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National
Dementia Action Alliance
Integration Event
How the integration of hospitals
and care home services can better
facilitate transfers of care
Wi-Fi
Name: RCOTGUEST
Password: Welcome2RCOT!
@Dementia_Action
#NDAAIntegration
National Dementia Action
Alliance
Integration Event
Chairs’ Opening Remarks
Graham Stokes, Director of Memory Care Services
HC-One
Janis Cottee
tide
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@Dementia_Action
#NDAAIntegration
National Dementia Action
Alliance
Integration Event
Welcome from RCOT
Karin Orman, Lead Professional Advisor
Royal College of Occupational Therapists
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@Dementia_Action
#NDAAIntegration
National Dementia Action
Alliance
Integration Event
Welcome from the NDAA
Sarah More, Engagement Officer
National Dementia Action Alliance
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@Dementia_Action
#NDAAIntegration
National Dementia Action
Alliance
Integration Event
Learning from people living with dementia and carers: what they want you to know
about the care home to hospital experience
Lynn Gamble, tide
Vesna Okaikoi, DEEP
Ruth Turner, tide
Teresa ‘Dory’ Davies, DEEP
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Chair
Fran Hamilton
Occupational Therapist & DEEP supporter
National
Dementia Action Alliance
Integration Event
How the integration of hospitals
and care home services can better
facilitate transfers of care
Wi-Fi
Name: RCOTGUEST
Password: Welcome2RCOT!
@Dementia_Action
#NDAAIntegration
National Dementia Action
Alliance
Integration Event
Understanding the current climate: what are the key challenges for those involved in the transfer of care and how are current initiatives easing these
pressures?
Jo James, Lead Nurse for Dementia, Imperial College Healthcare NHS Trust
Jenny Bloor, Operations Manager, Housing 21
Simon Griffiths, Interim Director of Local Delivery, Essex County Council
Carolyn Piper, Dementia Project Manager for North Central London, Enfield Care Home Assessment Team, North London Partners in Health and Care
Wi-Fi
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@Dementia_Action
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The Care Home Forum Project
Jo James
Lead Nurse , Dementia
Imperial College Healthcare NHS Trust
The situation
• Large Teaching hospital in London
• Multiple issues with discharge to care homes (patients bouncing back, complaints)
• Poor relationship between hospital staff and care home staff – blame culture
• Limited co-operation and communication
The Care Home Forum
• Invitations to local care homes for a monthly meeting to discuss how we can work better together • Need for better understanding of each other
• Need to communicate more effectively
• Need to have a little professional respect
• Need to factor in the pressures in each organisation
Plan
• Hold an event to get to know the hospital
• Share training opportunities
• Monthly ‘ What are the issues?’ forum meetings
The Event
• Meet and greet lunch – care home attendees and the staff from high user wards, esp. ward managers, discharge teams & Drs.
• Presentations – How hospitals operate / what happens when a person is admitted / discharged. How confidentiality / data is dealt with.
• Ward manager led tour – small groups to high user wards (6 wards)
Shared Training
What can we offer them?
• Open invite to Thursday training / Study days
• Bespoke training
What could they offer us?
• Training to hospital staff
• Managing cultural needs in care
• Decision making
• What happens when a resident is admitted
Monthly meetings
• At first it was hard…..
• But it improved after a few weeks.
• A lot of it was valid.
Did it work?
• Staff on both sides understood the issues
• Information was shared – how pts were, when a pt died.
• No more discharges on Friday afternoon.
• Care staff welcomed by ward staff for assessments.
• More respect.
“How the integration of hospitals & care home services can better facilitate transfers of care”
Jenny Bloor Operations Manager, Housing 21
Disclaimer……
We are all busy
This is what we are up against every working day…..
