Local Enhanced Service Clinical Lead Commissioner Reporting Mechanism/Frequency Payment Frequency Payment Contact This Version GP Cover of Nursing, Residential, Extra Care and Intermediate Care Homes Dr Mackay-Thomas Stuart Camden Clinical Commissioning Group Manual reporting/variable frequency Monthly Camdenlcs@nhs.net Date 24 March 2016 Care Home LES Spec 2016-2017 v1 Original Version, dated Care Homes LES 1213, September 2012 Review date March 2017 Service Specification for GP Cover of Nursing, Residential, Extra Care and Intermediate Care Homes Local Enhanced Service 2016-17 1. Service aims 1.1. Provide an additional level of care over and above that of the new General or Personal Medical Services Contract provided by all GPs. 1.2. Provide a proactive, preventative service. 1.3. Provide a single provider of GMS/PMS services to all patients in the named Nursing, Residential, Extra Care or Intermediate Care Home. All patients cared for within the home will be registered to the single provider on a permanent or temporary basis, 1 unless the patient exercises choice in agreement with their existing GP provider. Such circumstances are expected to be exceptional. 1.4. Improve the quality of care to older people in Nursing, Residential, Extra Care and Intermediate Care Homes, ensuring that all patients receive dedicated medical services. 1.5. Minimise the risk and complications within this vulnerable group, which includes patients with highly complex needs by providing and monitoring a comprehensive programme of care. 1.6. Fulfil the minimum requirements set out in the NSF Older People, 2001; Actions for End of Life Care: 2014-16; End of Life Care LES; Gold Standards Framework. 1.7. To provide proactive care in managing chronic disease and medicines including care planning especially around discharge and end of life care. 1 Temporary Residents must be registered with the Practice within five working days of the home informing the Practice of the patient. Care Home LES Specification 2016-17 v1 0 1
1.8. To reduce reliance on Out of Hours for crisis management as well as reduction in inappropriate non-elective admissions and A&E attendances. 1.9. To reduce inappropriate prescribing and wastage. 2. Duration 2.1. This LES will be provided from 1st April 2016 until March 2017 when it will be reviewed. 3. Eligibility criteria 3.1. All Camden GP practices can apply to provide this LES if they are fully compliant with all requirements of core contracts (General Medical Services, Personal Medical Services or Alternative Personal Medical Services). 3.2. This LES is open to all Practices, excluding practices under remedial process and practices that have a private contract with a home to provide medical services. 3.3. The specification for the LES will be made available to all practices and all existing practices currently providing the service will be asked to reapply. This is to ensure that practices sign up to the new specification and to demonstrate via application how the new specification will be delivered. 3.4. For practices to provide the services outlined in this LES, they will need to complete the application form. The Care Homes LES is only applicable to the definitions outlined below: 3.4.1. Nursing Home Nursing Home means any premises used or intended to be used for the reception of and the provision of nursing for persons suffering from any illness or infirmity but does not include: hospitals; children s homes; sanatoriums provided at schools or educational establishments; first aid or treatment rooms provided at employment premises, sports grounds, show grounds or places of public entertainment; premises used by doctors, dentists or occupational health practitioners; private dwellings; or other premises. 3.4.2. Residential and Extra Care Homes Residential and Extra Care Homes mean homes, other than a hospital, a nursing home, a children s home or a university, college or school which provides residential accommodation with both board and personal care for any of the following: old age and infirmity; disablement; past or present dependence on alcohol or drugs; or past or present mental disorder. 3.4.3. Intermediate Care Homes Intermediate Care Home means a home which provides active rehabilitation for, usually, up to six weeks to help someone to Care Home LES Specification 2016-17 v1 0 2
