Contents. Care Homes Admissions Avoidance Schemes. Leeds West Clinical Commissioning Group. Dec Final Version

Contents Care Homes Admissions Avoidance Schemes Leeds West Clinical Commissioning Group Dec 2014 Page 1 of 33 Final Version

Contents Con VERSION CONTROL 3 SUMMARY 4 BACKGROUND 6 EVIDENCE 8 LEEDS ENHANCED SCHEMES 17 EXAMPLES FROM OTHER ORGANISATIONS 22 CONCLUSIONS 29 REFERENCES 31 APPENDICES 32 Page 2 of 33

Version control Approver Role Signature Date Reviewer Role Signature Date Distribution List Name Sue Wilkinson Role Commissioning and Development Manager, Leeds West CCG Change History Version Date Author / Editor Details of Change 0.1 0.2 0.3 5/12/2014 H Holmes First draft 09/12/2014 H Holmes Additions following feedback 11/12/2014 H Holmes Additions following feedback The latest approved version of this document supersedes all other versions. Upon receipt of the latest approved version all other versions should be destroyed, unless specifically stated that previous version (s) are to remain extant. If any doubt, please contact the document Author. This review has been produced for Leeds West CCG by Yorkshire and Humber Commissioning Support. Full details of the review are available from state Name email: heather.holmes7@nhs.net The contents of the review are believed to be valid at the time of publication 05/12/2014. It is important to note that new research which could influence the content of the review may become available at any time after this date. Copyright NHS Yorkshire and Humber Commissioning Support 2014 Page 3 of 33

Summary YHCS are assisting Leeds West Clinical Commissioning Group (CCG) with a project aiming to explore any additional primary care enhancement that is needed for practices to deliver proactive care to care homes in Leeds West. A Care Homes Primary Care Scheme Task and Finish Group has been convened to explore and develop an equitable and cost effective model for primary care services to be delivered to care home patients. YHCS is supporting Leeds West CCG by synthesising published literature, summarising the details of local schemes including any evaluation that has been undertaken and providing examples of service models from other organisations. Based on this the following review is summarised in three sections: 1. Published literature 2. Leeds enhanced schemes 3. Examples from other organisations There is some primary research evidence on this topic although there are limitations in regards to the quality of this and the applicability to the UK (Graverholt, 2014). Guidance does exist from reviews of the evidence and professional surveys by the BGS, NICE and Social Care Institute for Excellence (SCIE). There is no definitive evidence which dictates a specific delivery model and whether additional care home services are better provided by enhanced primary care or specialist services although key themes about what constitutes good practice do emerge from these publications. It is likely that a combination of approaches whereby residents have access to enhanced, proactive, primary care and through this, access to a range of specialist services (such as community geriatricians and old age psychiatrists, allied health professions and community pharmacy) will deliver the best outcomes. A number of evidence-based recommendations also emerged from the BGS commissioning guidance focusing on; why special commissioning for older people in homes is required, what outcomes are needed from commissioning these services and the type of activities that the evidence indicates will achieve these outcomes. Key activities which the evidence indicate will help achieve desired outcomes include: care planning, interventions for end of life care, regular structured multidimensional review, assessments including medication reviews and regular scheduled visits by an appropriately commissioned GP or specialist nurse. Page 4 of 33

Summary It is recognised that more robust research in this area is required and the APPROACH study group are currently undertaking a study examining effective health care for older people resident in care homes result of which are due to be published in 2016. All Leeds CCGs have local enhanced schemes aimed at reducing unplanned admissions and A&E attendances. Schemes in all three Leeds CCGs seem to have similarities in the core elements of the care delivered according to the service specifications. This tends to be based on proactive elements of care covering: initial assessment, ongoing care and post discharge from hospital. All Leeds schemes have undertaken some form of local service evaluation generally looking at impact on A&E attendance and unplanned admission over time. There are some limitations of these evaluations, although results show a decrease in both of these indicators in one practice from Leeds West and 17 practices for Leeds South and East CCGs (results to be confirmed). Results of the Leeds North evaluation showed minimal impact for these indicators with some indication of increased activity. The schemes currently cover key themes as described in the publications above. There are a number of examples identified from other organisations and these generally are themed around different options that have been implemented including: local enhanced services, dedicated specialist teams and a couple of examples in Calderdale and Airedale where telehealth solutions have been utilised to support links to care homes. Most of the schemes published local service evaluation results based on reduction in A&E attendance or unplanned hospital admissions and the majority showed a positive impact of their service. It must be noted that self-reported service evaluations cannot be quality assured or critically appraised as with the research evidence. Overall, a lack of high quality evidence (i.e. research evidence and relevant systematic reviews) was available when reviewing schemes, services or interventions that have shown to be effective at avoiding emergency attendance or unplanned admission to hospital by care home residents. Although key messages and guidance is published by from BGS, NICE and SCIE, including commissioning advice and a focus on medication processes in care homes (NICE, 2014). There is no definitive evidence which dictates a specific delivery model. The CCG may want to consider a more systematic and robust evaluation methodology going forward for any new scheme developed, including standardised outcome measures. There is also little focus on the economic impact of the services in the local evaluation and this area may need to be explored further. Page 5 of 33

Background Nearly 400,000 older people live in care homes in the UK (BGS, 2011) and we know that their health and social care needs are complex, reflecting multiple long-term conditions, significant disability and frailty. This group of patients have high rates of both necessary and avoidable hospital admissions and evidence outlined by the BGS in 2011 indicates that standard healthcare provision meets their needs poorly, but well-tailored services can make a significant difference. Leeds West CCG currently has an enhanced scheme still active at Robin Lane Health and Wellbeing Centre which has been running since 2004/5. Payment for a similar enhanced service at Thornton Medical Centre has recently ceased. These services aim to provide enhanced clinical care for patients who are care home residents, improving the quality and effectiveness of clinical care. The aim set out in the service specification is for these services to be evaluated looking at the costs of A&E attendances and unplanned admissions as indicators. The service specifications from 2011 outline specific elements of care that will be covered in three blocks: initial assessment, ongoing care and post discharge from acute hospital provision. These areas are further broken down into elements of care to be included in the enhanced service and this covers a number of possible interventions including: Care planning End of life care planning Medico-legal aspects Comprehensive medicine review Eye examination Mobility and falls assessment Mental state assessment Continence assessment Osteoporosis risk assessment Tissue viability assessment Dietary assessment Patient and carer involvement and feedback Training needs assessment and appropriate training of care home staff Extremely high risk patient identification and intervention Post admission follow up, patient/carer involvement and case analysis Page 6 of 33

