria Agreed objectives and outcomes 8
Thank you for listening Any questions 9