Care Homes for Older People Service Level Agreement 2016-2019 All practices are expected to provide essential and those additional services they are contracted to provide to all their patients. This service specification outlines the more specialised services to be provided. The specification of this service is designed to cover the enhanced aspects of clinical care of the patient, some of which are beyond the scope of essential services. No part of the specification by commission, omission or implication defines or redefines essential or additional services. This SLA covers an enhanced service for care homes for older people and not any other care category of home. This SLA does not cover payment for patients in Care Homes under any other arrangement such as intermediate care (step up or step down) or STARR or community hospital beds for which separate reimbursement for GPs is agreed. Background Background Wiltshire CCG has a vision that Health and Social Care services should support and sustain independent healthy living and the design of our future system is based on three key principles: People encouraged and supported to take responsibility for, and to maintain / enhance their wellbeing Equitable access to a high quality and affordable system, which delivers the best outcome for the greatest number Care should be delivered in the most appropriate setting, wherever possible at, or as close to home Our public and stakeholder work confirmed that the Wiltshire population want more joined up services available in their communities and to realise this we have to extend and enhance our primary care services. The Five Year plan places Primary Care, alongside patients, at the centre of the health and social care economy. Given the central role of primary care in the implementation of our strategy, there are direct benefits to our population in being able to shape the local primary care strategies including workforce development and premises to support implementation and ensure outcomes are aligned to the strategic vision. The demographics continue to change, with increasing numbers of people living longer, eventually requiring 24 hour care. The residents of these homes invariably have complex, multiple, long-term, medical problems which require regular monitoring and input from a variety of healthcare professionals. General Medical Practitioners are central to the provision of this care. A multidisciplinary approach to delivering health care has, therefore, been developed, where General Practitioners will be part of a team of professionals including care home liaison staff, providing care to the people in care homes, and support for the care home staff in managing the health of their residents. Where possible, the future end of life service model will offer accessible and responsive services in the patient s normal place of residence. As at March 2016, there were 4419 care home beds across Wiltshire with an estimated 70% occupancy rate. 1
Finance Details This agreement is to cover the 36 months from 1 st April 2016 General Practice will be contracted to provide this service per registered patient in a Care Home bed per year at either Level A 200 or Level B 225. Payments will be made quarterly in advance based on the number of patients in a care home bed at the start of each quarter, collected through quarterly activity returns sent to the CCG. Proforma attached as appendix 1. Patients included and being claimed as part of this service should be read coded appropriately; for TPP practices this is: XalmT Registered patients living in a Residential Home 13F61 Registered patients living in a Nursing Home In signing up to this service the practice agrees to recording patient activity using the read codes above, and agrees for the CCG to reconcile quarterly activity returns to central reports run based on these read codes for audit purposes. Any discrepancies will be discussed with practices and payments may need to be adjusted accordingly. The CCG reserves the right to make changes to, add, amend or cancel this service with three months given notice. 2
Services to be provided (matched against CQC categories) Level A 200 per registered patient in a Care Home bed Safe 1. New residents are reviewed within 7 days of arrival at the home or on return from hospital Well Led 1b.Each home has a named GP lead with cover arrangements in place 2. Medications are reviewed at least 6-monthly 3. Planned weekly ward round by GP 4. Annual GP Review 5. Additional review at 3 to 6 months for less stable patients where necessary 6. Repeat prescriptions are processed by practice within 48 hours. Urgent prescriptions are processed by the practice within 24 hours Caring 7. Advanced care planning and care co-ordination information is up kept up to date 8. Treatment Escalation Plan (TEP) forms are completed for each resident once they have settled into the home Responsive 9. A clear contact protocol is in place for homes to contact the practice 3