• Processes
• Work Flows
• Internal Policies
• Internal Procedures
• Contract Specifications
• Contractual Obligations
• Regulatory Responsibilities
• KPI’s
• Targets
• Deadlines
• Time Frame/Time Bound
• Task Based
• Cost
• Complaints
Time
1. Anyone who works in the Health & Social Care Sector does not have time to do anything other than the 35 jobs that are all priority and are all being done at the same time
2. When someone is admitted into hospital there is always the hope they will also be discharged from hospital
3. But do we have time to DO THE RIGHT THING? The answer is YES we do
4. How do we feel as professionals when things haven’t gone right?
5. Lessons Learnt? But do we have time to remember the Lessons we Learnt?
Examples of Hospital Discharges
“FRED” – Discharged from hospital into our non nursing emergency bed, with a cannula still in
his arm and no trousers on, FRED was frantically trying to pull the cannula out of his arm and crying because he thought he’d been kidnapped and was being drugged.
“VERA” – Arrived at a home at 11.30 at night, in the rain, lying on a trolley, left on the car park
whilst the Paramedics were getting her personal items off the ambulance.
“MR. THOMPSON” – Arrived at a Residential Home, but he didn’t actually live there,
and MR THOMPSON had to wait for an hour and a half while the Paramedics found out where he lived. MR THOMPSON became upset and “aggressive”
&
“BRENDA, JOE, STAN, JACK, LUCY, DORA, GLADYS etc” – Discharged smoothly and efficiently from local hospitals with family/health
professionals/social worker/staff involvement and with a smiling, friendly face to escort them home.
Communication…..
It’s good to talk, isn’t that a British Telecom Advert from the 80’s? But how do we talk?
• Ward Staff to
• Residential Home Staff to
• Social Workers to
• Significant People
• How do we share a person’s critical information?
• Plan, Plan, Plan & Talk, Talk, Talk – Dementia Friends/Dementia Friendly/Dementia Words Matter
Person Centred
• What does a GOOD day look like?
• What does a BAD day look like?
• What can we do to help someone feel validated and in control?
• How are they feeling?
• Triggers/Comforters
• Passport between services
• Significant Persons involvement
• Escort
• Dementia Words
• The time of the Hospital Discharge
• Nutrition and Hydration
The Person First, Time & Communication Just 3 ideas, but ultimately it’s DOING THE RIGHT THING for the person not the patient number
Understanding the current climate
NATIONAL DEMENTIA ACTION ALLIANCE
What are the key challenges for those involved in the transfer of care and how are current initiatives easing these pressures?
Simon Griffiths, Interim Director of Local Delivery, Essex County Council
A LITTLE BIT ABOUT ESSEX
ABOUT NORTH EAST ESSEX
• Population 329k
• This Alliance covers the districts of Colchester and Tendring.
• The resident population of North East Essex is predicted to rise to around 377,000 by 2035, with the greatest increases expected to be in those aged 85 years and over.
• The most deprived small area
(approximately 1,500 people) in England is in Tendring.
DEMENTIA IN ESSEX
Approx. 19,000 people are living with Dementia in Essex
32% of ECCs admissions to residential care are for people known to have dementia
70% will also have other medical conditions of disabilities
There is so much information. Where am I supposed to start? (carer)
• 40% of carers experience psychological distress or depression
• People don’t contact us until they’re in crisis And when they do contact us, there are often two people in crisis, the individual with dementia and their carer. (Paid carer)
DEMENTIA IN ESSEX - A FEW MORE CHALLENGES • Admission to hospital and pyjama paralysis – 10 days bed rest could lead to 10 years muscle mass loss in over 80 year olds.
• Systems are fragmented and bureaucratic
• Services do not consider people as part of a family – or even in partnership with their carer
• Support is not personalised – and doesn’t enable people to maintain their capabilities, interests or relationships
• Systems rely heavily on the carer, but don’t support them very well
• Carers are often unable to access services when they are available and have few options available over night and at weekends
• Current avenues of support don’t help people and families to withstand the emotional pressures they face – stress, relationship breakdown, loneliness
• Existing systems push people towards residential care because they can’t find the support they need in the community
EXPERIENCE OF THE SYSTEM
At least 25% of general hospital beds are occupied by people living with dementia. On average people with dementia stay more than twice as long in hospital then other patients aged over 65.