Background YHCS have undertaken a review synthesising the published literature, summarising local schemes with any evaluation and providing examples from other organisations. The aim of this review is to support Leeds West CCG with commissioning intentions going forward. Page 7 of 33

Evidence The Quest for Quality In 2011 the British Geriatrics Society published a key document relative to this review. The Quest for Quality review assessed the quality of healthcare support for older people in care homes. This was undertaken through interviews with professionals and a review of the evidence. The main findings concluded that: Published studies and evaluations do not provide clear support for a specific model of care which best delivers the type of primary care needed, or which gets the best results from the other healthcare professionals, such as specialist nurses, geriatricians or old age psychiatrists. Therefore no definitive evidence emerges from the literature reviews to favour one model of primary care over another. There is little information available to evaluate whether different configurations of specialists and/or healthcare teams can replace or augment usual primary care. The relative merits of primary care organisation-based, cluster-based or GP-based nurse practitioners, compared to care home specialist teams are not known. One viable approach could be to increase investment in the GP services that have a specialist interest and formal responsibility for care homes and/or developing care home specialist case managers (nurse practitioner community matron, therapist) linked to General Practice. Another approach could be multi-disciplinary in-reach teams as an add-on to existing primary care. Care home-specific practices for areas with a high density of care homes could have the time, expertise and organisation to deliver the interventions referred to in this paper. No evidence exists to indicate if this is so in practice, nor of what the economic effect may be. It was outlined in the review that whichever model was utilised key messages for service commissioners and planners emerged and features and principles of an effective service to care homes were recommended as: o Primary Care Plus - various innovations have shown that GPs working differently (with or without an exclusive focus on care homes) can incorporate the proactive approach needed by working in partnership and applying patient-centred goals. This requires specification over and above the contractual obligations of conventional general practice. o Advance care planning optimises management of long-term conditions and prevents unnecessary complications surrounding disability and decisions about end of life Page 8 of 33

Evidence care. This includes use of advance directives. It can only be achieved in partnership with residents, their families or other advocates. o Partnership working with care homes establishes effective methods of communication and clarifies mutual expectations. This can be facilitated by care homes, community nursing and other health professionals using shared tools for assessments and care planning. It provides a basis for continuity and consistency of approach (even where there is rapid turnover in the workforce). o Case managers (usually nurses) broaden the limited and inadequate scope of traditional Primary care, and act as a clinical and communication bridge to specialist and other community health services. o Community pharmacists support improvements in prescribing practice and medication use. o Close links with community mental health teams improves assessment and care of residents with behavioural and mental health problems. o Sessional commitment from specialists such as geriatricians, rehabilitation physicians or palliative care teams provides reliable access and a shared approach to meeting the needs of residents without the cumbersome use of clinics and emergency departments. The British Geriatric Society also published Commissioning Guidance although the date of publication of this is not apparent from the document. The full evidence source indicates evidence was accessed in 2011 and it is therefore assumed to was published around this date. A number of evidence-based recommendations are outlined focusing on; why special commissioning for older people in care homes is required, what outcomes are needed from commissioning these services and the type of activities that the evidence indicates will achieve these outcomes. Key activities which the evidence indicate will help achieve desired outcomes include: Reviewing new residents and patient centred care planning. Prompt recognition of residents requiring imminent end of life care, identifying issues and goals and making appropriate treatment plans within a shorter specified time period. A regular structured multidimensional review at least every six months, or sooner if clinically indicated. This should be used to modify healthcare goals, and guide clinical interventions in and out of hours. Page 9 of 33

Evidence Assessments to include medication review in partnership with the community/care home s pharmacist at a frequency over and above essential GMS standards, at least every six months. A medication review should also be completed following discharge from an acute hospital admission. Assessments to include risk assessment, for example for falls, with appropriate prevention strategies. Creation of an advanced care plan for acute events and for preferred end of life care, in partnership with residents, their families and advocates. Agreement of reliable systems with appropriate support tools to enable effective telephone consultation and use of out of hours referrals. Regular scheduled visits by an appropriately commissioned GP or specialist nurse to review particular residents with new needs, perform routine reviews and to liaise with other health and social care professionals - including geriatricians who are, or who need to be, involved in a patient s care. Clarification of referral pathways and response times for specialist input including community rehabilitation services, palliative care teams, specialist nurses (for example, tissue viability), community mental health teams and geriatricians. When and where feasible, extension of the scope of enhanced clinical interventions for example sub-cut fluids and parenteral antibiotics for carefully selected patients and according to locally agreed protocols. A robust interdisciplinary and interagency clinical governance system which promotes quality improvement and involves the care home manager and relevant staff. The system should support education and training and encourage the development or use of clinical tools, protocols and service improvements. It should also allow for review of individual cases involving complaints and adverse incidents as well as reviewing overall performance of the local system by regular monitoring of chosen outcome measures. The guidance also suggests a number of measures for monitoring and evaluation of services. Failing the Frail In March 2010 the Care Quality Commission (CQC) conducted an on-line survey of PCTs about their services for people living in care homes. The BGS were involved in secondary analysis of the data to further inform its campaign about the quality of care in care homes. The main conclusions were: There is no consensus across PCTs as commissioners about what services older people in care homes need, how care should be provided and what services can do. This follows a decade of Page 10 of 33

