marc hopkinson gateshead care home programme. our mission & vision mission: working together to...
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Marc Hopkinson
Gateshead Care Home Programme
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Our Mission & VisionMission: Working together to improve the health of Gateshead
Vision:Care for people in a seamless wayEnsure commissioning is clinically led and driven by
patients and carer involvement Improve the quality of health services
Quality of Care
Working together
CompassionImproving
LivesRespect &
DignityEveryone Counts
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Needs increasing: scale
Now• 191,000 population• 18% over 65 years • 3.7% over 85 years• 0.85% living in care
homes• Median length of stay 20
months (23 in Nursing, 27 in Residential)
2030• 203,000 population• Aged 65 + increase of 1/3
(34,000 – 45,000) • Over 85 years - 90% increase
(3,900 to 7,500)
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Quality not right nowFrailty is the issue
• Care is reactive … we need specialist proactive• Variation e.g. multiple practices causes problems• Communication issues across settings -
admission/discharge • Care planning inc advanced care (In and OOH)
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Older People (40, 000 aged 65 +)
Residential Care Homes17 homes (596 patients)
Nursing Homes15 homes (907 patients)
Specialist Care Homes(including Learning Disability, Promoting
Independence Centres and Specialist Mental Health)
Older People supported to live at home aged 65+ (4273 patients)
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Aim:
To improve the care of patients and familiesthrough more integrated proactive care
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Objectives:
Improve each care setting and bring them into a ‘frailty team’• Increasing skills and understanding in homes.• Changing reactive primary care delivery to a
proactive model involving weekly visits by a lead GP from the care homes linked practice
• Comprehensive care planning and MDT case management led by specialist nurses at the weekly ward rounds with ongoing support to homes
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Objectives (Cont)
• Bringing specialists into a virtual team to support when needed and improving communication between
• Reduce avoidable hospital admissions• To be cost saving
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Pilot Results
• Investment of approx £50k• 98 patients case managed• 45.5% reduction in admission rates
based on 2008/09 data- admission days 440
- admission costs £243,146
• Savings assuming same conditions/reasons for admission for total care home population in Gateshead:
- 6763 bed days - £3,730,446
• ‘You gave me my father back’
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Care home staff
Specialist input (OAP, SALT, Physio)
Outpatient geriatrician
Inpatient
Lead GP, Specialist Nurse
Patients, Carers and families
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Expanding this across Gateshead
• Care homes trained• 28/34 Care homes linked to practices• 6 specialist nurses proving comprehensive
reviews, care planning, liaising and reactive care
• Medicines Management Team• GHFT Geriatrician • Laptops• Key partners- LA, OA Psychiatry
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Specialist Nurses
Commissioned
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The Project Group
• Dr Mark Dornan• Lesley Bainbridge• Lynne Shaw• Dr Daniel Cowie• Dr Louise Crabtree• Marc Hopkinson
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Any Questions?
http://gatesheadccg.nhs.uk/about-us/case-studies/