Care Homes spreading New Care Models - Mark Adams
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Care Homes
from the periphery to the system
spreading New Care Models
Mark Adams
Dan Cowie
Lesley Bainbridge
April 2017
Our Approach: ‘spread’
• 2008 to Vanguard
• Vanguard Years
• Vanguard and Beyond
2008 to Vanguard
Enhanced Health in Care Homes
Hopes, Measurements, Achievements
Reduce avoidable emergency
admissions through education Advanced
Individual
and clinical support improving Care
Assessment
thereby the quality of care. Planning
Initial Results
• 54% reduction in hospital
admissions Management
“Ward
Round’
Plan
Approach
• 56% reduction in A&E
attendance
THE LEARNING: • Frailty is the issue • Care is reactive not proactive • Inequitable health care access • Disempowerment of patients and their families • Multiple GP practices doesn’t work • Lack of advanced and anticipatory care planning • Working in care homes is challenging • Comparable with other studies
Ward Round : Virtual Ward
The Vanguard Years
2015 -2018SETTING UP
[
Successes
• A&E stabilisation - 1% increase [17 patients], anticipated growth 8.4%*
• Non elective admission reduction – urine infections, 2.9%, 19 patients Sep ’16, average
27 per month 15/16
• Prescribing nutritional supplement reduction – 6.5%, [3259] first two quarters of
16/17 compared to same time period 15/16
• Outpatient appointments reduction – 3.7% [205 saved appointments]
Challenges
• Deaths in hospital – 5% increase [7 patients]
• Preferred place of death – data not available for 15/16
• Care plan reviews – number increasing, needs to include preferred place of
death
*based upon 1415 / 1516 comparisonFrailty Summit
Vanguard and Beyond
Better Health People will live and age well as part of their community. If needed, care will be provided
Better Care close to or at home. If hospital is necessary, people will stay as long as needed, but
Sustainability
recover and recuperate in or around their homes.
.
Why? Unemployment +
We are living Our workforce is We can’t afford
deprivation +
longer with more dwindling + to carry on as we People’s Healthy
unhealthy
long term illness needs new skills are
lifestyle choices
Choice, Behaviours and Lifestyles
What? First and foremost we need:
Connecting Communities
Prevention + Wellbeing
Care + Support
Healthy lifestyle choices, behaviours, and self-care abilities; we need to
improve wellbeing through
Enhanced Primary Care
Connecting Communities to people and building assets. Then, only
when needed we will provide
Care and support in and around people’s homes that is timely,
Locality-Based Care
easily accessible with continuity at its core.
How? We will see care delivery at 3 levels:
Enhanced Primary Care with GP practices operating at scale, offering an Interface Model of
extended range of services and access over 7 days as well as list-based care. Care
Locality-based Care of population of 30,000-50,000 in 5 localities
with Integrated community teams of health, social, and voluntary sector
workers wrapped around GP practice groups in co-located settings (e.g.
Community Hubs)
A joined up Interface model of care that links community and
hospital professionals to prevent crisis and manage people with
complex needs (e.g. specialist advice, pathways, access - including
community beds and front door hospital care).How will it work together? Thinking about physical bases
Northumberland Tyne and Wear and North Durham – plan on a page
“A place-based system ensuring that Northumberland, Tyne and Wear and North Durham is the best place for
health and social care”
STP Transformation Areas STP Delivery Areas LHEs Collaboration/ Cross cutting Closing the financial gap
NCM themes
• Ensuring every child has the best start in life Learning
Disability Size of residual financial
NSECH
services – TLP
• Reduce the prevalence of smoking and obesity and Northumberland and (Adults and
challenge by 2021
reduce the impact of alcohol North Tyneside
Children)
PACS / ACO
• Radical upgrade in our approach to ill health prevention
and secondary prevention
£641m
• Enhance people’s ability to self care, increase their self Cancer Financial
esteem and self-efficacy
Alliance and challenge
GHFT and NUTH Strategic
collaboration Delivery
• Roll out Making Every Contact Count (MECC) Newcastle
Gateshead
EHCH and
• Maximise the opportunities to integrate Health and Social
Care MCP/PACS Mental Health
5YFV (Adults Summary Solutions
and Children)
• Implementing the GPFYFV
STFT and
• Improve access to high quality care CHSFT
South Tyneside, partnership
Sunderland and UHND Women (LMS
North Durham and Better
• Acute services collaboration across clinical pathways and
service models MCP Births and
Children’s (0-
19 years)
• Specialist commissioning
Information Technology – Great North Care
Workforce Estates – One Public Estate Accountable and outcome-based systems
RecordNTWND STP ‘Neighbourhood + Communities’ Framework
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