Evidence research and professional debate that has repeatedly highlighted the healthcare needs of care home residents. PCT interest in their services for care homes is limited. Many PCTs had difficulties in answering CQC s questions, just 51% had enhanced service agreements with GPs for work in care homes and only 12% of specialist community services involved a care home specific provider. CQC s data does shows that with 52 different combinations across 152 PCTs there are significant variations in the specialist services available to older people and only in 43% of PCTs are older people likely to have access to all the services they need. PCTs largely ignore the differences between and nursing and residential care homes and with people living in the community as for most services the same provider covered both sectors and where there were different providers they worked to the same response standard. CQC s data however is about commissioning intentions rather than the service received. Response standards vary greatly between services and areas and many of the longer standards seem inappropriate given the limited life expectancy of care home residents. Further nearly half of services for which there was data did not meet their response standards. Only 60% of PCTs provided a geriatrician service to all older people in contrast to 86-97% for the other exemplar services. These conclusions can be applied to older people living in the community. Social Care Institute for Excellence (SCIE) The recent SCIE publication - GP services for older people: a guide for care home managers (Dec 2013) outlines a number of recommendations primarily aimed at managers and senior staff of care homes but it has also been written with GPs in mind, as well as members of clinical commissioning groups and joint health and wellbeing boards. A number of recommendations emerged from this publication, key recommendations which are relevant to this review in include: Care home managers ensuring that residents are registered with a general practitioner (GP) of their choice. Providers and managers of care homes to taking necessary steps to ensure residents have appropriate, high-quality GP and primary care services readily available to them. These include daytime and out-of-hours general medical services (GMS) commissioned by NHS England area teams, and enhanced medical services commissioned by their local clinical commissioning group (CCG). Page 11 of 33

Evidence Care home managers and GPs should ensure that local pharmacists, dentists, opticians and hearing services, CCGs and NHS England area teams understand the needs of their residents. Care homes should work with GPs and pharmacists to develop a strategy for medicines management, including regular (e.g. six-monthly) medication reviews conducted by GPs and/or pharmacists. Managers should consider with GPs how to address medication issues in order to reduce high levels of prescribing error, and have a plan to obtain medication out of hours through liaison with GPs and pharmacies. GPs' role in relation to the resident, the home and the wider NHS A GP's primary relationship should be with the resident who is their patient, rather than with a care home. Working in partnership with the home is, however, essential to providing a good-quality service to residents. Practice suggests that good relationships between GPs and residents are built up through regular contact and respectful, interpersonal communication which builds trust and confidence. GPs should be proactive in offering residents the wide range of diagnostic and therapeutic services in primary care, and full access through referral to acute and specialist hospital-based physical and mental health services. These can all contribute to maintaining each resident's health, wellbeing and independence. GPs should be aware that access to secondary services (e.g. mental health services) may be a problem for older people in care homes. Care home managers and GPs should agree how to handle relationships, communications and joint working between the home and the practice, to deliver what works best for residents. Issues to be considered include GP availability and interest; alignment of practices and homes; continuity, joint protocols and role clarity; and development of shared understanding through, for example, the use of end-of-life frameworks and pathways. Care homes and primary care providers should recognise and support the role that nurses in care homes and GP practices can play in facilitating communication between homes and GPs. This includes practice nurses undertaking initial assessment visits and nurses in homes raising professional concerns. Nurse practitioners and other senior nursing staff can share up-to-date knowledge and skills with nursing and care staff in homes, and with residents and relatives. Page 12 of 33

Evidence NICE In Mar 14 NICE published their first social care guideline which recommends that providers of health or social care services should have systems and processes in place for managing medicines in care homes, including what is recorded and transferred when a resident moves from one care setting to another (including hospital). Specific recommendations for commissioners that are relevant to this review include: commissioners ensuring that there are systems and processes and in place outlining clear accountability for the effective and safe use of medicines, identifying, reporting, reviewing and learning from medicines errors involving residents and medicines reconciliation. Other key recommendations that relate to providers of healthcare (i.e. GPs, pharmacists, case managers community nurse) include: Supporting residents to make informed decisions and ensure that care home residents have the same opportunities to be involved in decisions about their treatment and care as people who do not live in care homes, and that residents get the support they need to help them to take a full part in making decisions. Reviewing medicines (medication review) - GPs ensuring that arrangements have been made for their patients who are residents in care homes to have medication reviews as set out in the residents' care plans. An agreement to how often each resident should have a multidisciplinary medication review should happen based on the health and care needs and safety of the resident. NICE recommend that the frequency of planned medication reviews should be recorded in the resident's care plan and that the interval between medication reviews should be no more than 1 year. GPs should work with other health professionals to identify a named health professional who is responsible for medication reviews for each resident and should ensure that medication reviews involve the resident and/or their family members or carers and multidisciplinary team. This may include a pharmacist, community matron, GP or member of the care home staff. A number of recommendations also focus on sharing information, keeping accurate records, medication errors, medicines reconciliation, safeguarding, dispensing and supplying and recommendations specifically for care home staff and providers. A NICE is quality standard is also being developed on managing medicines in care homes and this is due to be published in March 2015. Page 13 of 33

Evidence There is a NICE Quality standard associated with the mental wellbeing of older people. It specifically looks at mental wellbeing of older people (65 years and over) receiving care in all care home settings, including residential and nursing accommodation, day care and respite care. This quality standard uses a broad definition of mental wellbeing, and includes elements that are key to optimum functioning and independence, such as life satisfaction, optimism, self-esteem, feeling in control, having a purpose in life, and a sense of belonging and support (NICE, 2013). Clinical guidance published by NICE in 2008 also focuses on promoting older people's mental wellbeing. It focuses on practical support for everyday activities, based on occupational therapy principles and methods. This includes working with older people and their carers to agree what kind of support they need. NICE recommendations including offering regular sessions that encourage older people to construct daily routines to help maintain or improve their mental wellbeing. The sessions should also increase their knowledge of a range of issues, from nutrition and how to stay active to personal care. A number of clinical guidelines also exist for elements of care that form part of the service specification of the current enhanced service in Leeds West including: mobility and falls, mental health state assessment, continence, tissue viability, dietary assessment, end of life care and medicines review. It was not the focus of the review to look at the evidence base for these individual elements of care outside of search criteria and cohort specified in appendix 1. NICE is also currently developing guidance on transition between inpatient hospital settings and community or care home settings for adults with social care needs and guidance on the social care of older people with multiple long-term conditions both of which may be of interest to this review when published. Systematic reviews A systematic review conducted by Graverholt et al. (2014) assessed the effects of interventions designed to reduce acute hospital admissions from nursing homes. The authors searched for studies comparing any intervention aimed at reducing hospitalisation with usual care or a different intervention in residents at nursing homes for older people. The primary outcome was acute hospital admission. The review identified 4 systematic reviews (which included 33 relevant primary studies) and 5 primary studies that evaluated 11 interventions. Three types of intervention were assessed in these studies: interventions to structure or standardise clinical practice; geriatric specialist services; and flu vaccination. Page 14 of 33

