FRAILTY PATIENT FOCUS GROUP

Transcription

1 FRAILTY PATIENT FOCUS GROUP Community House, Bromley 28 November am to 12noon In attendance: 7 Patient and Healthwatch representatives: 4 CCG representatives: Dr Ruchira Paranjape went through the presentation slides which explained the current frailty pathway and the establishment of the Orpington Integrated Unit (frailty unit). Questions and comments were invited. These have been separated into the key themes that came through. 1. Co-ordination of Care 2. The Pathway 3. Staffing 4. Orpington Integrated Unit 5. Discharge and Ongoing Care 6. Carers 7. Voluntary (Third) Sector 8. Geriatric Support in the Orpington Integrated Unit 9. Communications 1. CO-ORDINATION OF CARE Q. Who is responsible for making all these connections for the patients as they go through the Proactive Care and Frailty Pathways? A. The Multi-Disciplinary Team (MDT) Liaison Co-ordinator. This is a nonclinical role but it is someone who is able to work with clinical colleagues and co-ordinate who needs to be where and when for each individual patient going through the MDT assessment. For the MDT meetings, they will ensure that all the paperwork is in place and that the right people are part of the discussion, depending on the needs of that particular patient. 1

2 Patients on the Proactive Care Pathway will have an Integrated Care and Support Plan which is shared with them. Their care will be overseen by an assigned clinical lead (based on their principal care needs), and coordinated by the MDT Liaison Coordinator with support from the Care Navigators. If required, the Integrated Care and Support Plan will be reviewed at MDT meetings. Q: Where are Community Matrons based? A: Community matrons are based in the community (employed by Bromley Healthcare) and are involved in a holistic assessment of the patient. Q: What is the difference between Care Navigators and an administrator? A: Care Navigators will work closely with the MDT Liaison Coordinators (whose primary focus is on organising the coordination of patient care), and will help both patients and professionals to navigate the health and care system in Bromley. The role includes a focus on a non-medical approach to patient management and supporting and sign posting appropriate patients to access third sector services, including access via a new social prescribing portal. The clinical needs of patients will always be looked after by an appropriately qualified health and care professional. Administrators are responsible for ensuring all paperwork relating to patient care is appropriately completed and filed, and will not necessarily interact directly with patients around their non-medical care needs. Q: How will social care be involved and how will health and care professionals know what social care services are available? A: The CCG continues to work with the London Borough of Bromley and social care is still an important part of the Proactive Care and Frailty Pathways and social care are represented on the relevant Boards within the overarching governance structure. Senior representatives from Social Care have contributed to the design of the Proactive Care and Frailty Pathway. The London Borough of Bromley has agreed that a Care Manager will attend the Proactive Care Pathway MDTs, where relevant. If a patient is known to social care, the MDT co-ordinator can also speak to the care manager in advance of the MDT meeting. If at the MDT meeting it is felt that a social care 2

3 assessment (for the patient or the carer) then a referral would be made in the usual way. Both the Holistic Assessment carried out by the Community Matron as part of the Proactive Care Pathway, and the Comprehensive Geriatric Assessment carried out when patients are discharged from the Orpington Integrated Unit include a social care assessment to ensure the social needs of each patient are considered and addressed. Additionally, the introduction of the new Social Prescribing Portal by the Bromley Third Sector will include a directory of all third sector services available to Bromley residents. The Care Navigators will also be working closely with the health and care professionals in their assigned Integrated Care Network (there are three in Bromley, each covering a third of the population) to ensure they are aware of all the non-medical support services available to patients. Q: Will the Community Matrons have capacity to deal with all frail patients requiring support on these pathways? A: As part of the Proactive Care Pathway, a holistic assessment will be carried out by a Community Matron with the patient, and their family or carer, prior to their health and care needs being discussed by a MDT. The Community Matron will present this assessment at the MDT. There are already Community Matrons assigned to each GP practice in Bromley and they will already be seeing some of the same patients as part of their existing caseload. These Community Matrons work for Bromley Healthcare, who provide the community services to the residents of Bromley. Bromley Healthcare know how many MDT meetings will be carried out each month and have ensured there will be enough Community Matrons to carry out the holistic assessments, attend MDTs and support the Proactive Care Pathway. Q: What would happen if a patient needs this support over the weekend? A. Patients who are on the Proactive Care Pathway will have an Integrated Care and Support Plan that includes the contact details of all the health and care 3

