Integrated Management & Proactive Care
for the Vulnerable and Elderly – IMProVE
Amanda Hume
Chief Officer
What is the IMProVE Programme?
•
The number of people who are elderly, vulnerable and living with a longterm condition in South Tees is increasing
•
The CCG working closely with social care and other health partners,
want to improve the quality of care this group of people receive and to
ensure that services remain safe now and are sustainable in the future.
To do nothing is not an option!
• Health care is constantly changing – 3 main drivers for
change
– Meeting patients’ changing needs
– Improving quality, safety and outcomes
– Achieving better value
• Evidence supports that there is more to be gained than lost
in changing services as more patients will have a better
experience and outcome
• A whole system approach is required – One service change
cannot be changed in isolation to the rest of the system
• Patients and their organisations need to critique current
provision and inform its redesign to better meet their needs
The CCG wants to actively engage with the public
in order to better plan and redesign services
•
To gain views on our vision for the IMProVE programme we held a wide
range of engagement activities:
– 5 ‘drop-in’ events across different localities
– We circulated a questionnaire – 99 responses
– We commissioned Carers Together to do a more in-depth survey –
almost 350 responses
– Our key focus is about commissioning services to meet the needs of
our population
IMProVE
Integrated Management
and Proactive Care
for the Vulnerable Elderly
Key themes emerging from engagement activity
September-November 2013
23 Queen Street, Redcar, TS10 1AB
tel: 01642 488977
email: carerstogether@btconnect.com
web: www.carerstogether.co.uk
Engagement activity
• Questionnaire
- CCG website
- Stakeholder organisations
- People registered on My NHS
- People who attended 5 public events
• An in depth survey of patients and carers
by Carers Together
Profile of survey respondents
• 348 respondents from Redcar, Eston,
Guisborough, Brotton and Middlesbrough
• 16% aged 66 -70
• 48.6% aged over 70
• 36.2% aged over 80
• 43.1% male; 56.9% female
• 87% living at home
• 58% were carers
• 23% were caring for someone with
dementia
Co-ordination of services
• 37.5% of respondents felt that local
services were organised very well
• 38% of respondents felt that local services
were organised fairly well
Suggestions for improvements
• Better collaboration and co-ordination
across health and social care
organisations and between services.
• More effective and efficient sharing of
information
• Better communication between providers
• Improved liaison with carers
• A more holistic view of the family situation
Respondent’s views
“The different departments do not interact
with each other which confuses everyone.
No one department seems to have the full
up-to-date information”
Access to GPs
Most respondents felt that their first port of
call was their GP and they rely on local
doctors.
Suggested improvements
• Better appointment systems, that are easy
to use and understand.
• Appointments need to be easier to make.
• Shorter waiting times for GP
appointments.
• GPs need to spend more time visiting
patients at home.
• Better continuity of care eg being able to
see the same GP on a regular basis
Respondent’s views
“We are very happy with our doctor and the
service he provides; he has telephoned
when needed and made sure we saw
consultants quickly if needed. It is difficult
to get an immediate appointment but he’s
so popular.”
Access to information
67.5% of respondents knew who to
contact for advice, guidance or support
about their long term condition.
Suggestions for improvements
• More information/guidance would be
helpful (53% of respondents) eg about
social care provision, treatment at home
and specific conditions eg dementia.
• Information needs to be consistent and upto-date.
• Ensure that patients, carers and families
understand the information they are given.
Respondents’ views
“Dad might benefit from someone giving him
more information as to the outlook of Mum’s
dementia and what to expect.”
“After going home physio ceased and I had no
idea what I should attempt.”
“Carers should be given more information about
when a condition worsens.”
“Sometimes I don’t understand medical terms
and would like it explained in plain English.”
Quality of care provided
• 3.4% of respondents said they definitely
received enough support to manage
their condition.
• 69.1% of respondents said they have
support to manage their condition to
some degree.
Suggestions for improvements
• Shorter waiting times for social care
assessments; specialist assessments eg
by OTs; installation of equipment.
• More support for housebound people.
• A better relationship with doctors who
understand patients’ conditions.
• Longer visits from community nurses.