Evidence Among the 7 interventions to structure or standardise clinical practice, 3 approaches were found to be associated with lower hospital admissions than usual care: 1. Programmes aimed at supporting residents, families and healthcare professionals in advanced care planning (2 studies); an intervention to help doctors identify residents who would benefit from hospice services (1 study) 2. A care pathway to treat residents with pneumonia on-site (1 study). 3. Mobile specialist services were assessed in the 2 studies on the use of geriatric specialist services in nursing homes. A programme of regular and on-call visits by a doctor to provide additional services for conditions associated with hospitalisation and a programme of comprehensive assessments of residents by a mobile doctor and nurse team were found to be effective. Limitations of this review include that meta-analysis of the selected studies was not possible owing to the variation in the nature of the interventions. All the included studies were of low or very low quality, and all but 1 was at high or unclear risk of bias. A limited number of studies were available for each of the 3 types of intervention, many studies had small numbers of patients, and the studies were in diverse countries that may have different care settings to the UK. A relevant systematic review was identified from the Cochrane Library. Aldred et al (2013) looked at interventions to optimise prescribing for older people in care homes found eight studies involving 7653 residents in 262 care homes in six countries. It evaluated interventions to optimise prescribing for care home residents. Most of the interventions had several components, often involving a review of medicines with a pharmacist and doctor. Some interventions included a teaching component and one study used Information Technology. Results demonstrated that there was no evidence of benefit of the interventions with respect to reducing adverse drug events (harmful effects caused by medicines), hospital admissions or death. None of the studies looked at quality of life. Problems relating to medicines were found and addressed through the interventions used in the studies. Prescribing was improved based on criteria used to assess the appropriateness of prescribing in two studies. It concluded that more high-quality studies need to be done to gather more evidence for these and other types of interventions. Further studies are needed to evaluate new technologies, including computer systems that support prescribing decisions. The study identified that more work needs to be done to make sure that researchers are consistently measuring outcomes that are important to care home residents. Page 15 of 33

Evidence Healthcare databases primary evidence A literature review was undertaken to identify and synthesise published evidence of services in care homes aiming to reduce or prevent hospital admissions. The search strategy and terms for the literature search can be found in Appendix 1. Searching the primary literature via the healthcare databases resulted in a number of studies although none of them provided robust evidence to particular model or delivering services to care homes in the context of this review. The Quest for Quality literature review in 2011 summarised there is little previously published research available on the professional views of GPs and geriatricians on healthcare support in care homes. They presented some which suggests that GPs and geriatricians believe the medical care delivered to care homes is perceived as low priority, and the quality is less than optimal. A study was identified that had recently looked at this area further. Gage et al. (2012) undertook a survey of care homes to establish their views about the effects of integrated working between care homes and the NHS. There are some limitations of this study as the response rate was low, resulting in a small sample size and therefore limited use results. The findings suggest that integration between care homes and local health services is mainly evident at the level of individual working relationships and reflects patterns of collaborative working rather than integration. The APPROACH study group (Goodman et al, 2013) are currently undertaking a study examining effective health care for older people resident in care homes. The study will involve a review of the research evidence on integrated working between health services and care homes, a national survey of care homes across England to establish the focus, range, type and level of integrated working that exists where health services work with care homes. In depth case studies of six care homes are also planned to track the care of those receiving integrated care. Research results are due to be published in 2016 and aim to inform how managers and practitioners plan service development in care homes. Page 16 of 33

Leeds Enhanced Schemes Description of the scheme Evaluation Results Evaluation Limitations Leeds West Robin Lane Started in 2004/5, the model of care at the practice evolved in 2011 when a Practice (community) Matron was employed who provides care co-ordination as well as direct clinical interventions whilst working closely with the primary care physician. Trained in care co-ordinating and advanced nursing skills, the Matron has established relationships with care home staff, community geriatricians and a wide number of organisations involved in patient care. The service involves: Proactive and planned care for care home residents. Regular and planned weekly visits by doctor and Matron. Regular care planning and care co-ordination with other services. Training and education with care home staff. Intuitive-based medicine approaches to emerging symptoms/exacerbations Protocol driven interventions. The service specification out lines details of what elements of care are covered and these can be found in the background section (page 6). Secondary Uses Service (SUS) data for care home residents registered at Robin Lane was evaluated from 2004-2014. The main findings reported by the practice were that: There was a long term decline in hospital unplanned admission rates. A reduction in A&E attendances and elective referrals is recorded 2009 2014 The average age of patients has increased from 84 to 88 yrs. The average age of death has increased from 85 89 yrs. The analysis of data is limited to run charts and although a trend line has been incorporated, there is no statistical analysis incorporated in the evaluation methodology. The business intelligence team have flagged a change in coding in 2011 which could have impacted on the all Leeds evaluation results. Assessment Unit Patients were originally classed as In Patients but from around October 2011 they were reclassified as Out Patients. Although this change happened in 2011 there have been additional Assessment Units since that date so it is not just a step change at a certain date. This has had a big impact on In Patient activity in SUS. No comparator i.e. this may be the trend with others practices who do not have the service. Not considered % bed occupancy. Thornton The service specification is the same as Robin Lane and details of elements of care covered can be found in the background section on page 6. SPC analysis indicated that overall A&E attendance and unplanned admission activity from the cohort seem fairly static over time with The business intelligence team have flagged a change in coding in 2011 which could have impacted on the all Leeds evaluation results. Assessment Unit Page 17 of 33

