Test and Learn Community Frailty Service for frail housebound patients and those living in care homes in South Gloucestershire

Transcription

1 Test and Learn Community Frailty Service for frail housebound patients and those living in care homes in South Gloucestershire Introduction This document introduces South Gloucestershire Clinical Commissioning Group s (CCG) plans for a proposed community frailty service pilot in South Gloucestershire. This service forms part of the CCG s plans for improving urgent and emergency care services. For more information, please visit Our proposal is to pilot a specialist community frailty team, led by a doctor with special interest in frailty. It will focus on those patients with frailty living in care homes and housebound patients in order to improve their quality of life. The development of the frailty service has been initiated by our GP member practices, and is seen as a high priority service area for development. It also aligns with the South Gloucestershire Joint Strategic Needs Assessment and feedback the CCG has received from public surveys. Frailty is a clinically recognised state of increased vulnerability it results from ageing associated with a decline in the body s physical and psychological reserves. Older people living with frailty who have a health challenge such as an infection, constipation or urine retention are at greater risk of dramatic deterioration in their physical and mental wellbeing. Challenges can also arise when older people experience a fall or have a change in their medication. By providing tailored services for these patients, we hope to improve their physical capabilities, enhance their support networks, improve their ability to manage activities of daily living, promote their independence, reduce the risk of falling, and reduce the risk of admission to hospital. The proposal The proposed community frailty service will promote a patient-centred approach to the identification and management of patients living with frailty, based on the principles of a Comprehensive Geriatric Assessment (CGA) with a focus on improved functional capability, independence and living well for longer. CGA involves a holistic assessment of an individual s health and social needs and has been shown to improve health outcomes. The design of the service has been based on evidence from other successful services around the country adjusted to suit our local circumstances. The service will sit alongside and enhance South Gloucestershire s current planned rehabilitation service, rapid response services and the active ageing initiative provided by Sirona Care & Health. This will enable a seamless transfer to the most appropriate service to meet the individual s need.

2 We will work closely with our providers Sirona and North Bristol NHS Trust (NBT), as well as GP practices and other partners involved in caring for those living with frailty. The service will be trialled as a test and learn pilot for 12 months across two clusters Yate and Kingswood South. The specialist community frailty team will be led by a GP with a special interest (GPSI) in geriatrics. It will consist of a multidisciplinary team specialising in people who have frailty and is likely to include an Occupational Therapist, a Physiotherapist, a Dietician, specially trained Health Care Assistants, a Psychiatric Nurse for the elderly, a Social Worker and admin support. The aim is to begin the pilot in October If the pilot is successful we will aim to expand the service to all areas in South Gloucestershire. Proposed Delivery Model As part of the test and learn process, the following model is suggested to test for effectiveness and sustainability. Please note this is an outline and is subject to change: The service will be piloted on a test and learn basis for 12 months The scope of the service will be for patients registered with a South Gloucestershire GP practice who are living in care homes, or who are housebound, and are known to be living with frailty or are displaying frailty symptoms The service will start in two areas of South Gloucestershire: Yate and Kingswood South The service will be available five days per week, during office hours. Outside of these hours Sirona Care & Health will manage any urgent interventions required with Brisdoc s out of hours GP service. The service will be based in a primary/community setting with links to GP out-ofhours services and a rapid access clinic for older people located in Cossham Hospital Accessing the service referral criteria will be in place. Patients suitable/advised for CGA following frailty assessment to be referred to the frailty team directly from care homes, via the community care team, from the registered GP or via the Multi-disciplinary Team (MDT) meetings. An appropriate CGA will be undertaken within one working day The frailty team will provide routine telephone advice during office offices and, where needed, will offer urgent telephone advice within one hour (during normal office hours) The team will be led by a GPSI in geriatrics it is proposed this is a shared role with the Complex Assessment and Liaison Service (CALS) team, which is led by Care of the Elderly consultants working for North Bristol NHS Trust The frailty team will link closely with GP out of hours services where patients require on-going care over weekends The CALS team will provide immediate telephone access to advice from the oncall Care of the Elderly consultant of the day to support the frailty team The CALS team will provide support and supervision (details still to be agreed).