Respondents’ views about what
would help
“Access to relevant information when
doctors and nurses have a collective
review and results of test and treatments
explained.”
“Having the same GP who knows about
your condition and not doctors who hardly
know you.”
Where care should be provided
63.5% of respondents felt that people should receive the
majority of their care for a long term condition, in a
mixture of home, community and hospital settings,
dependent on the person’s condition.
23.4% felt they should receive the majority of their care
at home.
11.9% felt they should receive the majority of their care
from their GP practice and community nursing staff
Suggestions for improvements
• More day care for people with dementia.
• Assurance of an efficient and reliable
network of care.
• Regular visits from named carers.
• Good communication so that there is
continuity of care, co-ordinated by
community nursing staff, according to the
person’s needs.
Respondents’ views
“I feel strongly that people are better cared for in
their own home rather than going into hospital as
many become disorientated when out of their own
surroundings – as long as carers are given time to
do the job when calling on patients living alone.”
“ Everyone has different needs. The main thing
should be continuity of care with someone that can
be contacted when a problem arises, whether in
hospital or at home.”
“Colin’s GP and mine are very good at coordinating our care. Colin’s GP has spoken to
other agencies and nurses about his care.”
Care closer to home
• There was some support (23.4%) for more
care being provided at home or in the
community.
• Some respondents felt that providing care
at home could aid recovery, prolong
independence and keep hospital beds free
for people who are seriously ill.
Suggestions for improvement
• Ensure an efficient and reliable network of
care.
• Provide contact numbers for and regular
visits from named workers.
• Improve local transport.
• Better communication and co-ordinated
care.
• More support from GPs and nurses.
Respondents’ views
“My husband, who is 90 years old, is my main
carer. Without my own transport, access to
services is difficult or nearly impossible.”
“Social services can do more joined up thinking
in organising care at home.”
“Communication and contact with the GP when
discharged from hospital and support at home
for as long as needed are important”
Quality of community provision
Quality, ease of access and extent of
community based services were important
to respondents.
Suggestions for improvements
• More frequent and longer home visits from
health professionals and home care staff.
• Swifter assessment of needs, access to services
and equipment, especially following discharge
from hospital.
• More practical support at home.
• More respite care provision.
• More on-call support at weekends/evenings.
• More support for unpaid carers.
Respondents’ views
“I think social services could visit people
more and help them, depending on what’s
wrong with them and also tell them what
special groups can help them.”
“Joined up working between doctors,
nurses and social services is needed.”
Hospital beds
• 50% of respondents felt that there are not
enough hospital beds.
• Some respondents would prefer to have
too many beds, rather than too few.
• 50% of respondents supported the idea of
closing community beds and providing
more care in the community, which would
aid recovery and promote independence.
Suggestions for improvements
• Better community heath and social care
services.
• Ensure that hospital beds are available
when needed.
• Have adequate budget and resources eg
staff, to develop and improve community
services.
Respondents’ views
“The concerns are that beds are not
readily available. The worry is that some
people are definitely better looked after in
hospital. But people with good support at
home do better.”
“There should be enough beds still
available for anyone who needs hospital
care, at all times.”
“Care outside of hospital is ideal for some,
but a growing elderly population means
beds will still be needed.”
Other issues
• Physiotherapy and Occupational therapy: reduce time
taken for assessment and access.
• Dementia services: better information for patients and
carers and more services
• Community hospitals: valued for their proximity to
home, relative and friends
• Travel: cost and lack of public transport
• Investment: greater investment in health and social care
services needed.
• Care homes: good, local care homes and staff training
needed.
• Care and Support: reliance on elderly carers
• Carers/family: need to keep carers/family informed
about health conditions and how to deal with them
• Listen to patients and include carers, wherever
appropriate.
Why do we need to change?
Julie Stevens
Commissioning & Delivery Manager
South Tees Clinical Commissioning Group
Major progress has been made in
improving the performance of the NHS in
the past decade
Waiting times for treatment in hospital have fallen
dramatically and generally remain stable
Hospital-acquired infection rates like MRSA have
fallen dramatically
The NHS continues to be highly valued by the public
Source: Ipsos Mori 2013
The NHS continues to perform well on most
indicators when compared to other countries
However, the current health and social
care delivery system has failed to keep
pace with the needs of an ageing
population, the changing burden of
disease, and rising patient and public
expectations
Fundamental change is
needed
It is time to ‘think
differently’
1. Variations in quality and
outcomes of care
‘The UK has the second highest
rate of premature deaths for which
effective clinical interventions exist
in 16 high-income nations.’
