Frail Elderly Care Strategy

Transcription

1 Frail Elderly Care Strategy Document Control: Document Author: Document Owner: Board Of Directors Electronic File Name: Frail Elderly Care Strategy Document Type: Corporate Strategy Stakeholder Consultation: Reader Panel (as described within this document) and Trust Board Approval Level: Board Of Directors Approval Body: Chair of the Board Of Directors Version Reference 1.1 Number: Number: TRAN/MR/120517/1.1 Version Issue Date: May 2016 Effective Date: May 2016 Review Frequency: Three Yearly Method of Dissemination: Intranet Search Keywords: Frail Elderly Care, Comprehensive Geriatric Assessment For Use By: All Staff Version History: Version Date Author Reason V th May 16 Mark Rundle, Senior To originate document Project Manager V th May 16 Mark Rundle, Senior Project Manager Further amendments made following internal Transformation Team discussion V th May16 Phil Weihser, Service Manager / Mark Rundle, Senior Project Initial version of Strategy finalised in support of evidence base and National Best Practice Manager V th May16 Phil Weihser, Service Frailty Criteria definition revised Manager / Mark Rundle, Senior Project Manager V th May 16 Jon Barber Partnership Working Update and other minor changes V1.3 V1.4 Ref: TRAN/MR/120517/1.1 Page 1 of 15

2 CONTENTS 1.0 INTRODUCTION Background Local Health Context The definition of Frail Elderly Links to other Stakeholders Principle Legislation or Guidance Referenced Trust Values Distribution Control STRATEGIC OBJECTIVES Trust Level Objectives Community Objectives Partnership Working Focus on Frail Elderly STRATEGY ROLES AND RESPONSIBILITIES Chief Executive Executive Director Trust Clinical Lead for Frail Elderly Care Matron/Senior Nurse with responsibility for Frail Elderly Care Divisional teams IMPLEMENTATION AND MONITORING OF THE STRATEGY Implementation of the Strategy Monitoring Appendix 1 - Equality Impact Assessment Ref: TRAN/MR/120517/1.1 Page 2 of 15

3 1.0 INTRODUCTION 1.1 Background In our society today, living standards are getting better, care and support is improved, advances in medical and surgical care continue and consequently people are living longer. Whilst many people remain active and well in older age there is also a greater chance of long-term medical conditions, frailty, dementia, and disability or need greater health and social care input. The recent Commission on Hospital Care for Older People (Health Service Journal, March 2015) recognised that people aged 65 in England can expect to live two more decades. By 2030 projected life expectancy will be 88 for men and 91 for women. One in four hospital inpatients has dementia, and 1 in 3 adults admitted acutely to hospital are in the last year of their life. The care of older people in acute settings continues to be a priority area with most Trusts facing pressures from increased A&E attendances at the front door of the hospital and delayed transfers of care at discharge. Traditionally health and social care has been seen as silos and medical care has been focussed on the management of patients with single conditions or pathways. However, older people can have a number of conditions and require a coordinated, personcentred approach requiring a different type and level of support. To get this right we need to look across the whole health and social care system and work in an integrated way to ensure the right care is given in the right place at the right time. 1.2 Local Health Context The 2014 NHS Great Yarmouth and Waveney Clinical Commissioning Group (CCG) 5 Year Strategic Plan details a number of the challenges we face as a health and social care economy. Our population is growing, people are living longer and often with complex health and social care needs such as diabetes, dementia and heart problems. Evidence shows that the local population has a particularly high use of acute hospital services including a high proportion of admissions from diseases that could be managed outside hospital. Closer and more integrated working is needed with our partners to make better use of existing services and to ensure the right care is provided in the right place at the right time. In October 2014, NHS England produced its longer term view of the NHS (Five Year Forward View [FYFV]) and how over the next five years health services need to change and how we now need a more engaged relationship with patients, carers and citizens so we can promote wellbeing and prevent ill-health. This is also within the context of the growing funding gap meaning the NHS could face an estimated thirty billion financial shortfall by Ref: TRAN/MR/120517/1.1 Page 3 of 15

4 JAMES PAGET UNIVERSITY HOSPITALS NHS FOUNDATION TRUST The diagram below provides an overview of the demographics and health challenges for the local health system: The chart below shows the projected increase in the number of people aged over 65 within the catchment of our local health system: Number of people aged 65+ in Great Yarmouth and Waveney CCG area (ONS Population Projections 2012) Female Male Persons Ref: TRAN/MR/120517/1.1 Page 4 of 15

