OLDER AND BETTER:LIVING WELL AT HOME OR IN THE COMMUNITY RESHAPING CARE PRORGAMME

Margaret Whoriskey JIT

TIM Eltringham, East Renfrewshire

Trudi Marsha Lanarkshire

Our Vision:

Older people in Scotland are valued as an asset, their voices are heard and they are supported to enjoy full and positive lives in

their own homes or in a homely setting

Our Policy Goal:

To optimise the independence and wellbeing of older people at home or in a homely setting

Current service provision by service type

65+

89.5%

Home care

Care home

NHS Continuing Care

All others

75-84

97%

88%

60%

75-84

65-74

85+

“Most older people (89.5%) do not receive ‘formal’ care in NHS continuing care, a care home or a home care service organised

by social work agencies.”

“To put it bluntly, we are presented with a huge structural and financial challenge that cannot be fixed through efficiency savings or marginal

changes to service provision on their own.”

Heath and Adult Social Care Expenditure 2007/08for Scottish population aged 65+ (Total=£4.5bn)

Other Social Work

5%Care Homes12%

Home Care7%

FHS8%

Prescribing9%

Community8%

Other Hospital care19%

Emergency admissions32%

Change Fund & Change Plans

• £70 million 2011/2012– expected circa £300 million over 4 years (1 – 2 % of total spend on older people)

• Bridging finance to lever improvement across the entirety of older people’s spend in health and social care

• Partnership planning process – Health, Local Government, voluntary and independent sectors

Percentage of Plans including Each

Category

Measuring progress

• Support at Improvement Network event for development of Core Set of measures (with common definitions for all partnerships). COSLA endorse this approach.

• Draft proposals issued in May to all partnerships.

• Key messages from consultation (24 Partnerships):– Focus on outcomes where possible. – Make it manageable. – Core Set used in conjunction with locally determined measures– Data should allow more detailed analysis where appropriate

Agreed set of Measures issued 4th July 2011

A: Nationally available outcome measures and indicators

A1. Emergency inpatient bed day rates 75+

A2. Delayed discharges and accumulated beddays used by DDs

A3. Dementia prevalence rates (from QOF)

A4. Percentage of people aged 65+ who live in housing (rather than a care home or a hospital setting)

A5. Percentage of time in last 6 months of life spent at home or in a community setting (further guidance to be issued)

Recommend further use of:

A6. Satisfaction/Experience measures people and carers (from the Community Care Outcomes Framework )

B: Local Improvement Measures

Anticipatory and preventative care • B1. Proportion living at home who have an Anticipatory Care Plan shared 75+• B2. Waiting times for a housing adaptation• B3. Proportion of people 75+ with a telecare package

Responsive / flexible home care and carers• B4. Reduction in hours of support after reablement• B5. Respite care for older people per 1000 population

Demand for acute care • B6. Rate of 65+ conveyed to A and E with principal diagnosis of a fall (SAS)

Effective flow in acute care • B7. Proportion of frail emergency admissions who access specialty unit within 24

hours

Use of long term residential care • B8. Rate and proportion of new entrants admitted from home; from acute hospital

(by specialty); following intermediate care; graduate from emergency respite

C: Partnership resource use

C1 Per capita weighted cost of accumulated bed days lost to delayed discharge

C2 Cost of emergency inpatient bed days for people aged 75+ per 1000 population

C3 A measure of the balance of care (e.g. split between spend on institutional and community-based care)

IRF data will support use of these measures in particular

Anticipatory Care Planning and tackling polypharmacy Falls and fracture preventionManage transitions through re-ablement, Intermediate Care and Virtual Ward alternatives to admission Manage flow of older people at A&E and in acute care Dementia whole system demonstrators Telehealthcare demonstrators – eg DALLAS

LTC ehealth demonstrators

East RenfrewshireReshaping Care for Older People

Community Capacity Building

Overview

•East Renfrewshire

•Local context

•Relationship and partnerships

•Progress to date

•Learning success points

East Renfrewshire

• South of Glasgow• Giffnock, Newton

Mearns, Barrhead, Clarkston

• 90,000 population• High number 85+• Relatively affluent

Foundations

• Integrated CHCP• Changing Lives 2006• Single Outcome Agreement• Talking Points and community care• outcomes • Working together for all our Futures

(Council Strategy)

Relationships, Partnerships and ways of working • Level of trust and previous working

together • Voluntary Action:

• Third Sector Interface• Third Sector Forum• Thematic projects

• Outcome focused planning• Understanding approaches i.e. asset

building, community capacity building, co-production

Reshaping Care for Older People

• CHCP and Voluntary Action Memorandum of Agreement

• Formal governance structure• Change Fund: Funding staffing

capacity with VA

Key aims• Community Capacity Building• Promotion of volunteering

Our Approach

• Sound evidence base• Shared learning across partners to

inform evaluation• Third sector engagement event• Develop the shared understanding

and developing a framework forplanning

• Work programme in development

Logic model (draft)

Will it work?