Source: Nolte and McKee 2011
In South Tees
• In Tees life expectancy is lower than the
England average. There are inequalities across
South of Tees with regard to life expectancy,
access to services and deprivation.
• Life expectancy is 14.8 years lower for men and
11.3 years lower for women in the most
deprived areas of Middlesbrough than in the
least deprived areas.
There are wide
variations in
performance and
gaps in the quality of
care of general
practice.
2. Funding Pressures
Current spending projections in the
NHS suggest significant financial
pressures on services for the next
20 years
3. Delivery Systems not fit for
the future
A significant proportion of patients
occupying beds do not need to be in
hospital on clinical grounds
Source: Goddard et al 2000; Audit Commission 2003
In South Tees
• An Independent Survey across South Tees
carried out around 18 months’ ago showed
that:
– 49% of patients in a community bed did not
need to be in there and could have been
appropriately supported by other services
– ?50% of patients in an acute bed did not
need to be there
There are significant problems with standards
of dignity and care.
Evidence tells us that unnecessary time in
hospital can be very harmful to frail older
patients, exposing them to risks, such has
hospital acquired infections, increasing the
likelihood of depression and loss of
confidence
Obesity is associated with an increased risk of diseases
including diabetes, heart disease, osteoarthritis and cancer.
In South Tees
• Estimated levels of adult ‘healthy eating,
smoking and obesity are worse than the
England average
• Rates of hip fractures, sexually transmitted
diseases, smoking related deaths and hospital
stays for alcohol related harm are worse than
the England average
4. Future trends:
Magnifying the pressures
Demographics are changing
•
The total population of South Tees is 273,742 of which 48,689 are over
the age of 65
Source: ONS mid-2012 population estimates and interim mid-2011 based population projections
Authority
Mid-2012 population estimate
Number
Middlesbro
138,744
Redcar &
Cleveland
134,998
Total
273,742
2021 population projection
No. (%) aged
65 +
21,293
(15.35%)
27,396
(20.29%)
No.(%) aged
85 +
2,591
(1.87%)
3,259
(2.41%)
Number
% aged 65 +
% aged 85 +
144,275
24,997
(17.33%)
31,782
(23.46%)
3,911
(2.71%)
4,540
(3.35%)
48,689
(17.7%)
5,850 (2.1%)
279,741
56,779
(20.2%)
8,451 (3.2%)
135,466
More people with long-term conditions
A rise in chronic disease
In South Tees
South Tees already ranks higher than
the England average for almost all
disease prevalence
In Redcar and Cleveland
According to the National Adult Social Care Intelligence Service
(NASCIC) 2011-12
• 24% more admissions aged over 65 to residential care
than peer authorities and 59% more than the England
average
• 28% more people over 65 receiving community
services and 59% more than the England average
Current challenges in South Tees
• ‘Heavy’ reliance on hospital based services
• High numbers of avoidable emergency admissions
compared to other areas regionally and nationally - 65% of
people admitted as an emergency are over the age of 61
• Delayed discharge from hospital, particularly from
community beds
• Health and social care services are not adequately ‘joined’
up which leads to delays in accessing appropriate services
and duplication of effort
• Patients do not receive the same level of rehabilitation in
community hospitals as they do in an acute hospital
• Not enough patients are given the opportunity to receive
rehabilitation at home – especially in relation to stroke
• In-patient stroke rehabilitation is not delivered to best
practice standards
• The complexity of care is increasing which means that
many more patients require multiple out-patient
appointments
• We are bound by history of where hospitals were built which can
reduce flexibility and be a barrier to improvement:
– Community hospitals are under-utilised – bed utilisation
averages just 44% in some community hospitals
– Uneven distribution of beds, clinical rooms and diagnostic
equipment over five sites (include the MICC)
– Void space is costing us around 1.9 million pounds
– Some of the community hospital estate requires significant
investment to bring up to modern standards
– Running and maintenance costs of Community Estate are
high
To do nothing is not an option!
