win care home service · expressed need for training and responsive specialist support from mental...
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WIN Care Home Service
Alison RicchiutiFylde & Wyre Project Lead
Background Fylde and Wyre Vanguard CCG -committed to exploring and developing NMoC
Encouraged and supported neighbourhoods of practices to propose and develop a pilot service specific to their identified patient population needs
Wyre Integrated Neighbourhood (WIN) –Six PracticesThornton, Poulton and Over WyreIdentified a care home service
2www.fyldeandwyreccg.nhs.uk
Why?
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• Ageing population
• Dementia 1 in 5 >80 years
• Complex health/social care needs and fragmented services.
• Avg. life expectancy 24 months
• High rates of unplanned admissions
• Opportunities for improving quality and cost effectiveness of care
• Need to develop collaborative care opportunities with our care home staff
colleagues
Aims
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• Improve health care for residents.• Improve patient experience & Quality of life.• Improve communication.• Improve medicines management.• Patient centered anticipatory care. • Building on collaborative working with care homes
staff• Identify learning needs and skills gaps for teaching
and training.• Reduce hospital inappropriate admissions.
Neighbourhood engagement
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Patient
Care Home Managers
Hospice
Practices
OOH ServicesMental Heath
Third Sector Social Services
WIN Team
Community Services
CCG
Stakeholder Feedback
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• Sharing of information• Better understanding of the barriers to effective communications
between practices and care homes. • Communication across the board identified inconsistences between
practices e.g Medication requests.• Lack of discharge information.• Local champions from care homes involved in an early smaller pilot
expressed need for training and responsive specialist support from mental health services ( in managing challenging behaviours etc)
Meet the team
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• Triage within 72 hours seen within two weeks• Talk to Harry, Care staff and family• Assessment of chronic diseases, dementia screen,
check MaR against GP records.• Encourage discussion around advanced care planning
and EPaCCs completed as appropriate • Pharmacist review and sometimes face to face • Individual Care co-ordination plan produced given to
home and asked to call appropriated numbers recorded shared with GP and Out of Hours
• Harry is scheduled for a visit in 6 months time to review his health plan
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New resident
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• Service contacts hospital & home to reduce length of stay
• Team contact post discharge and visit within 72 hours
• Assessment and discussion with resident, home and family as to why the resident went in
• Admission discussed at MDT with clinical GP lead to identify if considered avoidable or not.
• Lessons learned RCA form filled in and outcome shared with home and practice
• Pharmacist review of medications Action plan completed and Care Co-ordination plan reviewed and shared with GP and FCMS
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Hospital Admission and Discharge
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• Care home link nurse visits care home monthly• Advanced care planning discussion including if residents EPaCCS can be
shared• Discuss DNARCPR protocols and Just In case• Actions discussed jointly for resident Care home team share information
with FCMS and GP• Care home team link to all GSF Practice meetings sharing trends in
practice• Involvement of Trinity and EOL care home group
Supportive virtual rounds
Pharmacist interventions
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• Medication reviews• Visit home, review MARs with patient if possible• Look at indication, suitability, dosage, formulation,
usage• Best practice prescribing, following local and national
guidance.• Advise GPs on suggestions, implement with
agreement and notify homes.• 72hr discharge and new patient reviews.• Dealing with specific queries that come in from homes
that may otherwise be directed to GP.• Support & advice for team.• Neighbourhood given pharmacist authority to make
cost effective changes to certain medications where appropriate.
In Initial refl Initial reflection ectionitialreflectio
• Staff trust nervous about who the team was
• Constructive comments not taken easily
• Vision unclear not communicated• Short term increased work load
care plan writing and collection of resident information weights ect.
Team
• Recruitment• Training• I.T connectivity• EMIS Coding• Forging trust in homes• Care home training• Initial "hump" of workload in 1st round
of assessments and care planning
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Initial service evaluation
Care Homes
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• Sustaining relationships and learning
• Staffing in a small team Maintaining the morale and trust of the team amid job insecurity as pilot period coming to an end.
• Data collection• Care Plans understanding• Team understanding of change• Other services not always
knowing protocols i.e DNARCPR, Care co-ordination number
• Safeguarding • Piloting care home connect
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Half-way evaluation
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Reducing barriers
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How did you overcome them?
• Reflection and recognition of lack of services out there to support • Vision became clear over the first few months• Building relationships• Easy access to other MDT • Quicker and smoother response • Able to bounce ideas of each other having a mutual respect• Preventing unnecessary admissions and placement breakdown• Developed communication pathways with practices – all subtly different, working
towards uniformity• Communication pathway for the homes to contact the service – not acute service• Common and consistent processes and clinical coding across all practices.
Two years on…
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Care Home feedback“Primrose Bank would like to thank care home team for all their hard work and support. “Just wanted to take some time out to thank you and the WIN team on behalf of Pilling Nursing home for all your help and support during our ongoing development since opening”. “Worth their weight in gold” Alexandra Nursing Home.
