WIN Care Home Service · expressed need for training and responsive specialist support from mental health services ... “Just wanted to take some time out to thank you and the WIN

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?

www.fyldeandwyreccg.nhs.uk

• 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


• 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


Patient

Care Home Managers

Hospice

Practices

OOH ServicesMental Heath

Third Sector Social Services

WIN Team

Community Services

CCG

Stakeholder Feedback


• 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


8

• 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


New resident

9

• 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


Hospital Admission and Discharge

10

• 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


• 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

12

Initial service evaluation

Care Homes


• 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

13

Half-way evaluation


Reducing barriers


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…


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


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


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


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


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


• 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


A future service across the Fylde and Wyre based on national evidence and local success.

FWCCG Interim Care Home Service


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

23

Challenge and Potential Risk


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

Documents

WIN Care Home Service · expressed need for training and responsive specialist support from mental health services ... “Just wanted to take some time out to thank you and the WIN