4 professionals involved in providing care to the patient. This will include the contact details of who to contact over the weekend and in the evenings. If the health and care professional who visits the patient out-of-hours has not been previously involved in their care they will be able to refer to the Integrated Care and Support Plan that is held by the patient to understand what care is already being provided and by whom. Additionally, there are already existing out-of-hours GPs and community outof-hours services. 2. THE PATHWAY Q: How will you ensure the voluntary (third) sector has the capacity to meet the needs of the patients? A: All Bromley health and care providers, including the third sector have agreed to work closely together to deliver integrated care in Bromley, and the third sector organisations in Bromley are working with the CCG and our partners to play a greater role in providing health and social care to Bromley residents. Local third sector organisations have formed a federation called the Bromley Third Sector Enterprise to better coordinate third sector care for patients. The Care Navigators who will help both patients and professionals to navigate the health and care system in Bromley are employed directly by the Third Sector, and their role includes a focus on a non-medical approach to patient management and supporting and sign posting appropriate patients to access third sector services, including access via a new Social Prescribing Portal. This portal will help manage the referrals into the third sector services and as part of the governance over the Integrated Care Networks (ICNs) there is performance monitoring which will include the time taken for a patient to be referred to a service (including third sector non-medical services), as well as the time taken for the patient to then receive / gain access to that service. This will help the CCG to understand if they need to work with the third sector to provide additional capacity to meet the needs of the patients. Q: What difference will these pathways make and why are they being put in place? 4

5 A: Long term conditions are increasing, against a backdrop of a growing older population, which is creating increasing demand for the local health and social care economy. There is growing gap between demand and affordability which requires transformative action to resolve. The CCG is putting in place these changes as part of a national drive to improve quality, improve the health and wellbeing of Bromley residents, and improve efficiency of services. These changes will help the CCG to better manage the growing demand on the health and care system, whilst also improving health outcomes and reducing variations in the level of care provided. 3. STAFFING Q. What are the new posts being put in place to support these pathways, and what roles and responsibilities will these individuals have? A: There are several new roles being introduced to support the new ways of working. Most of these roles have already been recruited to and are summarised as follows: MDT Liaison Coordinator: This role has a primary focus on the organisation of the MDT meetings and the management of the patient through the process, including ensuring referrals have taken place and where necessary coordinating the care of the patients. Care Navigator: The Care Navigators will work closely with the MDT Liaison Coordinator and Community Matrons, helping both patients and professionals navigate the health and care system in Bromley. The role includes a focus on a non-medical approach to patient management and supporting and sign posting appropriate patients to access third sector services, including access via a new social prescribing portal. Care Navigator Manager: This new role acts as a point of management to the Care Navigators in the Proactive Pathway as well as having responsibilities with the wider Frailty pathway. MDT GP Chair: Each of the MDT GP Chair roles is aligned to one of the new emerging Integrated Care Networks in Bromley, and a key element of 5

