i ntegrated m anagement & pro active care for the v ulnerable and e lderly – improve

Integrated Management & Proactive Care for the Vulnerable and Elderly – IMProVE

Amanda HumeChief Officer

What is the IMProVE Programme?

• The number of people who are elderly, vulnerable and living with a long-term 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

IMProVEIntegrated Management

and Proactive Care for the Vulnerable Elderly

Key themes emerging from engagement activitySeptember-November 2013

23 Queen Street, Redcar, TS10 1AB tel: 01642 488977 email: [email protected] 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 localdoctors.

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.


• 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 up-to-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.


• 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


• 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 co-ordinating 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.


• 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 StevensCommissioning & 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

Authority Mid-2012 population estimate 2021 population projection

Number No. (%) aged 65 +

No.(%) aged 85 +

Number % aged 65 + % aged 85 +

Middlesbro 138,744 21,293 (15.35%)

2,591 (1.87%)

144,275 24,997 (17.33%)

3,911 (2.71%)

Redcar & Cleveland

134,998 27,396 (20.29%)

3,259 (2.41%)

135,466 31,782 (23.46%)

4,540 (3.35%)

Total 273,742 48,689 (17.7%)

5,850 (2.1%) 279,741 56,779 (20.2%)

8,451 (3.2%)

Source: ONS mid-2012 population estimates and interim mid-2011 based population projections

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 ClevelandAccording 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!


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?


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

ServiceDawn 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 re-ablement, 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-PatientStep 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



Fit for purpose rehabilitation Facilities 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






Out-Patients E / D



Estate capacity to deliver OPD in the community E / D

Critical mass of OPD activity E / D







Assessment Hub/Medical Day Unit 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






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




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






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

i ntegrated m anagement & pro active care for the v ulnerable and e lderly – improve

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