Leeds Enhanced Schemes There are around 250 patients at any one time (from 2 nursing and 6 non nursing homes, these include a high number of EMI/dementia and some homes accept palliative patients. In total the 8 care homes requesting around 40 acute visits from the practice each week. There have been in 3 enhanced care home schemes from 2005 and 2014. In the early years, our model was to deliver weekly GP ward rounds. Between July 2010 June 2011 the practice employed a Community Matron and an Elderly Care Nurse on secondment to deliver the scheme. This model involved: Weekly visits to 8 care homes Co-ordinating care by liaising closely with the link GP for the care home, as well as other healthcare professionals Delivering pro-active care in particular agreeing Advanced Care Plans and End of Life Care Planning (as well as the various assessments listed in the service specification) Education, training and support for care home staff the SPC analysis indicating that variation in activity is likely to be natural variation seen in the system. Only one data point for A&E admissions was outside of the upper control limit. Overall it is difficult to conclude the impact of the Thornton care home scheme from this data alone and it is recommended that as part of the wider review of the Leeds West CCG care homes scheme that a more robust and consistent evaluation methodology and framework which incorporates a wider range of evaluation measures is considered for any new scheme. Patients were originally classed as In Patients but from around October 2011 they were reclassified as Out Patients. Although this change happened in 2011 there have been additional Assessment Units since that date so it is not just a step change at a certain date. This has had a big impact on In Patient activity in SUS. No comparator i.e. this may be the trend with others practices who do not have the service. Not considered % bed occupancy. From July 2011 Sept 2014 the scheme changed and only covered non nursing homes. This model was a continuation of the previous model but without the Community Matron whose secondment had come to an end. The focus continued on End of Life care planning which has resulted in a real increase in the proportion of palliative patients dying in their preferred place of death (usually the care home) instead of in hospital. The CHAMOIS Project- Care Homes And Medicines Optimisation Implementation Service The service: Provides a specialist pharmacist medication review service Optimises the use of medicines for care home residents 460 medication reviews were completed in 5 months. Percentage of patients where No report obtained to assess limitations. Page 18 of 33

Leeds Enhanced Schemes Ensures the safety and quality of medication for frail elderly patients Meets the four principles for Medicines Optimisation established by the Royal Pharmaceutical Society A team of 1.8 WTE specialist elderly care clinical pharmacists provides an annual medication review to care home residents within our GP practices. The pharmacists provided patientcentred medication reviews in frail patients with highly complex medication. A business case has been approved to carry out medication reviews on patients who are new to care homes, post discharge and at annual intervals with targeted six monthly reviews. We now have plans for proactive educational sessions on medicines for care homes. Leeds South & East The scheme includes 16 GP practices and covers 24 care homes. There are two slightly different service specifications, one for homes with and one for homes without nursing. Practices must have: 10 or more registered patients residing in residential care homes within Leeds South and East CCG Boarders. These do not include those patients in Community Intermediate Care (CIC) facilities, POPPS facilities or temporary residents. Are able to demonstrate provision/accommodation for multi-disciplinary team members to fulfil the schedule of services including: GP/Advanced Nurse Practitioner/Pharmaceutical Adviser/Technician. Offer access to and have the ability to refer patients for review (as clinically required or where identified through risk stratification) to relevant Multi-Disciplinary Team problematic drugs either stopped or reduced following referral: Examples: 40% antipsychotic drugs in residents with dementia 91% opiate medicines 90% diabetes treatments 81% cardiovascular medicines 72% anticholinergenic medicines 50% sedative drugs These figures are still due for validation through the governance processes although evaluation indicates: 11% reduction in unplanned admissions. 20% reduction in A/E attendances. A qualitative evaluation was also reported in Jan 2014 which involved surveying care home managers, residents, family and friends of residents and GP practices involved in the scheme. Some key results were that: Until the full report is obtained the evaluation methodology and results cannot be understood and any limitations identified although the issue coding issue identified and described on page 14 could also impact on this data. Page 19 of 33

Leeds Enhanced Schemes Members, including Integrated Care Teams. Are able to provide, a minimum, of four hours per week of enhanced care that will be delivered by each professional for every 80 patients registered with the GP Practice in a specified Care Home. The following activities are included: initial assessment, care planning, on-going review, post hospital discharge review (within 2 weeks). Care planning to include: end of life (including DNAR), medicines review, eye examination, and a number of different assessments. These include: mental state and dementia, continence, osteoporosis, tissue viability and dietary. Care home managers were pleased with the service and particularly felt quality of care had been improved due increased and more regular time with the GP. GPs involved in the scheme felt call outs had been reduced. The final report can be viewed here Page 20 of 33

Leeds Enhanced Schemes Leeds North The scheme started in Oct 2013. It has a number options for practices to sign up to including: Care homes without nursing (residential homes). Vulnerable housebound (at risk of admission). Review of patients discharged after a non-elective admission. Generally the content of the scheme and the elements of care covered are the same as the other Leeds CCGs (initial assessment, care planning and ongoing review including post discharge follow up) although with a slightly different cohort. An evaluation of the scheme looking at data from Oct 12 Jul 14 was undertaken. The evaluation used Statistical Process Control (SPC) methodology to quantify variations in A&E attendances and admission over time. This included a period of time before the scheme was not in existence. The results indicate that for the cohort of patients evaluated there was an increase in A&E attendances and full non-elective admissions when compared against previous periods and also against the whole population. The evaluator identified that as NHS numbers that were provided were a snapshot all that is known is that patients were in a care home/housebound at a particular point in time and it is not known when the patient was admitted (or discharged) to the care home or how long prior to admission they had been there. The coding issue identified and described on page 14 could also impact on this data. Using the whole population as a comparator would need to be explored further to if this was a suitable comparator. There are some general challenges and caveats of local service evaluation that should be noted. There are lots of other confounding variables that could potentially impact on A&E attendance and admission to hospital for the cohort being evaluated. It is difficult to adjust or account for these confounding factors. One of the key factors would be the case mix of the cohort which will change throughout the evaluation time period as different patients are residents over the evaluation time. Page 21 of 33