5 Further data from the Public Health Information Team indicated that between 2009 and 2014 there has been an 11% increase in over 65s within the local population: Responding to these challenges as a whole health and social care system is vital. The care for older people starts with prevention with an emphasis on healthy aging and exercise. Primary care and community clinicians assess and manage older people with multiple long term conditions. Patient advocates, voluntary sector, support workers and carers help the patient navigate the different areas of the care system. First responders from the ambulance service work to see if the older person can be treated safely and successfully in their home. If acute hospital care is required, timely decision making from senior clinicians facilitates the right treatment at the right time. 1.3 The definition of Frail Elderly Frail elderly is theoretically defined as a clinically recognisable state of increased vulnerability resulting from aging-associated decline in reserve and function across multiple physiologic systems such that the ability to cope with every day or acute stressors is comprised. There are several clinical indicators suggestive of frailty like dementia, incontinence, falls etc. and reviewing literature there are different criteria adopted by different trust to define frailty. However the following criteria are simple and easy to use and are based on clinical evidence; Aged 75 and presenting with 1 or more of the following: Falls Reduced Mobility Altered Cognition (delirium/dementia) Incontinence (esp. faecal) New Stroke Care home resident (residential home or nursing home) 1.4 Links to other Stakeholders Ref: TRAN/MR/120517/1.1 Page 5 of 15

6 The CCG commissioning framework describes how all parts of the system will be developed to ensure that to work in partnership with continuing health care, integrated care, the statutory and voluntary sector and community services to re-engineer the community care model to enable more support for patients and informal carers in their home care settings. The Trust is an active participant in the regional Frail Elderly discussion as part of the Most Capable Provider Network and on the 25 th November 2015 hosted a Frail Elderly Service Review Workshop. The workshop included representation from a number of regional stakeholders including: Age UK (Suffolk) East Coast Community Healthcare East of England Ambulance Trust Great Yarmouth Borough Council Great Yarmouth and Waveney CCG IC24 Norfolk and Suffolk Foundation Trust Norfolk County Council Social Services Orbit Independent Living (East) Suffolk Coastal and Waveney District Councils Think Big With key points captured by the group including: More over 75 s are living in their own home, and on their own Services need to integrate (remove silo working ) with provision of a single point of access All providers need to be able to share information which is meaningful, accurate and timely Workforce development is needed for Health Visitors, General Workers, Key Workers, Care Home Staff, Hospital Staff and Out of Hospital Teams We should proactively promote health keeping well, living with long term conditions staying active, socialising and interacting The Trust continues to work with all key partners on developing the Great Yarmouth and Waveney Sustainability and Transformation Plan (STP). The emerging plan has a Healthy Old Age priority. This will develop and deliver a cohesive strategy for older people across primary, community, acute health and social care. The local STP has robust links to the larger Norfolk and Waveney STP. In addition a group has been established to enhance the services delivered between primary care and the acute hospital this has a focus on the services provided to the frail elderly. 1.5 Principle Legislation or Guidance Referenced There is a plethora of guidance and publications relating to Frail Elderly Care. This strategy has been developed making reference to the following key national publications: Fit for Frailty Parts 1 and 2, British Geriatrics Society, Ref: TRAN/MR/120517/1.1 Page 6 of 15