3 Our key aims: The key aims of the pilot service will be to provide a patient-centred, gold standard approach to management of patients living with frailty in the two test and learn areas that will: Provide a rapid and timely CGA to those patients in care homes and the housebound, who have symptoms of frailty and who have been identified as benefitting from a CGA. Support those living with frailty to achieve prolonged quality of life, improved functional capability and independence, and help keep patients living with frailty from slipping into the more severe frail (2%) cohort of patients Provide a focussed approach to reducing emergency admission of patients living in care homes and housebound patients Provide support to care homes to improve the care offered to those patients living with frailty, with a particular focus on end of life so that patients do not get admitted into acute settings against their wishes. We anticipate that approximately 100 fewer patients per year will need to be admitted to hospital as a result of this service. Case for change: The South Gloucestershire Urgent and Emergency Care Strategy states that an ageing population with increasingly complex needs is leading to ever rising numbers of people needing urgent or emergency care. This is a particular issue in South Gloucestershire where the number of people over the age of 85 years of age is projected to increase by 27% by 2018 and by 153% by The strategy also warns that as people live longer, more people will require treatment and support for life changing diseases including dementia, diabetes and other long term conditions (and frailty). With sufficient and well organised resources in the community and sharing of information between different services, treatment and support can be provided effectively in a planned way. This will help to avoid unnecessary admissions and also to reduce the time spent in hospital for those who do need to be admitted. The strategy describes the need for a system wide approach and the proposed frailty service would assist the CCG to achieve this vision. Benefits: The service is expected to deliver the following benefits: Improved quality of life for patients in care homes and the housebound Decrease in the number of injuries due to falls in people aged 65 and above A reduction in delayed transfers of care from hospital Reduced rehabilitation in the community as a result of avoided admissions and more stable patients Reduce admissions at NBT from care homes by 35% Reduce A&E attendances at NBT from care homes for the over 75s by 35% Reduce length of hospital stays for patients aged over 65 Contribute to the national and local requirement to achieve 95% of people who attend A&E to be admitted or discharged in four hours

4 More standardised levels of care and governance at a higher level across the care home providers Better educated care home workforce with increased skills Specialist multi-disciplinary frailty team based in the community Released primary care capacity Freeing up capacity in secondary care Reduced social care costs for individuals and South Gloucestershire Council. Improvements in care homes to include: Increase in care homes receiving regular review visit by a frailty team member Increase in residents with advanced frailty care plans Reduction in the number of patients admitted from care homes following a fall Increased care homes / staff numbers who have received recent training/support Increased care homes who have received dementia awareness training for care home staff Enabling people at end of life to remain in their home rather than be admitted to hospital Reduction in waits for care homes to reassess patients in hospital. What will success look like? Success will be a community based frailty service that is fully integrated with other services for the frail and elderly in the community and with seamless links and pathways with community care and secondary care provision. The service will be led by a doctor and provide a dedicated team of therapists and staff who are skilled and trained in the management of people living with frailty. The service will offer rapid access to advice and timely comprehensive CGAs, in line with British Geriatric Society (BGS) guidelines. Staff across the community will be familiar with the concept of frailty assessment where appropriate in order to identify which patients require rapid intervention from the frailty team and a comprehensive geriatric assessment. Care homes will be working closely with the frailty team, with the outcomes of reducing admissions, improving care for residents with frailty, encouraging independence and maximising physical capabilities, and improving end of life experience for patients. Housebound patients who are living with frailty will be identified and care plans agreed as appropriate. Timescales: The service is proposed to go live in October 2015 There will be a mid-term review of the service A final evaluation of the service will take place after a year. Patient and Public Involvement

5 South Gloucestershire CCG has a statutory duty to involve patients, carers and the public in the development of commissioning plans to change and develop local health services. The right of patients to be involved in the planning and development of health services is also set out in the NHS constitution. Regardless of the legal requirement, South Gloucestershire CCG is committed to PPI being at the heart of its work. We will continue to listen and act upon patient and carer feedback at all stages of the commissioning cycle because of the added value of commissioning services that are informed by the experiences and aspirations of local people. There is a Patient and Public Involvement and Communications Plan for this pilot, which sets out in greater detail the intentions to involve and engage patients and public within the pilot. In summary this sets out that we will ensure that: The pilot will retain a person-centred focus All sections of the populations within the pilot have the opportunity to influence and comment on the design and delivery of the pilot There will be timely feedback on engagement describing who we engaged, what we heard, and how the feedback has influenced the work People have a good understanding of the pilot, where it is in operation, how people can use it, what people can expect from it, and how we anticipate learning from the pilot Any learning taken forward from the pilot takes account of the views of patients and the public. Equalities The public sector equality duties outline how South Gloucestershire CCG as a public body must, in the exercise of its functions, have due regard for the need to: Eliminate discrimination, harassment, victimisation and any other conduct that is prohibited by or under the Equality Act 2010; Advance equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it; Foster good relations between persons who share a relevant protected characteristic and persons who do not share it. An equality impact assessment will be undertaken to inform who we should be continuing to involve in this project, and to identify potential inequitable impacts on any groups with protected characteristics of the implementation of the service, and any mitigation required. How you can get involved: Please visit our website follow us on us via contactus@southgloucestershireccg.nhs.uk or write to us at the following address: South Gloucestershire Clinical Commissioning Group, Corum 2, Corum Office Park, Crown Way, Warmley, South Gloucestershire, BS30 8FJ.