Examples from other organisations As an addition to the literature search of published evidence, a search was undertaken to identify examples of similar schemes undertaken in other organisations. Although these can be used to learn from the examples of other service delivery models, it should be noted that outcomes are self-reported and cannot be quality assured or critically appraised as with the published literature. Description of the scheme Sheffield (2011) - LES A GP locally enhanced service (LES) was developed, based on work with care homes in one GP practice, funding was secured to run a pilot to test the impact of delivering an enhanced GP service on reducing avoidable hospital admissions. The LES was provided by 11 practices to 14 residential and nursing homes in one practice based commissioning consortium. The model includes: Each home is aligned to one practice which accepts all residents who choose to register. A service agreement is set up between home and practice. One or two named GPs provide proactive care. An annual medical review is arranged, leading to a medical care plan organised between residents and carers, to anticipate/plan for exacerbations and crisis, including end of life. The care plan is kept in the home and flagged on out of hours (OOH) databases to alert anybody on call out. Provision is made for a planned weekly surgery in the home with 6-monthly medication reviews. There is rapid access to a named community geriatrician. An event form completed for all emergency admissions by the care home manager and the GP enables shared learning, with a monthly practice review of emergency admissions. Additional payment to GPs is based on the number and type of beds covered. Reported outcomes (reference) It is reported that the model has achieved a reduction in avoidable hospital admissions. In year one of the scheme, there was a reverse in the trend of rising emergency visits from care homes in the area, with a reduction in emergency admissions by six per 100 care home beds (approximately 9 per cent) compared with the previous year. This translated into a gross savings of 145,000 in a single year for the 500 care home beds taking part in this small-scale pilot. The number of A&E attendances fell by three per 100 care home beds (approximately 10 per cent) at a time when A&E attendances were rising in other areas. The use of emergency care practitioners following 999 calls also fell by approximately a third. Feedback from the pilot showed that, of care home residents, 94% agreed that the GP service gave them the help they wanted and needed, and 84% agreed that they felt they received better care with the new GP service. For care home staff, 97% agreed that their relationship with GPs had improved and 86% agreed that the new service helped them understand more about residents health. Finally, for family members, 97% agreed that the person they care for received better care. Page 22 of 33

Examples from other organisations http://www.bgs.org.uk/index.php?option=com_content&vie w=article&id=1941:casestudysheffield&catid=194:casestudie s&itemid=820 Calderdale CCG (2014) Dedicated team community matrons (inc telehealth) Working in collaboration with Calderdale Council, the Quest for Quality service was launched in March 2014 aiming to cover 25 care homes in the area. Includes development of a multidisciplinary team who are available to support and advise staff in care homes on the prevention and proactive management, including falls prevention and medication management. A key part of the service is the use of telehealth and telecare interventions that aim to support long term condition management. A dedicated team of community matrons provide support to care home staff and GPs. They are supported by a consultant in elderly care as well as a dedicated community pharmacist and a range of other services including dieticians, therapists and end of life specialists. Sandwell PCT (2011) - dedicated team The care homes review team consists of a Consultant Geriatrician, a nurse and a pharmacist The remit of the team is: Undertake health checks on residents in care homes, which is holistic and multidisciplinary and where necessary carry out physical examinations and take bloods where necessary. Undertake full medication reviews. Review Nursing care plans/risk assessments/nursing interventions. Appropriate referrals including liaison and clarification Provide prompt written summaries for each resident to the care home, to the GP, community pharmacy linked to the home, and where appropriate, to the mental health team or other teams. Provide a summative report to the Cluster and the care home at end of each home visit. Support staff in caring for residents, give advice and identify training needs. Conduct a medicines audit There is currently no outcome information widely available. In the first year of operation, medication savings of 30 090 were identified, or 406 per resident reviewed. They were unable to show any definite effect on admissions. http://www.calderdaleccg.nhs.uk/news/calderdale-ccglaunches-care-homes-initiative/ http://www.networks.nhs.uk/nhs-networks/shropshire-andstaffordshire-heart-andstroke/documents/clinical%20support%20to%20care%20ho mes%20and%20nursing%20homes%20-%20nhswm.pdf Page 23 of 33

Examples from other organisations Leicester (2010) shared management A pilot project including shared management of patients in residential homes between GP practices and community geriatricians. The pilot offered GP practices access to comprehensive geriatric assessments, care planning, rapid written feedback and a telephone advisory service. Bath and north east Somerset (2008) dedicated team A study by the Joseph Rowntree Foundation looked at a joint NHS and local authority initiative providing a dedicated nursing and physiotherapy team to three residential care homes. The initiative aimed to meet the nursing needs of residents where they live and to train care home staff in basic nursing. After six months, out-of-hours consultations fell by 16% and requests for visits by 37%. Hospital admissions were also reduced by more than half. The total cost of hospital admissions fell by 60%. GP care home support 'cuts deaths and workload', Pulse, 15 Mar10 http://www.pulsetoday.co.uk/story.asp?storycode=4125361 The results included reduction in hospital admissions and prevention of nursing home transfers. Cost savings were estimated, ranging from a worst case scenario of 2.70 extra per resident to the more likely scenario of 36.90 savings per week. Savings were mainly through reduced use of NHS services, while the PCT and social services both funded the intervention. http://www.jrf.org.uk/sites/files/jrf/2202.pdf South Manchester (2011) dedicated team The service covers 300 nursing home beds in nine homes. The service is staffed by a team of three geriatricians, two advanced practitioners, a GP, nurse case manager and doctors in training together with a dedicated administrative team. The service acts on two levels: 1) Planned (scheduled) proactive care. All patients in a nursing care bed are reviewed using methods described below. This is a continuous, adaptive process. For those identified as at risk of unscheduled hospital admission, a senior clinical review occurs and anticipatory care planning is undertaken. Risk stratification into a long-term conditions model, assisting in determining the frequency of proactive review Undertake planned proactive reviews within all nursing homes once a week Full medication review for each patient at least every six months. Develop and implement integrated and personalised care plans covering health and A pilot for the service showed the following outcomes. These results were collected within the first two years of service and used historical benchmarks to demonstrate improvements. Measure Prior After Variance Patients with one or more emergency medical admission 26 17 35% Total number of emergency medical admissions 31 23 26% Page 24 of 33