• Transformation is not only the preserve of public services.• The achievement of positive outcomes involves working with communities to build capacity. • Achieving the Talking Points outcomes leads to greater resilience and reductions in reliance on public services.• Will help shift the balance of care and achievement of key Quality Outcomes.

Learning/factors of success

• Foundation of community capacity building understanding, knowledge and experience in voluntary sector and health improvement

• History and level of joint working • Shared understanding and ambition to work together and do things differently

RSVP “Wee Red Bus” hired by NHS Greater Glasgow & Clyde for 12 weeks to take patients to the Falls Clinic , including Jim who cares for his wife Helen who has Alzheimer’s

“Collaborative partnership working benefits all parties involved, maximises resources and ensures better results for older people”

Meanwhile Levern Valley Older People’s Team refer Helen to VA Befriending Project for social support - on assessment it transpires that Jim also needs type of service of provided through ‘Chataway’ telephone befriending run & delivered by volunteers.

Helen and Jim also hear about the RSVP Assisted Shopping Service using the Wee Red Bus, accompanied by volunteer buddies and start to take part

Through their contact with RSVP Jim and Helen find out about support services available through the Carers Centre & Alzheimer’s East Renfrewshire Project

RSVP start a weekly tearoom at underCOVER to encourage greater social interaction between people using the service and Jim and Helen come along

VA Befriending Project Worker involved in setting up a seniors steering group to shape and develop use of the underCOVER building and Jim has agreed to become a member of the group

Helen & Jim given information on the RSVP Medical Appointment Service run by ‘seniors’ volunteers using their own vehicles . Helen & Jim start to use the service for their GP appointments

Reshaping Care Older People Lanarkshire

Examples of funding approvals to date

Provision of medical services to 2 Local Authority care homes

Increasing capacity in Community Assessment Rehabilitation Service

More effective Old Age Psychiatry services

Integrated Discharge Facilitator – 3.0 posts

Hospital at Home Scheme/ Community Acute Care Elderly (ACE)

Roll out of re-ablement model

Implement Lanarkshire Falls and Bone Health Strategy

Supported transport home from A&E

Increasing capacity of community network support systems

Enhance Joint Equipment service

Lanarkshire Community ACE Pilot

The Perfect Storm?

Better Quality Care

Better Quality Care

Less ResourceLess ResourceLess ResourceLess Resource

Less BedsLess BedsLess BedsLess Beds

Less DoctorsLess DoctorsLess DoctorsLess Doctors

More PatientsMore PatientsMore PatientsMore Patients

Over 75 Admissions(Percentage Growth)

Over 75 Admissions(Percentage Growth)

Admission Avoidance Hospital at Home

Admission Avoidance Hospital

at Home• Admit patients directly from the

community avoiding physical contact with the hospital, or may admit from the emergency room.

• 10 RCTs (n=1333)

• “There is no evidence from the analysis to suggest that admission avoidance hospital at home leads to outcomes that differ from inpatient hospital care.”

Test of Concept

• Cumbernauld and Kilsyth

• c 3500 Over 75s

• All over 75yrs GP calls requesting admission

• ALL Nursing Home Residents (Any Age)

• “One Week Only”

Community Community ACE TeamACE Team

Community Community ACE TeamACE Team

CrisisCrisis!!

CrisisCrisis!!

GPGPGPGP

ACE?ACE?ACE?ACE?

First First AssessmentAssessment

First First AssessmentAssessment

Second Second AssessmentAssessment

Second Second AssessmentAssessment

WithiWithinn

1hr1hr

WithiWithinn

1hr1hr

TreatTreatTreatTreat

PhysiPhysioo

PhysiPhysioo

OTOTOTOT

HomecarHomecaree

HomecarHomecaree

EquipmenEquipmentt

EquipmenEquipmentt

ReferraReferrall

ReferraReferrall InvestigaInvestiga

teteInvestigaInvestiga

tete

DischargDischargee

DischargDischargee

MDTMDTMDTMDT

Case Study One 86 year old lady with history of confusion

who lives with her husband.