regain daily living skills that may have been lost during a period of ill health. (Intermediate care may also be provided where a period of assessment is needed to establish someone s longer term needs). 4. Service to be provided under the LES 4.1. The Practice is required to work to the following service specification for Nursing, Residential and Extra Care Homes: 4.1.1. All patients in a care home will be registered with the GP practice commissioned to provide the care home LES for that care home, except the rare exception where a resident chooses to register with a different GP and is accepted by that GP. 4.1.2. Practices should have signed up to the EOLC LES. However there will be a separate After Death Analysis and action plan specifically for review of deaths of care home residents. This should be discussed and agreed with the care home manager. 4.1.3. The practice must have done the online assessment under the Deprivation of Liberty Act which safeguards adults who lack the mental capacity to make decisions without aid. 4.1.4. A nominated lead clinician or nominated deputy will provide an enhanced level of clinical care, to the registered patients on a regular basis to the Home, including routine and emergency visits. Minimum clinical sessions: Number of beds Minimum Clinical Session* 1-25 1 per week 26-50 1 per week 51-75 1.5per week 76-100 2 per week * A clinical session is the equivalent of 4 hours 12 minutes (based on Camden LES) and is based on block of 25 beds. 4.2. Conduct an initial review for all patients upon admission to the Home within 5 working days of being informed which will include: 4.2.1. an initial physical and mental health assessment; 4.2.2. medication review; 4.2.3. information gathering; 4.2.4. the initiation of a joint care plan and the offer option of an Advance Care plan if their health deteriorates in the future. It should also include their preferences of End of Life care, establish resuscitation status of the resident and document in the notes as per EoLC strategy; and 4.2.5. liaise and/or meet with relatives. 4.3. On completion of the initial assessment, the Practice will determine with the home the frequency of future non-urgent visits, ensuring that previous medical records are available. Care Home LES Specification 2016-17 v1 0 3
4.4. Comprehensive Medical Review for all patients within a maximum of one month of their admission to care home including: 4.4.1. full medical history; 4.4.2. physical and mental health assessment; 4.4.3. documentation of a care plan and advance care plan, including preferred place of care if dying and resuscitation status; 4.4.4. liaise with other Health and Social Care Professionals where relevant, including acute medical services, primary care services and social care; 4.4.5. on completion of the initial assessment, the Practice will determine with the home the frequency of future non urgent visits, ensuring that previous medical records are available; and 4.4.6. compliance with the NICE Quality Standard 24 (http://publications.nice.org.uk/quality-standard-for-nutrition-support-in-adultsqs24) and meeting the goals; this has an impact where the care home provider should also be providing food to match the patient s individual need such as high calorific food, food of a consistency suitable for the patient (for example, liquidised) rather than GPs Rx sip feeds. 4.5. Following the first comprehensive assessment, some patients will require routine medical monitoring whilst some will require a comprehensive intense period of review. It is anticipated that some patients, following admission, have minimal medical needs but may develop more complex or new medical problems which require more intensive medical input. The increased level of medical input may be temporary or permanent, the latter possibly leading to terminal illness. The Practice will prioritise the review period for each patient and agree with the home the frequency of medical review. However, it is agreed that the Practice will carry out a comprehensive medical review at least every six months for each patient, or more often if indicated, including around any admission (planned or unplanned). 4.6. Patients with dementia should be sought out at the reviews and a basic Mental Capacity assessment (e.g., GP-COG) should take place. 4.7. All patients should have a medication review on a 6 monthly basis with pharmacist support where available. They should be offered vaccinations against flu and pneumococcal in line with GMS contract. 4.8. Out of Hours (OOH) cover is provided by the Borough OOH provider. Practices providing the service must ensure that they keep the Coordinate my Care CMC register up to date after any major review so that relevant other providers, such as OOH community nursing and the Specialist Palliative Care team, have access to the most up to date details for patients. 4.9. Practices providing the service will provide a practice policy covering: 4.9.1. the days and times for both visits, that will be attended by a clinician; 4.9.2. a named clinician to ensure the service specification is met and a deputy; 4.9.3. the development and production of an up to date register of home patients; Care Home LES Specification 2016-17 v1 0 4