Examples from other organisations social care needs for all patients, and share these with out of hours care providers. Provide up-to-date information, advice and support for rehabilitation and for relatives of patients with long-term conditions. Provide care homes and patients with access to and/or advice about any assistive technology/equipment to support activities of daily living and more independent lifestyles. Provide (or refer to) a comprehensive range of palliative care services in line with the Gold Standards Framework. 2) Reactive (unscheduled) care. In office hours a same day call out service is operated for residents identified by the care home staff to have become unwell and in need of urgent assessment. Number of emergency medical admission bed days Average length of hospital stay (days) 638 207 68% 20.6 9.0 56% Positive results have also been achieved for end of life care. 80% of deaths occurred in the nursing homes (2008-9 data), 47% were GSF coded on the front of notes, 58% had an advance care plan in place at time of death and there was 93% compliance with expressed wishes. http://www.bgs.org.uk/index.php/ch-support-manchester Barking & Dagenham (2011) - LES Provision of enhanced general medical services for all nursing home residents within the borough. The scope of this LES is derived from the current level provision of services by general practitioners to local nursing homes, the service includes: A dedicated weekly session per nursing home including visits; A more comprehensive assessment of all new admissions; A yearly assessment of all residents; Demonstrably increased availability via telephone for medical advice and triage Lead responsibility for assigning appropriate aspects of service provision to other care professionals; e.g. medicine management and pharmacist support or preventative work carried out by nursing or health care assistants. Airedale NHS Foundation Trust (2011) - Telehealth Hub The service is provided by Immedicare a partnership between Airedale Hospital and technical providers Involve and has gone live in over 100 homes, with contracts to provide services to 222 nursing and residential care homes around the country. It involves linking the care home using video conferencing equipment to a Telehealth Hub, based at the at No published results. http://www.bgs.org.uk/index.php/barking-dagenham-se An audit undertaken in July 2013 looked at the impact of the telehealth hub on services in Airedale found a 35% reduction in hospital admissions on the previous year (without telemedicine). The audit was based on hospital episode Page 25 of 33

Examples from other organisations Airedale Hospital. Clinicians can carry out virtual consultations, talking face- to-face with the patient and occasionally carrying out examinations using close up hand-held high definition cameras if necessary. Patients, who would previously have been sent by ambulance to their local hospital s Accident and Emergency department, and often admitted to hospital, can now be seen and treated remotely. They can be monitored from the hospital s Telehealth hub, as often as required depending on their condition, with the back up of hands on treatment from community nursing teams, a paramedic or hospital care if needed. The Telehealth hub is staffed by specialist nurses who can assess and triage patients as well as support the nursing and residential care home staff to provide any additional care. One of the benefits of telemedicine is that it helps relieve pressures on urgent care services. statistics for around 2,000 residents in 23 local care homes. It also found the use of A&E fell by 53% and the number of hospital bed days were down 59%. Since the Telehealth Hub opened in September 2011, until 31 December 2012, there have been 578 clinical consultations and around 198 hospital admissions avoided. Analysis of calls made to the Telehealth Hub during the Christmas period (Friday 21 December 2012 to Friday 4 January 2013) showed that around half were from patients own homes and the other half from nursing homes. Two thirds of the calls from nursing homes resulted in patients avoiding having to be admitted to hospital or visit A&E, this result increased three quarters of calls from patients own homes. http://www.airedale-trust.nhs.uk/blog/airedale-achievesmilestone-of-100th-care-home-to-get-round-the-clock-careonscreen/?utm_source=rss&utm_medium=rss&utm_campaign =airedale-achieves-milestone-of-100th-care-home-to-getround-the-clock-care-on-screen Newcastle Bridges Commissioning Consortium (2011) dedicated link GPs Dedicated GPs (known as link GPs) work with each of the 56 care homes in Newcastle involved with the project to continue the learning from regular education sessions and support the care home to implement clinical policies and procedures. Monthly education sessions for staff and GPs include topics which are known to be the most common reasons for hospital admission such as falls, chronic obstructive pulmonary disease (COPD), wound management, nutrition and urinary tract infections. Admissions from the care homes involved with this project have reduced by 1.5 per cent. There has been a reduction in short lengths of stay in hospital and in 2010, 14 per cent fewer care home residents stayed in hospital for less than three days. In addition, 12 per cent fewer residents died within three days of being admitted. Feedback from the education sessions shows that 86 per Page 26 of 33

Examples from other organisations Each link GP is working with care home staff, residents and their families to develop advance care plans and improve end of life care. cent of participants felt that their knowledge had improved as a result of sessions and care home staff feel more confident about being proactive. For example, carrying out urinalysis prior to referring to a GP and initiating advance care planning discussions with residents. Staff are also now more likely to telephone the GP surgery for advice as a result of the improved relationship between primary care and the care homes. The link GPs have provided over 150 hours of structured tutoring and support to care home staff to address the reasons for inappropriate hospital admissions. There are many benefits to this project. The main ones being improved working relationships between primary care and care homes and improved knowledge and confidence so that care home staff know how to provide better care for their residents. http://webarchive.nationalarchives.gov.uk/20130805112926 /http:/healthandcare.dh.gov.uk/case-study-newcastlebridges/#before Liverpool (2013) MDT team The model delivered by Liverpool covers 68 care homes covering 3000+ residents. The care home support MDT includes: 14 Community Matrons, Nurse Consultant for Older People, 2 Pharmacists, Physiotherapy input, Dietetics, Speech and Language Therapists, 0.5 WTE Community Geriatrician. The community geriatrician is a dual funded post between community an secondary care covering 5 sessions per week including an element of education. The team focus on the use of advance care planning and anticipatory care planning using a five stage process of: 1) Identification of residents that would benefit from ACP 2) Assessment including capacity 3) Discussion with resident and / or family 4) Formulation of the ACP document 1,245 ACPs since November 2009 52% due to Advanced Dementia Majority of the rest due to increasing frailty Reduction in deaths in hospital within 24 hours of admission reduced by 52% (27% to 13%) Presentation by Dr Rebecca Bancroft, Consultant Geriatrician (available on request). Page 27 of 33