Family feedback“Thank you for getting my Mum home sooner post discharge and checking everything has been OK. You’ve been a great support.”“Thank you for your kindness and support in helping us make Mum’s last few days comfortable and in the right place. You went above and beyond to ensure, Mum got the best care and for that we’ll be forever grateful.”
Two years on
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PPC/ PPD and DNARCPR discussed74%
£280,901Total cost savings 16/17
Of which £68,818 medication savings
New residents seen within two weeks100%Care plans completed. 100%
1,118 daysLength of stay reduction by
15-16 (2,916 days) 16-17 (1,798 days)
Med reviews completed (March ‘17)91% Admissions reduction of
8915-16 = 25016-17 = 161
Lessons learned
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1. Education required for health professionals completion of DNARCPR’s
2. RCA’s requiring an MDT approach
3. Recognition of common themes in admissions i.e. falls
4. Important to involve family - Managing family expectations
5. Safeguarding can increase LOS
6. Identified gaps in key skills and competences ( such as wound and EoLC) in nursing homes
7. Requirement for the acute hospitals to understanding the level of frailty of residents in care homes.
8. Advanced care planning and using consistent sharing processes.
9. What can be achieved through a shared vision and desire to collaborate for a common goal
10. Consistent sharing process of collection of data in EMIS.
Case study
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Chris 81years old.History of Frailty, dementia, stroke and diabetes.Chris was independent up until 2011 Diagnosed in 2011 with Dementia .Family struggling to cope 2015-16.Admitted to Rest home section of the Nursing Home following an admission from a fall and fracture 2016.Wandered frequently and high risk of falls.Home and wife would always feeding him finger foods.WIN Team would witness Chris singing “Let it go ” Disney classic from Frozen and he would often dance.Chris would sometimes be mischievous and creep up behind you whilst having conversations with others but was like a gentle giant.
Case study
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Care home WINMay 2016Home Informed WIN of the new resident
May 2016Chris assessed incl pharmacy review , care plan completed and requested home to discuss advanced care planning with home
June 2016Home discussed with family and requested DNARCPR along with PPC/ PPD
June 2016Care plan updated following Advanced care planning shared with EPaCCS
Aug 2016 Supportive ward round and continued monthly
Nov 2016 Chronic disease review and advise around fortification
May 2017Fall in home sustained serious head laceration and admission
May 2017 Visit by WIN Identification of drug changes when comparing MAR against discharge letterReferral made to falls team and Dietician. Green months – years prognosis EPaCCS notifiedCDM completed. Admission avoidable
June 2017Supportive ward round and continue monthly
June 2017 Med review following admission. Updated EMIS records of changes
Sept 2017Fall in home and admission
Sept 17Visit by WIN discussion around deterioration EOL and falls to highlight with safeguard teamCare plan completed
End of Sept 17 Care home identify EOL weeks (Yellow) and inform WIN and GP
End of Sept 17WIN update EPaCCS and change care plan. Request 4 core meds
10/17Care home confident in looking after Chris in EOL
10/17 Continue to support home with EOL
9/10/17Chris died peacefully in the care home surrounded by his family
10/10 WIN and surgery informed
Success
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• Conduit to support better communication and a shared vision• Organically grown from the neighbourhood • Enhancing Neighbourhood and care home relationships and trust. • Increased EOL recognition• Quality of care for residents and families• CCG encouragement and support
• Sharing learning to inform other NMoC and service developments (neighbourhood leg wound service )
• Further possibilities in streamlining neighbourhood protocols to improve quality and flow and gaps in service e.g
• Wound care protocols for ordering• Shared protocols in covert medications• Common homely remedies agreement
Success
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A future service across the Fylde and Wyre based on national evidence and local success.
FWCCG Interim Care Home Service
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Interim Workforce ( Nov 2017 – Mar 2019)• Nurse Practitioners• Health Care Assistants• Pharmacist• GP Neighbourhood Support• Integrated Falls Service• Enhanced Primary Care (EPC)Future Integrated Neighbourhood Team• District Nursing• Community Matron• Therapy Services• Mental Health Services• Social Services• Extensivist Service (ECS)
2 Interim Care Home Teams between 1st November 2017 – 31st March 2019Fylde - (Kirkham & Wesham and Lytham Neighbourhood)
Wyre – (Fleetwood and WIN)
• Recruitment • Loss of the GP EMIS and duplication of work • Maintaining relationships and building new relationships in the wider
footprint • Selling the service to other neighbourhoods who’s pilots were not so
successful
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Challenge and Potential Risk
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Future Vision – Integrated NeighbourhoodsD
iagnostics and specialist acute care
Wellbeing support
Carecoordination
Triage
Assess
Signpost
Primarycare
Patie
nts
and
prof
essi
onal
s re
fer i
nto
a ne
ighb
ourh
ood
hub
incl
udin
g ca
re h
omes
.
2Better
utilisation of the local health and care workforce
3Improved
utilisation and sustainability of local services
Patientactivation
Communityconsultants
Communitynursing
Therapy
Mentalhealth
Socialcare
1Improved
outcomes and experiences of
care for patients