WHAT DOES GOOD LOOK LIKE?
• Prevention
• Finding information and
advice to support living well
with dementia in the
community
• Supporting carers
• Reducing the risk of crisis
• Living well in long term care
• End of life
• A knowledgeable and skilled
workforce
INNOVATION IN ESSEX
• Intervention and support at patient & carer crisis point • Respite solutions and supporting the family whilst in crisis • Educating families in dementia or medication
INNOVATION IN ESSEX
• In reaching into care homes, focusing on clients with Dementia. • Reviewing people with problematic symptoms of dementia &
other complex presentations. • More timely interventions appropriate to people’s needs,
helping enable people to remain in their usual place of residence .
Enhanced
Care Home
Liaison
Admiral
Nurses
• Intervention and support at patient & carer crisis point • Respite solutions and supporting the family whilst in crisis • Educating families in dementia or medication
Early
intervention
vehicle
• Emergency triaged response to 999 call to avoid admission. • Responds to elderly “falls” patients. • Rapid assessment by Paramedic and OT.
INNOVATION IN ESSEX
Working with residential and nursing homes
Quality Improvement methodology Creative thinking
• Roll out the Dementia Friends programme across Primary Care
• Develop community assets • Rolling out the Dementia Friends programme across the
optical, pharmaceutical and dental sector
GOLD
STANDARD
FRAMEWORK
- EDUCATION
• Roll out the Dementia Friends programme across Primary Care
• Develop community assets • Rolling out the Dementia Friends programme across the
optical, pharmaceutical and dental sector
INNOVATION IN ESSEX
• Engaging with care homes and domiciliary providers • Models of trusted working to spread across the system • Trailing fit for purpose assessment
TRUSTED
ASSESSOR
PALLIATIVE
CARE
• My Care Choices • Hospice doctor on wards • Collaborative education events
Integrating hospital and care home services to better facilitate transfers of care…
A North Central London Perspective
National Dementia Action Alliance Wednesday 17 July 2019
Who are we – North Central London
38
The Challenges…
• Frail, vulnerable and dependent populations.
• Inadequate proactive preventative measures
• Failure to manage mental health and long term conditions including end of life care
• Confidence of care home staff
• Responsiveness of primary care
• Capacity of existing community services
• Variation in capability across care home providers
• Financial burden
39
Models of Care
• Aim: Measure the impact of older people’s integrated mental and physical health teams on emergency admissions and length of stay in hospitals, with a focus on people with dementia and / or functional mental health presentations.
• Objective: Undertake an evaluation measuring the impact of;
Barnet, Enfield and Haringey NHS Foundation Trust –
Care Home Assessment Team
An integrated community mental and physical health care team supported by Geriatricians and a Consultant Psychiatrist have been commissioned to provide training and guidance to care homes.
40
1. Reduce the need for acute emergency and reactive care, by improving the direct management of individual patients in care homes, improving the knowledge, skills and confidence of care home staff.
2. Improve end of life care, increasing the number of residents who die in their preferred place.
41
Enfield Care Home Assessment Team: Aims of the service…
Improve the lives and deaths of residents
in care homes across Enfield.
• To educate and build capacity and confidence within staff to proactively manage the health of the residents.
• Provide tailored physical and mental health and well being support to reduce risk of exacerbation of LTC’s
• To provide clinical triage and better transfers of care
• To integrate well with all health and social care services
• To enhance the patient experience and quality of life
Including providing unplanned care
• Unscheduled and unplanned call outs
• Crisis management e.g. Falls
• Urgent referrals from GPs and other care professionals
42
Aims
43
0
1000
2000
3000
4000
5000
6000
7000
2013-14 2014-15 2015-16 2016-17 2017-18
Nu
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A&
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Total number of A&E attendances and non-elective admissions, 2013 - 2018
44
0
1000
2000
3000
4000
5000
6000
7000
2013-14 2014-15 2015-16 2016-17 2017-18
Nu
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of
A&
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Total number of A&E attendances and non-elective admissions, 2013 - 2018
35% reduction
in total number of hospital attendances (-2,118).