4.9.4. a named administrative person responsible for prescription requests, communications, requesting medical records and maintaining practice held patient records (the process for this work should be detailed); 4.9.5. a named person responsible for ensuring the home is made aware of changes to a patient s case management including medication changes (the process for this work should be detailed); 4.9.6. the process for home staff, residents and families/carers to raise concerns and make referrals to the enhanced services provider; 4.9.7. the timeframe for prescription requests; 4.9.8. roles and responsibilities in dealing with an incident and a process for incident reporting to the CCG and care home; 4.9.9. the practice s policy for dealing with complaints and ascertaining learning; 4.9.10. the practice s role in challenging discrimination, promoting equality and respect and human rights, and treating patients, their relatives, and carers with dignity and respect; and 4.9.11. a contingency plan for named clinician absences. 4.10. The Practice also agrees to: 4.10.1. Respond to urgent visit requests the same day it is reported; 4.10.2. Ensure that routine visits are not made during patient meal times; 4.10.3. Ensure that adequate contingency arrangements are in place to provide full cover for the LES should planned or unplanned changes in service arise; 4.10.4. Give reasonable notice of any planned or unplanned changes in visit times to allow Home staff to inform relatives who may have made an appointment; 4.10.5. Share management of the care plan with the patient, the patient s relatives, home staff and other professionals as appropriate; 4.10.6. Meet QOF standards (if appropriate, avoid unnecessary tests in very elderly or demented patients); 4.10.7. Issue repeat prescriptions within one week of the request; 4.10.8. Provide a medical report, if requested, when a client is presented to a complex care panel or community care panel; 4.10.9. Any incidents involving GPs will be recorded via the Care/Nursing Home s current Serious Untoward Incident Policy. In addition to this Camden CCG Quality and Safety Team will be informed regarding any incidents; and 4.10.10. The GPs will raise an alert directly with the LA (linda.pugh@camden.gov.uk) for any concerns they note about safeguarding and collaborate with the LA on any investigations. 4.11. In preparation for the visit to the home, the Practice lead clinician or deputy should have appropriate records and details of the patients available and liaise with a member of staff from the care home to highlight concerns and actions. Where notes are not available, the Practice should ensure that a full and comprehensive history is obtained. 4.12. Attendance at a 6-monthly care home training event, which would include: Care Home LES Specification 2016-17 v1 0 5
4.12.1. discussing the audit results on antipsychotic prescribing; 4.12.2. review of admission audit ; 4.12.3. after death analysis; and 4.12.4. any other learning from the enhanced service. 4.13. The Practice agrees to work in line with the minimum standards set out in the NSF Older People, 2001; Actions for End of Life Care: 2014-16; End of Life Care LES; Gold Standards Framework. 4.14. The Practice is required to work to the following service specification for Intermediate Care Homes: 4.14.1. All patients in a care home will be registered with the GP practice commissioned to provide the care home LES for that care home, except the rare exception where a resident chooses to register with a different GP and is accepted by that GP. 4.14.2. Practices should have signed up to the EOLC LES. However there will be a separate After Death Analysis and action plan specifically for review of deaths of care home residents. This should be discussed and agreed with the care home manager. 4.14.3. The practice must have done the online assessment under the Deprivation of Liberty Act which safeguards adults who lack the mental capacity to make decisions without aid. 4.14.4. A nominated lead clinician and nominated deputy (when lead not available) to provide an enhanced level of clinical care to the registered patients on a regular basis to the Home, including routine and emergency visits. Minimum clinical sessions: Number of beds Minimum Clinical Session* 1-25 1 per week 26-50 1 per week 51-75 1.5per week 76-100 2 per week *A clinical session is the equivalent of 4 hours 12 minutes (based on Camden LES) and is based on block of 25 beds. 4.14.5. The Practice must provide care to all patients admitted into the home, regardless of the patient s length of stay. Practices are still obliged to provide care if the patient is only staying in the home for a few days and is not registered with the Practice. 2 4.14.6. In preparation for the visit to the home, the lead clinician or deputy should have appropriate records and details of the patients available and liaise with a member of staff from the care home to highlight concerns and actions. Where notes are not available, the Practice should ensure that a full and comprehensive history is obtained. 2 Temporary Residents should be registered with the Practice within one working day of the home informing the Practice of the patient. Care Home LES Specification 2016-17 v1 0 6