6 this role will be in providing clinical leadership to the MDT meetings and providing clinical judgement and oversight to the case finding by other health and care professionals to ensure the right patients are identified for the integrated case management. Mental Health Professional: This is a new post which has been developed with local partners to enhance the Out of Hospital Transformation in Bromley and to provide support to the Proactive Care and Frailty pathways. Interface Geriatrician: This role will work across community and acute sectors (PRUH and Orpington sites), with most of their clinical sessions being community based. The remit includes working with MDTs both in the acute trust and within the three ICNs; this includes being a named geriatrician lead for one of the three ICNs. Social Prescribing Administrator: This role is responsible for the operational delivery of the web-based online Bromley Social Prescribing Directory - Bromley Connect for Wellbeing - as a quality assured and upto-date source of information providing a referral system for the Bromley ICNs. The role will require proactive engagement with the MDT Liaison Coordinators, Care Navigators and other professionals within the ICN MDTs to raise awareness of and stimulate interests in and usage of the Bromley Social Prescribing Directory. Q: How will the Orpington Integrated Unit be staffed? A: The Orpington Integrated Unit will be staffed by Geriatricians, Junior Doctors, Nurses, Therapists, Health Care Assistants, Transfer of Care Bureau staff (including a Care Navigator Manager, social workers and other relevant support staff), and other relevant staff required, such as porters, administrative clerks etc. Q: Will the wards in the Orpington Integrated Unit have good leadership to ensure the wards do not become dependent on a high number of temporary staff? A: The PRUH have already recruited a number of the senior posts as part of their workforce plans, and are continuing to recruit to relevant posts. The Orpington Integrated Unit will be staffed by a combination of existing staff and 6

7 newly recruited staff. We agree that there needs to be consistent and experienced staff working in the unit. 4. ORPINGTON INTEGRATED UNIT Q: Will there be criteria about how long people stay in the Orpington Integrated Unit? A: Wherever possible health and care professionals will endeavour to treat a patient in their home / permanent place of residence and minimise admissions to the Orpington Integrated Unit. Geriatricians in consultation with the patient s GP will decide who can be admitted to the Orpington Integrated Unit. This includes patients with a known diagnosis or ongoing needs but cannot be treated at home, requiring a stay of less than approximately seven consecutive days. Q What happens to patients who do not respond to treatment whilst in the Orpington Integrated Unit for a few days, and who need further rehabilitation? A: Patients whose condition escalates whilst in the Orpington Integrated Unit and require care in an acute setting will be transferred to the PRUH. Those patients who are assessed as needing longer on-going care will be moved to the appropriate care setting. Q: Are there going to be any single units? A: The final designs for the Orpington Integrated Unit are with the PRUH. Once these are known we can share these. Q: Are there going to be any chairs within the Orpington Integrated Unit? It is hard for elderly people to sit in chairs for any length of time. A: The Orpington Integrated Unit will have chairs at the side of the beds. It has been designed in collaboration with people who work in elderly care so it is a suitable facility to meet the needs of the elderly population it will serve. 7

8 5. DISCHARGE AND ONGOING CARE Q: Once a patient is discharged from the Orpington Integrated Unit, who will stay in touch with them in the community to make sure they have all the help needed post discharge? A: Discharge from the Orpington Unit will be coordinated by the Transfer of Care Bureau, which is an existing service within the PRUH. This team ensures that the appropriate support is in place when a patient is discharged. This may include community or third sector services. The PRUH has a patient information leaflet about discharge from hospital available on their website. This is also given to patients being discharged. As part of the new pathway there will be also be a Care Navigator Manager based at the Orpington Integrated Unit who will identify the non-medical support or changing needs of people on the pathways whilst they are inpatients and ensuring patients being discharged, have access to the right third sector services to help avoid future admissions. Patients who are already on the Proactive Care Pathway will be contacted by the Care Navigator working within the relevant ICN at the point of discharge, to resume coordination of their care within the community. 6. CARERS Q. Once a patient returns to their home and feels services are not working, what happens if the patient s carer is not available? It is critical that carers are involved and there are benefits for patients and staff if they are. A: Patients who are on the Proactive Care Pathway will have an Integrated Care and Support Plan that includes the contact details of all the health and care professionals involved in providing care to the patient. This will include the contact details of who to contact over the weekend and in the evenings. Patients discharged from the Orpington Integrated Unit will have a discharge plan that will set out the contact details of all the health and care professionals involved in providing care to the patient. 8