Against a 23% increase in Enfield’s 65+ year old non care home population.
• A&E attendances reduced by 47%, (-1,834). Against a 23% increase in A&E attendances by the 65+ year old Enfield non care home population.
• Non-elective admissions has decreased by 13%. Against a 24% increase in non-elective admissions by the 65+ year old Enfield non care home population.
• This equated to a 9% reduction in costs (-£598,671). Against a 34% increase in costs for the general population aged 65+ (+£7,113,284).
45
Hospital Attendances
46
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42
11-20 beds 21-30 beds 31-40 beds 41-50 beds 51-60beds
61-70beds
71-90 beds
A&
E at
ten
dan
ces
and
NE
adm
issi
on
s p
er r
egis
tere
d b
ed
Care Homes by number of registered beds
Average number of A&E attendances and non-elective admissions per registered bed for CHAT managed care homes in and out-of-hours,
between 2013-2018.
Average number of attendances in hours Average number of attendances out-of-hours
47
Episode Diagnosis Total % of total
Total ALL Falls (breakdown of falls below) 1139 23%
Respiratory / COPD / chest infection / cough 546 11%
Urinary Tract Infection / Urine problem 417 8%
Septicaemia / Sepsis 415 8%
Gastro / bowl obstruction / abdo pain / constipation /
diarrhoea / vomiting 392 8%
Cardiac / chest pain / hyper/ hypotension 349 7%
Difficulty in breathing / shortness of breath 153 3%
Catheter 148 3%
Transient loss of consciousness (TLoC) / collapse /
unresponsive 129 3%
Pain 95 2%
48
Falls leading to hospital attendance or admission were reduced by 7%. On average, 99% of residents died in their preferred place (10% of
residents who died did not have their preferred place of death wished recorded).
1514 residents (39%) have had their medication reduced or stopped as
result of CHAT input. Calculating one year’s reduction in costs of prescribing equated to £7,506 of savings.
7,606 care home staff and managers attended training on 59 subjects. The CHAT team record the number of hospital attendances and GP visits
they believe they have helped to prevent, which equated to 8,409 hospital attendances and 8,109 GP call outs between 2013 and 2018.
CHAT OUTCOMES
49
Dr Fenn, Forest Road GP: “The CHAT team make a real difference to patient care. The approach is an integrated one working with patients, families and secondary care. There no longer seems to be a barrier between primary and secondary care. I can genuinely recommend them as the best example of integrated care that I have seen in my career”.
PRIMARY CARE - INTEGRATED CARE
50
Resident and mental health service user from
Murrayfields Nursing Home: “CHAT always
listen. They try to help me manage my own
anxiety and concerns but recently when it was
all too much they got a psychiatrist in to see
me and I was so thankful.
MENTAL HEALTH PATIENT - INTEGRATED CARE
Transfer of care - Initiatives
51
Initiatives to support care homes implemented; Red bag scheme – emergency bag of essential information, medications, practical personal items – glasses, discharge clothing etc. This is me tool - form for anyone with dementia, delirium or other communication difficulties to explain the person. Significant 7 – a toolkit for investigating signs of patient deterioration such as hydration, pain, confusion, etc. 111*6 - NHS urgent medical advice telephone line for care homes. Social care placement liaison – placement breakdown management.
52
Model of care; Multi-disciplinary team approach - Partnership of the hospital Geriatricians working in the community and upskilling the Community Matrons Trusted Assessors - Reduce the number of patients / waiting times of patients, awaiting discharge from hospital and help them to move from hospital back home speedily, effectively and safely. Visiting them within 24 hours.