Fall from her bed last night and was returned to bed by SAS. GP contacted by family as experiencing general deterioration, reduced mobility and increased confusion.

ERC had been contacted by GP to arrange admission for investigation and treatment.

Management• Admin contacted husband advised of response time, requested

medical notes

• Nurse attended within 15 minutes and carried out a full system examination, 12 lead ECG, bloods, urinalysis, continence assessment, developed working diagnosis and initial management plan – UTI with delirium. Husband also identified as having a chest infection, liaised with GP

• Consultant reviewed working diagnosis, prescribed antibiotics, medication review, reassured family

• Functional review undertaken by AHP to support mobility during acute illness

• 7 hours Re-ablement / week

• Reviewed daily for 2 days

• Pre Barthel 48 Post Barthel 53

Case Study Two Contacted by Merrystone to review 78

year old man who lives with his wife. He had experienced 3 falls in past 24 hours. Had existing homecare support 7/7 x2.

Merrystone reported no other issues other than regular falls.

Pattern of regular admissions monthly to acute.

Management• Admin contacted wife, advised of response time and

requested medical notes

• AHP attended within 30 minutes, obtained history, undertook functional assessment and identified new balance issues requiring medical review, walking aid provided

• Nurse attended obtained full history and conducted full system examination, 12 lead ECG, bloods, urinalysis, identified complex medication issues requiring consultant review

• Consultant reviewed developed working diagnosis- complex polypharmacy resulting in parkinsonism symptoms, linked with CMHT and family re medication changes, liaised with GP

Pre Barthel 52 Post Barthel 52

Management• Consultant reviewed developed working diagnoses:-

• Complex polypharmacy

• Parkinsonism symptoms (?Valproate related)

• (Postural instability, freezing, rigidity, tremor)

• UTI

• Complex Psychiatric History

• Referred to CMHT and family re medication changes, liaised with GP

• Conservative plan agreed to avoid minimise risk and make home life manageable

Pre Barthel 52 Post Barthel 52

Case Study Three 81 year old lady who lived with her

husband. Husband who was main carer recently admitted to Monklands. Neighbours concerned as lady seen wandering and deterioration

No food / shopping in house.

SW had contacted headquarters to arrange emergency respite placement

Management• Admin arranged medical notes and informed GP

• Nurse contacted SW to obtain full history. Full systems examination undertaken. 12 lead ECG, bloods, urinalysis. No acute medical issues identified. Review arranged by CMHT. Son contacted to arrange shopping.

• Consultant stopped all medication and excluded any other acute issues liaised with GP

• Re-ablement 7 hrs/ week

Learning•Testing concept

It is possible to provide safe community

alternatives to acute care

•Embed model in existing community services

•Workforce development - new roles

acute and community exposure needed

recruit attitude not aptitude

•Staff ability to manage new levels of risk essential

•Rapid access to all services needed

•Transport – x-ray

Robopractitioner?

Robopractitioner?

Next Steps?

Phase 2 - Further larger pilot (c 9,000 over 75s, 6 months?)

Staff Training and RecruitmentProtocol / Guideline Development / Referral PathwaysLinks with Primary Care / Psychiatry / Social Work IT developmentTelemedicine Evaluation

Phase 2

SUB HEADING TO BE

•JIT lead for all Partnerships – bespoke programmes and thematic •Reshaping Care Improvement Network •National Improvement Measures •Joint Commissioning Strategies 2012- 2020

Change Plans: Supporting Partnerships

Improvement Network

•Established on 1 April 2011

•Programme of events, web ex sessions •E Bulletin

•Regional groups being explored

EVALUATION

•Third sector /community capacity building – proposal under development

•Scottish Centre for Public Health Collaboration

MID YEAR PROGRESS REPORT

•To report on progress with implementation and use of change fund and committed spend •First report end of August 2011, update for December 2011

Margaret.whoriskey@scotland.gsi.gov.uk

http://www.jitscotland.org.uk/action-areas/reshaping-care-for-older-people/change-fund-library-of-

resources/