Integrated Management & Proactive Care
for the Vulnerable and Elderly – IMProVE
Consultation process
Siobhan Jones
Public and stakeholder consultation
The NHS is accountable to the public, communities and patients that it
serves.
It has a duty to involve patients and the public in decisions about their care
and in any plans to change how that care is delivered.
Patients, carers and other stakeholders have a right to be involved in he
decision-making process.
Legal and regulatory framework
CCGs must enable the effective participation of the public in the commissioning
process itself, so that services reflect the needs of local people.
Health and Social Care Act 2012
You have the right to be involved, directly or through representatives, in the
planning of healthcare services commissioned by NHS bodies, the development
and consideration of proposals for changes in the way those services are
provided, and in decisions to be made affecting the operation of those services.
NHS Constitution
The process of service change
•
Major service changes must put patients and the public first, by leading to
higher quality and more sustainable services
•
The focus of changes should be on proposals that lead to improved
outcomes, reduced health inequalities and more efficient models of care
•
Change must be clinically-led and underpinned by a clear clinical evidence
base
•
The design and development of proposals should reflect current and future
commissioning intentions
•
Patients, the public and staff should be engaged throughout.
Decision-making process
CCG Governing Body consider feedback from the consultation process as
well as taking in a number of other issues including:
•
•
•
•
Clinical
Financial
Practical
Quality and safety
Our consultation
•
•
•
•
Will last for at least 13 weeks
Share proposals and case for change
Public meetings
Work directly with community and voluntary organisations and
Healthwatch
• Website
• Newspaper/media
• What else?
Integrated Management & Proactive Care
for the Vulnerable and Elderly – IMProVE
Progress and Next Steps
Ali Tahmassebi
What have we achieved so far?
Co-ordination/Integration of Services
What have we done so far?
• Co-located some health and social care services – Redcar Rapid
Response Health and Social Care Teams work together in one
building
What are our future plans?
• Develop a single point of contact for community health and social
care
– one telephone number
– signposting patients to the right place at the right time
– A ‘hub’ for supporting alternatives to admission and early
discharge where possible – right place, right time!
Levers
• The Better Care Fund – Shared budgets between health and
social care to enable improved commissioning of services
GP Access
•
The CCG is supporting practices to change their systems and processes
to improve access – Doctor First
•
Challenge Fund
Access to Information
•
We have been working with our providers for some time on trying to
improve the information they give to patients/carers and professionals
•
We can use contractual levers to facilitate this
•
We would welcome further discussions with yourselves around how we
improve this
Quality of Care
• Set up new rapid response teams
The aim of these team is to support patients in their own home
to avoid unnecessary admission where possible and to support
patients on discharge from hospital when required
• Work with local authorities to develop re-ablement services –
enabling people to re-learn the skills for daily living after periods
of illness
• Created Community Innovations Fund for 2013/14 – working
with community agencies on new projects - £206,662 awarded
Identifying patients at risk of future
admission and giving them additional support
•
Implemented a tool in general practice to predict those patients most at
risk of future admission
•
Community matrons visit those patients and liaise with the GPs to
develop holistic management plans – educating patients on their
condition, ensuring they have the necessary support they need and
advising what to do if their condition exacerbates
•
Patients are usually ‘managed’ for approximately 3 months or until they
feel more confident about their health condition
•
Teams are working towards case-loads of up to 600 patients across Tees
Rapid Response – A Case Study
Improving the Patient Pathway –
Community Nursing Rapid Response
Service
Dawn Parkin
&
Chris Gatenby
Community Nursing Rapid Response
•
•
•
Admission avoidance service.
Referrals currently commissioned to be accepted from;
– GP’s
– Community Matrons
– A&E
– AAU’s
– ECP’s (MIU/Urgent Care)
Provides nursing care to patients in crisis in order to avoid admission.
Community Nursing Rapid Response
•
•
Operates 0800-2300 7 days a week.
Patient needs to be safe with existing mechanisms of support
overnight.
•
A registered nurse will respond to referral within two hours.
•
Medical cover GP led/NDUC out of hours.