Level B 225 per registered patient in a Care Home bed ALL SERVICES FROM LEVEL A AND Safe 10. Six monthly service review meeting Well Led 11. Provide evidence of a joined up and collaborative approach with other professionals 12. Support the Home to identify staff training needs and undertake procedures and/or enable nursing staff to undertake and support with a range of services or support access 13. Demonstrate patient / relative feedback on current services 4
Service Aims This service aims to provide clinical input to the assessment of patients admitted to the Care Home. Where applicable this assessment will contribute to the multidisciplinary care plan developed for each patient. The care provided should be based on clinical or good practice guidelines. The practice will provide assessments/certification as required under current legislation, e.g. issuing medical certificates of the cause of death, and medical certification assessment under the terms of the Adult Support and Protection Act/Adults with Incapacity Act, where appropriate. Arrangements for requests for verification of death and for issuing the medical certificate of the cause of death are to be agreed between the Care Home and Practice. Service Outcomes Include: Improved management of patients in care homes to ensure a better patient experience. Reduction in urgent admissions through implementing risk stratification, care coordinators, and care co-ordination for those patients at greater risk of non-elective admissions. This is facilitated by advanced care planning. Improved management of dementia patients within the community setting Maximising the use of the most appropriate provider for patients, first time, in line with patient choice and provider availability i.e. the right place at the right time Prompt recognition of residents requiring imminent end of life care, identifying issues and goals and making appropriate treatment escalation plans within a shorter time period. The practice should ensure that up to date details of palliative care arrangements and anticipatory care arrangements for patients are shared with the Out of Hours service and Ambulance services. A decrease in the number of fractured neck of femurs as a result of falls Relatives should know who to contact when they wish to discuss the care of a resident The practice will be expected to participate in the monitoring of this service, including referrals to A&E and the Out of Hours service, over 65 years of age readmissions, medicine management issues and patient and relative experience of the service. Service Objectives 1. New residents are reviewed within 7 days of arrival at the home or on return from hospital General Practice will work with a named GP Lead and care home staff to jointly carry out a full initial assessment of all newly registered resident patients within 7 days (maximum) from the day of their admission to the Care Home, as clinically indicated, or following any significant clinical change (the CCG acknowledge that notes transfer may delay the initial assessment, however practices should attempt to encourage quick note transfer by contacting the previously registered GP). As a minimum this assessment should include: o Reviews of clinical parameters indicative of patients physical health needs such as nutrition, hydration and skin integrity and in-line with any local guidance. To also include: o Review of clinical conditions, including both physical and mental health o o Screening for dementia as appropriate Consider condition-specific management plans, e.g. management of acute exacerbations for patients with severe COPD or rescue medication protocols for patients with epilepsy. In particular clear instructions should be given with regards to transfer out of the home e.g. hospital admissions after discussing with patient and relevant carers / relatives. 5
2. Medications are reviewed at least 6-monthly On admission a medication review with particular reference to poly-pharmacy and high risk medication should be undertaken with a senior carer from the home, and/or pharmacist where pharmacist reviews are already in place Following this, a medication review should be undertaken at appropriate intervals working with the CCG Medicines Management Team for any specific queries All reviews should be documented in the Home and GP patient records Reviews should include: clinical indications, interactions, adverse reactions, dosage checks, monitoring e.g. blood tests and patient concordance with medication. Any changes should be documented in both the Home and GP records NICE QS 85, STOPP and Beers criteria should be used to inform safer prescribing in this population An agreed system should be agreed between the practice and Home to ensure timely and appropriate repeat medication to avoid un-necessary waste and provision of urgent one off prescribing in response to unforeseen illness and symptom review. Protocols should be developed with care home staff for high risk medications such as warfarin, insulin and lithium to ensure appropriate monitoring and safe administration of these drugs Please note - any medication reviews should be in line with local formularies and in accordance with CCG medicines management guidelines available from: https://prescribing.wiltshireccg.nhs.uk General Practice is reminded to not provide 7day prescriptions for medication compliance aids (dosette boxes) unless specifically necessary for clinical reasons and the patient is considered too risky to have more than 7days medication at any one time in their possession. 