7 Falls in Older People Guidance, National Institute for Clinical Excellence (NICE), Changing Care Pathways with Point of Care Diagnostics, Oxford Healthcare NHS Trust (Dr Dan Lasserson), 2015 Acute hospitals and Integrated care from hospitals to health systems The King s Fund, Safe, compassionate care for frail older people using an integrated care pathway NHS England February Five Year Forward View (FYFV) - NHS England, October 2014 Quality care for older people with urgent & emergency care needs Silver Book British Geriatrics Society 2012 The evidence base for integrated care Kings Fund & Nuffield Trust, 2011 Examining New Options and Opportunities for Providers of NHS Care - The Dalton Review, December 2014 NHS Great Yarmouth and Waveney Clinical Commissioning Group (CCG) Five Year Strategic Plan, June 2014 Facing the Future: Smaller Acute Providers. Monitor June 2014 Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry - Robert Francis QC, February 2013 Transforming Urgent and Emergency Care Services in England - Sir Bruce Keogh, November A Promise to learn a commitment to act: Improving the safety of patients in England. (Berwick Review into Patient Safety) Don Berwick, August Hard truths, the journey to putting patients first Department of Health, 2012 Hospitals on the edge? The time for action Royal College of Physicians, 2012 The Deloitte Centre for Health Solutions Better care for frail older people working differently to improve care, 2014 British Geriatrics Society Guidelines, Best Practice Guide 2010 British Geriatrics Society in association with the Royal College of General Practitioners and Age UK. Fit for Frailty. London: British Geriatrics Society, 2014 Birmingham and Solihull Frail Elderly Programme Plan, January The Academy of NHS Fabulous Stuff Acute Care for Frail older people in Leicester University Hospital of Leicester NHS Trust September Older People in Acute Settings NHS Benchmarking Report April 2015 Transforming urgent and emergency care services in England NHS England August 2015 Developing an ideal old age service RC Psychiatrists June Dr PJ Connelly & Dr Nilika Perera. The Norfolk Principles of Care, October NHS England End of Life Care Trust Values This Strategy conforms to the Trust s values of putting patients first, aiming to get it right, recognising that everybody counts and doing everything openly and honestly. The Strategy incorporates these values throughout and an Equality Impact Assessment is completed to ensure this has occurred. 1.7 Distribution Control Printed copies of this document should be considered out of date. The most up to date version is available from the Trust Intranet. Ref: TRAN/MR/120517/1.1 Page 7 of 15

8 2.0 STRATEGIC OBJECTIVES 2.1 Trust Level Objectives Through implementing this Strategy, the Trust will fully implement a model of care (based on the already established principles of an Ambulatory approach) for Frail Elderly Patients. This model of care will consist of the following objectives: Objective 1 Establish a Multidisciplinary Virtual Frail Elderly Team which will be clinician-led (in the absence of a Geriatrician) and include support from Nursing, Occupational Therapy, Physiotherapy, Mental Health and Social Care and support staff/rehab assistants. Objective 2 Implement a clinical review (which includes access to medical records to determine previous history and investigation results) to establish a treatment plan based around the introduction of Comprehensive Geriatric Assessment (CGA) and prescreening tool Prisma7 (this information will form an intrinsic part of the nursing bluebook; subsequently captured electronically to enable targeted utilisation of Virtual Frail Elderly Team and KPI monitoring) Objective 3 Ensure frail elderly patient cohort is placed in most appropriate area for sufficient care needs (i.e. treat underlying admission cause as opposed to holistic frailty treatment). Objective 4 Implement a tailored assessment within the confines of the front door of Acute Medicine that provides direct access to diagnostic tests (including X-ray, electrocardiogram, near-site blood testing and urinalysis). Objective 5 Wherever possible, the patient will be discharged back to their normal place of residence within a period of less than 72 hours (with access to all the community support services they need provided by our community partners in a timely manner) Objective 6 After initial assessment, patients requiring further care will be transferred to an appropriate medical ward as an inpatient, whereby the same Virtual Frail Elderly Team will continue to provide clinical support and on-going patient care; in turn enabling expedited discharges. 2.2 Community Objectives The hospital continues to work closely and develop approaches with East Coast Community Health (the community provider) which provides a wide range of out of hospital services through a multidisciplinary team. This effective partnership supports a broad range of patient groups including the frail elderly. The overall objective is to support people to continue to live in their home. This has been in part responsible for the much reduced conveyance rate by ambulance to the hospital. For example Great Yarmouth and Waveney CCG has the highest number of responses per 1000 residents for falls but has the lowest conveyance rate to hospital at 47.59%. This is likely to impact many frail elderly people in the local area. Ref: TRAN/MR/120517/1.1 Page 8 of 15