Outcomes
•
Patients care coordinated and multi-agency working enhances
outcomes;
• Community Therapy Rapid Response
• Social Care Rapid Response
• Core Community Nursing
• Integrated Community Care Team
• Third Sector organisations
• Acute Care
• Provide safe and effective care in the patients own home
environment
COPD Admission Avoidance Patient
Journey
•
•
•
73 yr old lady.
PMH;
• COPD, diagnosed 2011, not attended GP for follow up.
History
• Increasing SOB
• GP treated with antibiotics and steroids
• Diagnosed exacerbation of COPD
• Referred to Community Nursing Rapid Response.
• Patient was urinating in a bucket on the floor as unable to access
toilet (upstairs).
Patient Journey continued
•
•
•
•
•
•
•
Nurse visited within 2 hours & completes holistic assessment -Sa02
84% on air.
Nurse liaised with GP to arrange home O2.
Nurse ensured patient aware of medication regime and was compliant.
Equipment - Commode & Nebuliser loan
Patient supported at home for 72 hours
Exacerbation resolved – unnecessary admission avoided
Referral to Community Matron – ICCT green bed until safe to discharge
back to GP care
Coordinated working - Patient Journey
•
•
•
•
60 yr old gentleman, highlighted from predictive risk tool as being at
risk of admission.
Assessed and managed by Community Matron via the Integrated
Community Care Team (Virtual Ward).
PMH
• COPD
• Weight loss unknown cause.
History
• Exacerbation of COPD, delayed seeking help.
• Community Matron visits prior to Bank holiday weekend
• Referred to Community Nursing Rapid Response.
Patient Journey cont…
•
•
•
•
•
Rapid Response team visited patient over weekend
Patient referred to Social Care Rapid Response who visited within 2
hours, and provided support 4 times a day to manage social care
needs.
After weekend care transferred back to Community Matron
COPD rescue pack prescribed by Matron for further exacerbations.
Continued support via ICCT Green Bed until patient able to self
manage, then will be discharged back to primary care.
In Summary
•
•
Community Services Division have been commissioned to provide
services to avoid admission.
Community Nursing Rapid Response works in a dynamic way to
provide robust support to patients in crisis to keep them in their
home environment.
Remember Rapid response service
•
Please think of Rapid response service for your patients before
hospital admission
Future Model
Based on best practice elsewhere in the country:
•
Step-down in-patient rehabilitation: High quality packages of planned
rehabilitation care supporting vulnerable adults in effective recovery and reablement, in particular those patients recovering from stroke and fractured
neck of femur.
•
Step-up Care: Beds for elderly patients requiring stabilisation or treatment
in order to avoid secondary care admission such as, remobilisation following
falls, exacerbation of long-term conditions, end of life support and for minor
illnesses, eg urinary tract infections, chest infections
•
MDT assessment units to provide local rapid assessment and
comprehensive diagnostics for elderly patients
•
A greater range of out-patient services with supporting diagnostics to help
clinicians make quicker diagnoses
•
Medical day units providing simple care locally, IV antibiotics, blood
transfusions and potentially some cancer therapies
What could this mean?