3. Planned weekly ward round by GP Planned visits to the home will be done by appropriate members of the practice team to assess patients, arrange investigations, treatment and referrals to other services as required, liaising with appropriate sources of advice and support. The Practice will ensure there is appropriate communication and liaison in place with the home as appropriate. These should also include a review of the clinical parameters described above. 4. & 5. Annual GP Review & Additional review at 3 to 6 months for less stable patients where necessary Patients will be systematically reviewed regularly, suggested to be three or six month intervals (as appropriate) and/or in discussion with the senior staff of the Care Home. Practices will also carry out a subsequent review for each patient; o Following significant clinical change o Following hospital admission Following the initial assessment practices will provide a copy of the assessment findings to the care home and will provide the Out of Hours and Ambulance services with a summary of any advance care planning decisions. Planning for transfer of patients from residential to nursing care may also be needed with social services input. 7. & 8. Advance Care Planning & Treatment and Escalation Plans (TEP) Where possible instigate advance care planning and, when appropriate, collate advance care planning discussions Ensure, where appropriate, that patients, relatives and carers have discussions around their end of life and treatment wishes. This should be facilitated by use of the pan-wiltshire Treatment Escalation Plan (TEP) GP s should support the Home in continuing to develop and implement End of Life care plans and TEP in accordance with the patient and their family s wishes including the patients preferred place of death Where appropriate deliver End of Life care involving end stage symptom control and pain relief identifying when anticipatory medicines or prescriptions should be provided. Support the Home by giving time and support to anxious and upset relatives in relation to the End of Life care plan 6
When appropriate, Do Not Attempt Cardiopulmonary Resuscitation DNACPR decisions using TEP are set up as appropriate and agreed with the patient and/or relatives. Ensure the agreement is recorded in case notes and reviewed at appropriate intervals. Agreements should follow the patient when moving between homes and treatment settings. Following any subsequent review, practices will provide a copy of the assessment findings to the care home and will provide the Out of Hours and Ambulance services with a summary of any advance care planning decisions linking to TPP EPACCS work stream to create integrated TPP system to promote information sharing and on return from hospital the form should be replaced if needed within 7 days of return from hospital. This information should be readily available to OOH, ambulance and other members of the multi-disciplinary team when needed. 9. A clear contact protocol is in place for homes to contact the practice Working with the home, clear protocols and systems of communication should be established to ensure appropriate use of medical services. This protocol should include urgent clinical problems, non-urgent clinical problems, prescriptions, administration tasks General Practice working to a Level B service only should also: 10. Hold a six monthly service review meeting - attended by the named GP and Senior Care Home staff (where helpful these will also be attended by CCG Commissioning and Medicines Management staff). The purpose of this meeting is to review the effectiveness of delivery of the service, identify new opportunities for quality improvement, and review any complaints or significant events which are mutually relevant. Developing close links between care homes, community mental health teams, community rehabilitation services, specialist community nursing, allied health professionals and geriatric medicine means a structured and proactive approach to care can be taken, built around the patient and primary care 1 11. Provide evidence of a joined up and collaborative approach with other professionals (such as GPs, Geriatricians, community staff, care home, AWP representatives and Pharmacist) which may include MDT meetings, shared pathway development, case reviews, virtual ward rounds and sharing of expertise, learning and innovative practice. Education and development sessions can be developed for care home staff (or joint sessions for smaller homes) 12. Support the Home to identify staff training needs, ensuring staff are competent and support Nursing staff that are insecure with the complexity of the medical needs. Joint learning, training or reflective practice may help both general practice and the care home to identify improvements in working practices. 