Examples from other organisations 5) Medication review 6) Regular clinical review (undertaken by a community matron) Page 28 of 33

Conclusions In conclusion, there is some primary research evidence on this topic although there are limitations in regards to the quality of this and the applicability to the UK (Graverholt, 2014). Guidance does exist from reviews of the evidence and professional surveys by the BGS, NICE and SCIE. Although there is no definitive evidence which dictates a specific delivery model and whether additional care home services are better provided by enhanced primary care or specialist services, some key themes about what constitutes good practice do emerge from these publications including: Regular review and care planning Delivery of proactive care for complex care needs, including for example end of life care Medication effective and safety and the importance of medication reviews Regular scheduled visits by appropriate professionals Sessional commitment by specialist health professionals (e.g. geriatricians, mental health teams) Clear pathways for referral including Out of Hours (OOH) Appropriate training for care home staff Local examples and evaluations are available although there are some limitations with local service evaluation including the impact of confounding variables that could potentially impact on outcomes and the difficultly in adjusting for these. The services current delivered across Leeds are consistent with recommendations provided in the above mentioned publications with schemes in Leeds West delivering on key themes above. The CHAMOIS Project- Care Homes And Medicines Optimisation Implementation Service specifically focuses on key elements of the NICE medicines management guidance. It may be worth identifying clearer outcome measures and evaluation methodology for all practices involved in the any new scheme or service developed moving forward. Examples from other organisations are also reported and these may support learning from how others have implemented similar schemes and their respective outcomes. It must be noted that outcomes cannot be quality assured and it may be worth further exploring specific interventions with these organisations. There is no doubt that better evidence is needed to inform recommendations on reducing unnecessary hospital admissions from care homes, but any evidence needs to be understood in its proper context. There is currently some research being undertaken in this area, the APPROACH study group plan to publish results of a study looking at examining effective health care for older Page 29 of 33

Conclusions people resident in care homes in 2016. In the UK, many interventions are currently being tried to reduce unnecessary hospital admissions. In England, the Better Care Fund is supporting initiatives to reduce avoidable emergency admissions. The fund is being used differently by each CCG, one example being to provide input from emergency health services directly into care homes. The review does not provide conclusive evidence on the most clinical or cost effective approach in providing the required provision of care to care home residents. The published literature provides themes of what should be included although it is not definitive on how and who should deliver the care. National examples provide learning on models that have been implemented elsewhere although there are some limitations with local evaluation. Schemes currently run in Leeds deliver key elements recommended in the evidence indicating that they are clinically effective although it is difficult to draw conclusions about the cost effectiveness of the current services from evaluation information available and this element requires exploring further. There are emerging opportunities as outlined in The NHS Planning guidance for 2015/16 (NHS, 2014). This publication emphasises the development of new models of care including a multidisciplinary community provider model and enhanced clinical support for care homes. The multidisciplinary community provider model could enable a broader vision beyond care homes alone, to include all elderly or frail people in the community, which Leeds West has planned for the future. The forward plan indicates that organisations can submit interest to be part of first cohort prototyping new models of care and will receive support from the newly formed national new models of care boards. This is something with Leeds West CCG may want to consider further. Page 30 of 33

References Alldred P et al., 2013. Interventions to optimise prescribing for older people in care homes, Cochrane Collaboration. http://onlinelibrary.wiley.com/doi/10.1002/14651858.cd009095.pub2/abstract British Geriatrics Society, 2011. Quest for Quality, British Geriatrics Society Joint Working Party Inquiry into the Quality of Healthcare Support for Older People in Care Homes: A Call for Leadership, Partnership and Quality Improvement. British Geriatrics Society, no date of publication specified, Commissioning Guidance, High Quality Health Care for Older Care Home Residents. http://www.bgs.org.uk/campaigns/2013commissioning/commissioning_2013.pdf Full evidence review of BGS commissioning guide http://www.bgs.org.uk/campaigns/2013commissioning/care_home_guidance_fmag.pdf British Geriatrics Society, 2010. Failing the Frail: A Chaotic Approach to Commissioning Healthcare Services for Care Homes. Analysis of data collected by CQC about PCT support for the healthcare of older people living within nursing and residential care homes. Gage et al., 2012. Integrated working between residential care homes and primary care: a survey of care homes in England, BMC Geriatrics, 12 p71 http://www.biomedcentral.com/1471-2318/12/71 Goodman et al., 2013. Effective health care for older people resident in care homes: the optimal study protocol for realist review, Systematic Reviews, 3 p4 http://www.systematicreviewsjournal.com/content/3/1/49 Graverholt et al, 2014. Reducing hospital admissions from nursing homes: a systematic review, BMC Health Services Research, 14:36. NICE, 2008, PH16 - Occupational therapy and physical activity interventions to promote the mental wellbeing of older people in primary care and residential care: This guidance was previously entitled 'Mental wellbeing and older people, NICE. NICE, 2013, QS50 Mental wellbeing for older people in care homes. NICE, 2014, SC1 Managing medicines in care homes, NICE. https://www.nice.org.uk/guidance/sc1/resources/guidance-managing-medicines-in-care-homes-pdf NHS, 2014. The Forward View into action: planning for 2015/16. http://www.england.nhs.uk/wp-content/uploads/2014/12/forward-view-plning.pdf Social Care Institute for excellence, 2013, SCIE guide 52: GP services for older people: a guide for care home managers. http://www.scie.org.uk/publications/guides/guide52/ Page 31 of 33

Appendices Appendix 1 Literature search strategy The following resources were searched: British Nursing Index EMBASE CINHAL HMIC NHS Evidence Cochrane Library Social Care Institute for Excellence Google The following search terms were used and amended appropriately for the healthcare database being searched: 1. NURSING HOME/ OR RESIDENTIAL CARE 2. (care ADJ home*).ti,ab 3. 1 OR 2 4. HOSPITAL ADMISSION 5. (prevention OR avoidance).ti,ab 6. 4 AND 5 7. 3 AND 6 Page 32 of 33

Appendices Yorkshire and Humber Commissioning Support Douglas Mill Bowling Old Lane Bradford BD5 7JR Page 33 of 33