Developing Integrated Care in Hertfordshire Chris Badger Operations Director, Older People Hertfordshire County Council
Hertfordshire s Approach A system that delivers the right care and support at the right time and in the right place for individuals, their families and their carers Simple ways of accessing and understanding services Better coordination to reduce duplication Addressing needs early Sharing intelligence An appropriately skilled workforce Delivery of the Vision: Integrated Health & Social Care WS1: Integration of Core Teams WS2: Supporting Integrated Commissioning WS3: Avoiding emergency admissions WS4: System Flow WS5: Data Sharing & ICT
Serious Concerns Significant reduction in over last few years Number of providers in serious concerns 2013 2014 2015 2016 2017 30 11 13 7 3 Coordination with NHS CCG nursing and Community Trust colleagues Proactive monitoring Change of policy Annual visits not three-yearly
Integrated Approach to Risk of Provider Failure and Market Oversight 2 homecare providers 1 care home destroyed 1 care home taken over within 24 hours of concerns raised All in last 12 months
Confident Staff Upskilling staff to feel more confident about supporting residents health & wellbeing Multidisciplinary Teams Support & advice from pharmacists, dieticians, geriatricians, mental health professional, doctors, therapists & nurses Rapid Response A range of services including a frailty vehicle delivering expert care, supported by teams of healthcare professionals, doctors and nurses Effective Technology GP access to patient information when they visit them in their care homes and data analysis Enhanced GP care Targeted support Impartial Assessor Tech in Care Homes Early Intervention vehicle Care Home pharmacist Red Bag HomeFirst Community linked geriatric team Complex Care training End of Life care Multi partner integration Social care integration
6-9 months training programme Paid backfill whilst training Training cascaded afterwards Ongoing support Weekly visits by the qualified fitness and dementia tutors, conducting the Beyond the Armchair exercise programme Complex Care training Premium paid 6
Care Home Impartial Assessor To pilot having a Impartial Assessor at Lister Hospital to speed the 2 way transition between discharges from the hospital and Care Home in order to reduce delays Monday to Saturday 9am to 5pm Patient medically fit for discharge Impartial Assessor completes assessment Care Home receives assessment, agrees it Based at Lister Hospital & works with Discharge team (IDT) Patient transferred back into the Care Home Benefits: Facilitate the discharge process Free up resources for Care Home staff Increase bed-flow & status Reduce miscommunications
Early Intervention Vehicle (EIV) Dedicated ambulances staffed by a Paramedic or Emergency care Practitioners and a Health and Social Care Professional, responding to triaged 999 calls. 7 day cover 07:30-18:30 999 Emergency (red flags) Predefined pathways No 65+ Dehydration Dementia UTI s Falls Head injuries without loss of consciousness Acute decline in function and mobility Yes No Yes Emergency response Appropriate response Early Intervention Vehicle Working in partnership Benefits: Health and Social care working together Reactive (ECP) and Proactive/ongoing support (OT) Not limited to care homes Reduces pressure on EEAST ambulances Promoting independence in older people Preventing hospital admissions Reducing residential placements
Complex Care training Impact so far From April 2015 From May 2016 213 champions trained 44% care homes received training 45% reduction in hospital admissions and A&E attendances. 6.6% improvement in local authority monitoring scores, compared to 2% in non Complex Care homes Early Intervention Vehicle 1,162 visits From Aug 2016 272 assessments of which on average 72% were kept in the community of which on average 19% were Care Homes Impartial Assessor 357 Saved bed days Average of 57% reduction in the development of pressure ulcers Average of 75% of residents MUST scores reducing from 2 to 0 Data as of 3 rd May 2017 Assessed & discharged YTD = 196 Readmission rates YTD = 5
Key Ingredients De-emphasise structure Focus on quality Focus on workforce and skills Joint roles Relationships Care Providers Association
Good Care Day and Good Care Week
Breaking news stories
Evaluation 101 people directly recruited into caring roles 65,650 recruitment savings Extra 116,150 hours of care