Making better use of our community estate:
• Potential closure of beds
• Potential closure of hospitals
• Potential to commission beds from elsewhere – independent sector
Potential savings from this will support improvements in our community services:
• Opportunities to commission new or different services from a range of providers
including the voluntary sector
• More therapists working in the community
• More community nurses
• Increasing the responsiveness of community staff
• More social care support – we will be working with local authority colleagues to enable
this
• Improving quality by delivering to best practice
• Better supported patients, living independent lives
Requires a phased approach to implementation – period of ‘double-running’
Developing Options
•
We want to develop and agree quality criteria which we can use to
support the development of potential options which we can consult upon
•
This is our starter for 10 which we will be amended and agreed following
everyone’s feedback
•
We have already had input from GPs, Consultants and Community
Health Professionals
•
We want to have your input too –we will talk about this later this
afternoon
In-Patient
Step Up and Step Down Rehabilitation Care
E/D
Adequate numbers of Ward Staff who can deal with elderly patients with co-morbidities including dementia
E/D
Adequate therapy input, physio and OT
E/D
Meets NHS essential standards for quality and safety
E/D
Meets NHS essential standards for environment
E/D
Meets environment standards for dementia
E/D
Fit for purpose rehabilitation Facilities
E/D
Access to x-ray facility
E/D
85% Utilisation of beds
E/D
Access to community staff with necessary palliative care training
E/D
Patients are able to have a choice of their preferred place of death
E/D
Access to near patient testing
E/D
Ultrasound Facility
E/D
Adequate Parking
E/D
% population living within 30 minutes drive
E/D
% population able to access location by public transport within 1 hour
E/D
% of population able to access location by public transport in-hours
E/D
% of population able to access by public transport out-of hours
E/D
Stroke In-Patient Rehabilitation
E/D
Adequate therapy input, physio and OT
E/D
Meets NHS essential standards for quality and safety
E/D
Meets NHS essential standards for environment
E/D
Fit for purpose rehabilitation Facilities
E/D
Access to x-ray facility
E/D
Specialist stroke rehabilitation on one site and in accordance with Stroke NICE Rehabilitation Guidance
E/D
Therapists whose stroke makes up 50% of their workload
E/D
95% Utilisation of beds
E/D
Ultrasound Facility
E/D
Adequate Parking
E/D
% population living within 45 minutes drive
E/D
% of population able to access location by public transport in-hours
E/D
% of population able to access by public transport out-of hours
E/D
Out-Patients
E/D
Access to x-ray facility
E/D
Access to near patient testing
E/D
Estate capacity to deliver OPD in the community
E/D
Critical mass of OPD activity
E/D
Ultrasound Facility
E/D
Adequate Parking
E/D
% population living within 30 minutes drive
E/D
% population able to access location by public transport within 1 hour
E/D
% of population able to access location by public transport in-hours
E/D
% of population able to access by public transport out-of hours
E/D
Assessment Hub/Medical Day Unit
E/D
Meets NHS essential standards for quality and safety
E/D
Meets NHS essential standards for environment
E/D
Meets environment standards for dementia
E/D
Access to x-ray facility
E/D
Access to near patient testing
E/D
Ultrasound Facility
E/D
Estate capacity which has the ability to ‘house’ patients for up to 4 hours for assessment and up to 24 hours
for treatment
E/D
Staff with enhanced skills to deliver IV therapies and have links to acute sites to support maintaining skills
E/D
Multidisciplinary team to carry out assessments
E/D
Critical mass of patients requiring medical day case therapies
E/D
Adequate Parking
E/D
% population living within 30 minutes drive
E/D
% population able to access location by public transport within 1 hour
E/D
% of population able to access location by public transport in-hours
E/D
% of population able to access by public transport out-of hours
E/D
Preferred Place of Death – Not at Home
E/ D
Adequate numbers of Ward Staff who can deal with elderly patients with co-morbidities including dementia
E/D
Meets NHS essential standards for quality and safety
E/D
Meets NHS essential standards for environment
E/D
Meets environment standards for dementia
E/D
Access to community staff with necessary palliative care training
E/D
Patients are able to have a choice of their preferred place of death
E/D
Adequate Parking
E/D
% population living within 30 minutes drive
E/D
% population able to access location by public transport within 1 hour
E/D
% of population able to access location by public transport in-hours
E/D
% of population able to access by public transport out-of hours
E/D
For each configuration/option assess:
Finance
Indicative Costs of
Implementation
E/ D
Recurring Costs
E/D
Potential for investment in
other services
E /.D
Sustainability (5 yrs)
Age of Building/Fit for
purpose
E/ D
Medical Advances
E/D
Demographics
E /.D
Workforce
E/ D
Impact upon other
services
Depends upon contingencies
Next Steps
•
Finalise quality criteria and agree weighting/scoring mechanism
•
Develop options and appraise – Reference Group with participants from
key stakeholder groups – this group will include Healthwatch
•
The CCG governing body will make the final decision as to which
option/options to consult upon – there may be more than one
•
Talk to the public - formal consultation is required when ‘proposed
changes are likely to impact upon the manner in which services are
delivered and the range of health services available’
The above will be underpinned by a comprehensive communications and
engagement plan
Work in Progress - Confidential