9 2.3 Partnership Working Focus on Frail Elderly There are a number of areas where the Trust is aligning its approach to delivering services for the frail elderly to those services delivered by others. This is in recognition that a system wide approach is required to both focus on preventative approaches to maintain people living at home and support services wrapped around the needs of the individual when they are discharged more expediently from the hospital. Some of the approaches to which this strategy aligns to are outlined below; Most Capable Provider (MCP) System wide Out-of-Hospital Service redesign The Trust is working with 5 other provider organisations, including social care, to integrate services. This forms part of the MCP commissioning intention for out-ofhospital services. It builds upon the multidisciplinary teams made up of health and social care professionals whose aim is to provide care at home whenever it is safe, sensible and affordable to do so. The MCP specifically includes frailty as an area for system wide service redesign to provide services around the patient, focusing on individual need and helping people to regain independence. This will include a key role for the third sector in supporting people to live at home in both a preventative and post discharge role. These plans are being developed. These plans are well advanced and the Trust s strategy is aligned to the delivery programme set out in the MCP model. In particular the Trust has a signed Memorandum of Understanding with the community provider (East Coast Community Healthcare), All Hallows Hospital, Norfolk and Suffolk Foundation Trust and both Norfolk and Suffolk County Council s Social Care Services. It is the strategic intention to develop a Joint Venture between key providers to deliver these services, and these plans are well advanced. Sustainability and Transformation Plan (STP) The Trust is also a key player partner in the Great Yarmouth and Waveney STP (GYWSTP) supporting the Norfolk and Waveney STP. A key priority of the GYWSTP is Healthy Old Age and is engaging a wide range of partners and will include primary care and the voluntary sector. The Trust s Frail Elderly and Care Strategy is aligned to the objectives of the wider system strategies. This ensures that the new pathways for delivering services to the frail elderly within the hospital are supporting, and supported by, an integrated system approach. Partnership with Primary Care. The Trust is developing its partnership approach with primary care and joint discussions have identified the needs of the frail elderly to be an area where closer working would benefit the patient and the system. These plans are being developed but will be focused on maintaining, where appropriate, independence and living at home through consideration of new technologies such as telehealth. Other partnerships The Trust will seek to engage support and partnerships with areas of National Best Practice (such as the Community-based Emergency Medical Units set up by Oxford Ref: TRAN/MR/120517/1.1 Page 9 of 15

10 University Hospitals); with the intention of adopting innovative ways of managing the medical frail elderly patient cohort within the community in turn ensuring the patient is treated in the right place, at the right time avoiding unwarranted hospital admissions. The key objective is reduced dependency of patients resulting in fewer admissions to long term care providers and actively seeking re-enablement. By the adoption of the above whole-systems approach it is recognised in literature that multi-dimensional assessment and multi-agency management of older people leads to better outcomes provided they are delivered in an integrated manner across primary and secondary care, and health and social care interface: The approach will increasingly focus on the use of new technologies such as telemedicine. The implementation of virtual clinics, telephone follow-ups and other such approaches will also service to provide more efficient and timely services to meet the needs of the frail elderly. 3.0 STRATEGY ROLES AND RESPONSIBILITIES 3.1 Chief Executive Although the Chief Executive has ultimate responsibility for the implementation of this Strategy in ensuring its requirements are met, responsibility has been delegated to the Executive Director. Ref: TRAN/MR/120517/1.1 Page 10 of 15

11 3.2 Executive Director The Director of Operations is responsible for providing Board Level Leadership for Frail Elderly Care. They will ensure that there are Trust wide policies, processes and structures to support the delivery of assurance regarding the quality of care. 3.3 Trust Clinical Lead for Frail Elderly Care The Trust Clinical Lead for Frail Elderly Care has overall responsibility for the development and implementation of this strategy and the trust approach to care at end of life. 3.4 Matron/Senior Nurse with responsibility for Frail Elderly Care The Matron/Senior Nurse with responsibility for Frail Elderly Care will work collaboratively with the Clinical Lead in delivering this strategy and ensuring the nursing and midwifery contributions are made. They will also ensure that specialist care teams provide clinical leadership and oversight to the specifics of Frail Elderly Care within the Trust and also that there is alignment with care across Great Yarmouth and Waveney. 3.5 Divisional teams The Divisional Teams will be responsible for the implementation of this strategy and monitoring of care through existing frameworks and audit programmes. 3.6 All staff All staff employed by the Trust have a responsibility for the quality of the service which they provide, and all clinically qualified staff are individually accountable for ensuring they audit their own practice in accordance with their professional codes of conduct and in line with the standards set out within this document. 4.0 IMPLEMENTATION AND MONITORING OF THE STRATEGY 4.1 Implementation of the Strategy The Frail Elderly Care Project Team led by the Executive lead will ensure the implementation of this strategy through a work programme designed around the Transforming Frail Elderly Care. This strategy covers a one year period. 4.2 Monitoring An audit programme will be developed to ensure regular review of practice and compliance. This will report to the Transformation Programme Board. An Annual report will be developed and will report to Safety Quality Governance Committee. Ref: TRAN/MR/120517/1.1 Page 11 of 15