4.14.7. The Practice agrees to work in line with the minimum standards set out in the End of Life Care Strategy 2008 & Gold Standards Framework. 4.15. The Practice also agrees to: 4.15.1. Agree the visit timetable with the Home, as per section 4.2, so that a mechanism can be established for concerns and issues raised by staff and relatives to be addressed; 4.15.2. Ensure that routine visits are not made during patient meal times; 4.15.3. Give reasonable notice of any planned changes in visit times to allow Home staff to inform relatives who may have made an appointment; 4.15.4. Respond to urgent visit requests the same day it is reported; 4.15.5. Share management of the care plan with the patient, the patient s relatives, home staff and other professionals as appropriate; 4.15.6. Support the Nurses and contribute to the management of complex cases; 4.15.7. Issue repeat prescriptions within one week of the request; 4.15.8. Ensure that the resuscitation status of a resident is established and documented and reviewed on a regular basis; 4.15.9. Provide a medical report, if requested, when a client is presented to a complex care panel or community care panel; 4.15.10. Any incidents involving GPs will be recorded via the Care/Nursing Home s current Serious Untoward Incident Policy. In addition to this Camden CCG Quality and Safety Team will be informed regarding any incidents; and 4.15.11. The GPs will raise an alert directly with the LA (linda.pugh@camden.gov.uk) for any concerns they note about safeguarding and collaborate with the LA on any investigations. 4.16. Initial Assessment The Practice will carry out an initial assessment, if required, for all patients upon admission to the Home within five working days of being informed. The initial assessment, based on the information available, will include the following: 4.16.1. Initial physical and mental health assessment; 4.16.2. Medication review; 4.16.3. Arrange required investigations necessary; 4.16.4. Information gathering and review of medical history; 4.16.5. Initiation of joint care plan for future management of the resident and demonstrating this has been discussed with the patient and their relatives/ carers; 4.16.6. Complete one month s FP10; 4.16.7. Liaise and/or meet with relatives (unless otherwise indicated); 4.16.8. GP to liaise with REACH therapists for provision of rehabilitation where indicated; 4.16.9. Establish resuscitation status of the resident and document in the notes Care Home LES Specification 2016-17 v1 0 7
4.16.10. Compliance with the NICE Quality Standard 24 (http://publications.nice.org.uk/quality-standard-for-nutrition-support-in-adultsqs24) and meeting the goals; This has an impact where the care home provider should also be providing food to match the patient s individual need such as high calorific food, food of a consistency suitable for the patient (for example, liquidised) rather than GPs Rx sip feeds. 4.17. Routine Management of Patients On weekly visits the lead clinician or deputy from the Practice should provide the following: 4.17.1. Physical and Mental Health assessment, where relevant; 4.17.2. Liaise with other Health and Social Care Professionals where relevant, including acute medical services, primary care services and social care; 4.17.3. Liaise with senior qualified nurses for nursing homes or the senior carer in residential homes; and 4.17.4. Liaise and or meet with relatives (unless otherwise indicated). 4.17.5. Subject to Consultant advice, the lead clinician or deputy from the Practice will be required, where appropriate, to: be available to attend Consultant reviews and case conferences; and liaise with the appropriate Consultant for advice as applicable. 4.17.6. Attendance at a 6-monthly Care home training event, which would include: discussing the audit results on antipsychotic prescribing review of admission audit after death analysis and any other learning from the enhanced service. 4.18. Please note, patients residing in an immediate care bed for longer than six weeks should be cared for as per section 4.17. 