2 Undertake procedures and/or enable nursing staff to undertake and support with a range of services or support access to: a. Investigate, treat and manage incontinence through normal good practice and taking into account any appropriate protocols b. Working with nursing and care staff to ensure tissue viability with a view to enabling older persons to remain as active as possible c. Use of syringe drivers/peg feeds/phlebotomy/ear cleaning and syringing service 13. Demonstrate patient / relative feedback on current services. The effects of developing positive relationships between GP s, residents and family members includes medication concordance, GP s being called out appropriately and residents understanding their medical issues 3 1 Social Care Institute for Excellence (2013) Evidence Review on partnership Working Between GP s, Care Home Residents and Care Homes 2 NHS West Midlands (2011) Clinical Support to Care Homes and Nursing Homes: Examples of Innovation in the West Midlands, Quality, Innovation, Productivity and Prevention (QIPP) Development Team, NHS West Midlands 3 Brand, P. (2013) Care Homes 2013: Improving Access to and Experience of GP Services for Older People Living in Care Homes, SCIE Practice Survey, London: Social Care Institute for Excellence 7
Mental Health Care Home Liaison: The Care Home Liaison Service (CHLS) will ensure GPs receive copies of patient CPAs. GPs will receive written updates to inform them of their patient s admission and discharge from an AWP inpatient ward, and from the CHLS service. Additionally the CHLS are available to liaise with GPs to providing prescribing and care advice relating to Dementia. At times CHLS staff may also accompany GPs on Care home ward rounds to provide support in reviewing the wellbeing of residents; this will take place based upon the needs of the care home residents as assessed by CHLS staff. Care Home Responsibilities The Care Home will ensure it meets the required Health Care standards The administrative arrangements for new admissions, medical records, prescribing systems, planned visits, unscheduled and Out of Hours calls, data required for chronic disease registers and annual reviews The Home s registered Nurses and other trained staff are trained to appropriate standards to ensure the service is maintained It is the responsibility of the person in charge of the Care Home to liaise with Specialist Nurses and AHP services and to alert the GP to new admissions requiring assessment It is the responsibility of the care home to notify the practice regarding the outcome of any advance care planning decisions Care homes covered by the enhanced service will be expected to liaise with the practice and to engage with care home liaison staff Care homes will be asked to feedback to the CCG on an annual basis; and will comment on their experience of medical cover provided by the practice, and the timeliness of access to a GP. The care home will also evaluate whether the service has fulfilled the LCS requirements, and achieved the desired outcomes. Training/Service Development Clinicians providing this service will have a responsibility for ensuring that their skills are regularly updated and be appraised on what they do and take part in necessary supportive educational activities. General Practice will be asked to feedback to the CCG on an annual basis; and will comment on their experience of partnership working between the home and the GP, the timeliness of access to care home staff, and evaluate whether the service has fulfilled the LCS requirements, and achieved the desired outcomes. A template to be made available to all practices participating by the CCG. It is suggested the registered practice develops a system of prior notification with the home of those patients that require attention or review during the planned visit, allowing patient records to be available as well (where appropriate) to take a verbal update from Senior Nursing staff on duty. 8
NHS Outcomes Framework Domains & Indicators Domain 1 Preventing people from dying prematurely Y Domain 2 Enhancing quality of life for people with long-term Y conditions Domain 3 Helping people to recover from episodes of illhealth or following injury Domain 4 Ensuring people have a positive experience of Y care Domain 5 Treating and caring for people in safe environment and protecting them from avoidable harm Y Local defined outcomes A number of outcomes are expected to be achieved, in full or in part, as a result of successfully implementing this service. These include: More patients cared for in the community, kept out of crisis and out of hospital Ensure a continuing reduction in inappropriate admissions to acute trusts from Care Homes More effective and efficient use of the full range of community care home beds Increased proportion of people able to die in their place of choice Continued improvement in effectiveness and value for money of prescribing activity Improved relationships between the patient and GP Increased use of preventative measures Better knowledge of care home staff and GP s about residents health More efficient service delivery and access to services Reporting Practices participating in this SLA will need to report every six months as a locality review and discussion, to be reported into Group Executive, using the proforma in Annex 2: Care Home SLA Practice Report to Locality on Care Home SLA. 9
Appendix One Care Home Reporting Proforma Care Home LES Excel return DRAFT.xlsx 10