12 Appendix 1 - Equality Impact Assessment Policy or function being assessed: Frail Elderly Care Strategy Department/Service: Assessment completed by Phil Weihser / Mark Rundle Date of assessment: May Describe the aim, objective and purpose of this policy or function. 2i. Who is intended to benefit from the policy or function? To set the direction of travel in delivering Frail Elderly Care within the James Paget Hospital and community. Staff x Patients x Public Organisation x 2ii How are they likely to benefit? Improved, consistent and standardised delivery of care for Frail Elderly Patients 2iii What outcomes are wanted from this policy or function? High quality and consistent care for people who are frail within the hospital For Questions 3-11 below, please specify whether the policy/function does or could have an impact in relation to each of the nine equality strand headings: 3. Are there concerns that the policy/function does due to their race/ethnicity? 4. Are there concerns that the policy/function does due to their gender? 5. Are there concerns that the policy/function does due to their disability? Consider Physical, Mental and Social disabilities (e.g. Learning Disability or Autism). 6. Are there concerns that the policy/function does due to their sexual orientation? Ref: TRAN/MR/120517/1.1 Page 12 of 15

13 7. Are there concerns that the policy/function does due to their pregnancy or maternity? 8. Are there concerns that the policy/function does due to their religion/belief? 9. Are there concerns that the policy/function does due to their transgender? 10. Are there concerns that the policy/function does due to their age? 11. Are there concerns that the policy/function does due to their marriage or civil partnership? 12. Could the impact identified in Q.3-11 above, amount to there being the potential for a disadvantage and/or detrimental impact in this policy/function? 13. Can this detrimental impact on one or more of the above groups be justified on the grounds of promoting equality of opportunity for another group? Or for any other reason? E.g. providing specific training to a particular group. Y N x Where the detrimental impact is unlawful, the policy/function or the element of it that is unlawful must be changed or abandoned. If a detrimental impact is unavoidable, then it must be justified, as outlined in the question above. Y N x Where the detrimental impact is unlawful, the policy/function or the element of it that is unlawful must be changed or abandoned. If a detrimental impact is unavoidable, then it must be justified, as outlined in the question above. 14. Specific Issues Identified Please list the specific issues that have been identified as being discriminatory/promoting detrimental treatment 1. None Ref: TRAN/MR/120517/1.1 Page 13 of 15 Page/paragraph/section of policy/function that the issue relates to

14 3. INSERT HERE Proposals How could the identified detrimental impact be minimised or eradicated? If such changes were made, would this have repercussions/negative effects on other groups as detailed in Q. 3-11? 16. Given this Equality Impact Assessment, does the policy/function need to be reconsidered/redrafted? 17. Policy/Function Implementation N/A Y Y N N Upon consideration of the information gathered within the equality impact assessment, the Director/Head of Service agrees that the policy/function should be adopted by the Trust. Please print: Name of Director/Head of Service: Sue Watkinson Title: Director of Operations Date: May 2016 Name of Policy/function Author: Phil Weihser Title: Service Manager (Emergency) Date: May 2016 (A paper copy of the EIA which has been signed is available on request). 18. Proposed Date for Policy/Function Review May 2017 Please detail the date for policy/function review (3 yearly): May Explain how you plan to publish the result of the assessment? (Completed E.I.A s must be published on the Equality pages of the Ref: TRAN/MR/120517/1.1 Page 14 of 15

15 Trust s website). Standard Trust process 20. The Trust Values In addition to the Equality and Diversity considerations detailed above, I can confirm that the four core Trust Values are embedded in all policies and procedures. They are that all staff intend to do their best by: Putting patients first, and they will: Provide the best possible care in a safe clean and friendly environment, Treat everybody with courtesy and respect, Act appropriately with everyone. Aiming to get it right, and they will: Commit to their own personal development, Understand theirs and others roles and responsibilities, Contribute to the development of services Recognising that everyone counts, and they will: Value the contribution and skills of others, Treat everyone fairly, Support the development of colleagues. Doing everything openly and honestly, and they will: Be clear about what they are trying to achieve, Share information appropriately and effectively, Admit to and learn from mistakes. I confirm that this policy/function does not conflict with these values. Ref: TRAN/MR/120517/1.1 Page 15 of 15