5. Quality and safety 5.1. Camden Clinical Commissioning Group is responsible for obtaining assurance that all the services it commissions are safe and are of good quality. All practices delivering the LTC LES must provide assurance that they are compliant with all stipulations outlined in Section 3, Eligibility above, as well as the following: The practice is registered with the Care Quality Commission (CQC). The practice meets requirements of NHS England for the provision of Core, Additional services and any related Directed Enhanced Service (DES) or National Enhanced Service (NES) that the practice are commissioned to deliver. 5.2. Practices are to report any incidents (including near misses, significant events, incidents and Serious Incidents (SIs), complaints and patient feedback relating to this local enhanced service to Camden CCG Quality & Safety Team via secure email: qands.camdenccg@nhs.net. SIs must be reported within 24 hours following identification. Care Home LES Specification 2016-17 v1 0 8
6. Criteria, pricing and monitoring arrangements 6.1. Each practice commissioned to provide the LES will be reimbursed on the rates below: 6.1.1. quarterly payments in arrears - 450 per bed per annum for nursing and residential home; and 6.1.2. quarterly payments in arrears - 1,400 per bed per annum for intermediate homes. 6.2. Performance measures: The Performance Measure Method (monitor, audit or portfolio) Frequency Responsibility of Outcome Review of ADA reports for those patients that were cared for in a Nursing, Residential or Care Home. Review of medication for patients in line with prescribing protocol. Review of all nonelective admissions from a care home using previous fiscal year data. Completion of ADA template and action plan and to be submitted to borough office. Action plan from medication review to be submitted to borough office Completion of action plan to help reduce non-elective admissions Annually Practice Ensures quality gold standard of care for those at End of Life in homes. Targets set by EOLC les and action plan. Six monthly Practice Ensures quality prescribing in a cohort of patients who are complex by virtue of being elderly, on multiple medications and often with multiple co-morbidities. Annually Practice Ensures 95% appropriate admissions and the action plan is to address systems in place to prevent inappropriate admissions Reduction in nonelective admissions from a Care Home Monitoring of SUS/SLAM data Quarterly Islington or Camden Borough Office As above 6.3. Development of a care plan and where appropriate of advance care plan including preferred place of care if dying. All practices providing the service will be given some baseline data for their home including, information on A&E attendances, non-elective admissions from previous two years and other appropriate prescribing information where available. Practices will also be given audit templates for each audit as well action plan templates and dates in the diary for the two Care Home GP training events. 6.4. In case of incidents, including serious incidents, please complete the Incident Reporting form and email to qands.camdenccg@nhs.net with Care Homes SI in the subject line as per Caldicott Guardianship principles: 6.5. Ongoing project governance and oversight of the project will sit with the Localities team in the CCG governance structure. The LES will be monitored quarterly looking at nonelective admissions data and A&E attendances from the homes and will be fed back to the provider. Care Home LES Specification 2016-17 v1 0 9
7. Exit and suspension arrangements 7.1. The Contractor can terminate the scheme by providing one month written notice to the CCG Primary Care LES Team. The CCG may terminate the scheme within 28 days if, following suspension of payments the contractor fails to re-establish services according to the service specification or take appropriate action to address deficiencies within eligibility criteria. Before issuing an exit notice, the parties will meet to discuss the reason for termination. If after this meeting the reason for terminating is not resolved then the relevant partly will issue an exit notice. 7.2. Either primary care providers or the CCG can exit this agreement by providing a minimum of six months written notice. 7.3. Either party can appeal against a suspension or termination notice to the CCG s Director of Commissioning. 7.4. Payments under the scheme will be suspended if at any time the practice is unable to provide services in line with the service specification or fail to meet contractor eligibility criteria. Before any suspension the practice and Camden CCG will meet discuss the reason for the suspension identifying any possible resolution. If the matter is not resolved the CCG will issue a suspension notice to the practice within seven days. Care Home LES Specification 2016-17 v1 0 10