Transfer of care – Key factors of Success
YEAR 2012-13 2018-19
No of Care
Homes (beds)* 4 (222 beds) increasing to 17
(749 beds).
36 (1,471 beds)
2 care homes in another borough Staffing
• 16 hours/wk NMUH
Geriatricians
• 0.6 wte psychologist
• 1 wte Band 7 matron
• 0.6 wte Band 3 admin
• 16 hours/wk NMUH Geriatricians
• 16 hours dedicated Consultant
Psychiatry time
• 1 wte Band 8a manager / matron
• 4 wte Band 7 matrons
• 2 wte Band 7 specialist mental health
nurse, one with OT specialism
• 1 wte Band 4 assistant practitioner /
phlebotomist. 0.8 wte Band 3 admin
Pilot projects;
• 0.6 wte Band 7 matron in Haringey.
• 3 wte Band 7 matrons / trusted
assessors
• 1 wte Band 8a prescribing pharmacist
• 0.6 wte Band 6 pharmacy technician. 53
Team Structure
Over to you…
54
Carolyn Piper ([email protected])
North Central London’s STP
Melanie Pettitt ([email protected])
Care Homes Assessment Team Manager (CHAT)
Jennie Bostock ([email protected])
NHS Enfield CCG
National
Dementia Action Alliance
Integration Event
How the integration of hospitals
and care home services can better
facilitate transfers of care
Wi-Fi
Name: RCOTGUEST
Password: Welcome2RCOT!
@Dementia_Action
#NDAAIntegration
National Dementia Action
Alliance
Integration Event
Workshop
Bringing hospitals and care homes together: a workshop to support better facilitation for
the transfer of care for people living with dementia
Please move to your allocated group as per the number on your name badge
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@Dementia_Action
#NDAAIntegration
National Dementia Action
Alliance
Integration Event
Closing Remarks
Martin Green, Chief Executive
Care England
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Professor Martin Green OBE Chief Executive
Care England
Integrated Care and Health
National Dementia Action Alliance
17/07/2019
Commissioning and policy integrated
Wellbeing, physical and emotional
Relationship based care
Self-funder/Public funder –Same outcome
Workforce integrated
respect/training/resources
Reputation/public understanding
Diversity and responsiveness
Services for People
Healthcare spend over c£180 billion +
Social care spend c £18.2 billion
£220.2 billion on Health/Social Care/Benefits
Fragmentation across the system
Another Green Paper ?
Silo thinking and silo acting
Lack of transparency over costs in all sectors
Social care broken: More money for the same solution?
Healthcare funding increases never solve the problem
Inequality in access and funding across age groups
Context: Austerity? Fragmentation
Inclusion, Access and Equality
Clear and consistent national policy
Clear community based planning
Parity of recognition between Health and Care
Outcome based commissioning
End to duplication/Better Information flows
Planning process streamlined
Integration of policy, practice and budgets
Think People and Outcomes NOT Organisations and Systems
Caring for the Carers
Recognition and reward
Cross Government workforce planning
Cross sector training budgets
Career pathways in care
Clearer regulatory expectations
Career structures and higher pay
Pensions and benefits
Diversity
Doing things differently
Finding new ways of delivering care
Engaging with local needs
Moving away from commissioned services
Commissioners become community based market shapers
Professor Martin Green OBE
Chief Executive
Care England
@CareEnglandNews
@CareEngOfficial
Professor Martin Green
Care England
National Dementia Action
Alliance
Integration Event
Chairs’ Final Remarks
Graham Stokes, Director of Memory Care Services
HC-One
Janis Cottee
tide
Wi-Fi
Name: RCOTGUEST
Password: Welcome2RCOT!
@Dementia_Action
#NDAAIntegration
National
Dementia Action Alliance
Integration Event
How the integration of hospitals
and care home services can better
facilitate transfers of care
Wi-Fi
Name: RCOTGUEST
Password: Welcome2RCOT!
@Dementia_Action
#NDAAIntegration