9 When a GP refers a patient to the proactive care pathway they will be contacted and visited by a Community Matron and Care Navigator, where relevant. The Community Matron will carry out a detailed assessment which will form the basis of a patient s Integrated Care and Support Plan. The Community Matron Assessment includes sections on a patient s current care, including social care involvement and also a section on carer involvement. It will be the Bromley Healthcare Community Matron carrying out the assessment; the Care Navigator will provide assistance regarding any nonmedical, third sector support. The Community Matron or other relevant MDT member, can refer patients to social care using existing pathways. The ICN Project Manager is currently working with LBB to give the MDT Coordinator the facility to check if a patient is known to social care and involve them where appropriate. Where relevant, a representative from social care will be at the MDTs to contribute to the support plan. There will also be a social worker on site at the Orpington Unit to support discharge and multi-disciplinary planning 7. VOLUNTARY (THIRD) SECTOR Q: Can you explain the role of the third sector in the new pathways, including the role of the Care Navigator? A: All Bromley health and care providers, including the third sector have agreed to work closely together to deliver integrated care in Bromley, and the third sector organisations in Bromley are working with the CCG and our partners to play a greater role in providing health and social care to Bromley residents. Local third sector organisations have formed a federation called the Bromley Third Sector Enterprise to better coordinate third sector care for patients. The Care Navigators who will help both patients and professionals to navigate the health and care system in Bromley are employed directly by the Third Sector, and their role includes a focus on a non-medical approach to patient management and supporting and sign posting appropriate patients to access third sector services, including access via a new Social Prescribing Portal. Patients who are specifically referred to volunteering as a route to improving their health and wellbeing, will be supported to access opportunities via the Community Links Bromley Volunteer Centre. 9

10 Q: There is quite a significant dependence on the voluntary sector. How will you regulate the third sector? A: The Third Sector will not be responsible for dealing with any clinical / medical patient needs, their focus is on supporting non-medical elements of patient s wellbeing. The Social Prescribing Portal will manage the referrals into the third sector services and as part of the governance over the Integrated Care Networks (ICNs) there is performance monitoring which will include the time taken for a patient to be referred to a service (including third sector non-medical services), as well as the time taken for the patient to then receive / gain access to that service. These performance metrics will be reviewed monthly by the CCG to ensure the third sector is sufficiently managing the demand on its combined services. Q: Who pays for the third sector services provided to patients? A: The Social Prescribing Portal is a database of all the services available to Bromley residents that initially the Care Navigators will have access to (going forward the access will be opened up to GPs and other Bromley health and care professionals). Some agencies charge for some services so the person accessing the portal (the Care Navigator) will need to check what the relevant agency is charging for the required service. The portal sets out what is funded by the CCG and the council (and therefore can be provided at no cost or at a subsidised cost to the end user), and what the end user must pay for themselves. Q: Will these new pathways create a lot of demand on voluntary sector services which is more than they can cope with? A: The Social Prescribing Portal is key in ensuring that health and care professionals in Bromley, including the Care navigators, know what services are available, understand the services being offered and the remaining capacity within that service to take on new referrals, and know what the cost of the service is for the end user. This will help refer patients to the right services as well as ensuring that referrals are not made into services that do not have the capacity to take on new referrals. 10

11 8. GERIATRIC SUPPORT IN THE ORPINGTON FRAILTY UNIT Q: How many geriatricians are there in Bromley? A: In addition to the existing geriatricians based at the PRUH, including a newly appointed Interface Geriatrician who will support the Proactive Care and Frailty Pathway, the PRUH is also currently recruiting a further two interface geriatrician posts to support the roll out of the Orpington Integrated Unit. Q: Will the GP always be able to contact a geriatrician, or is the access to the Geriatricians just during working hours? A: GPs will be able to contact Geriatricians during working hours using a direct access phone number. Details of how this works outside office hours and runs alongside the Geriatrician on-call provision are being finalised. Q: What happens to those people with long term conditions that are not old? A: Where appropriate a patient s GP will refer them onto the Proactive Care Pathway, which is for all Bromley patients aged over 18. The eligibility criteria for the Orpington Integrated Unit and the Frailty Pathway is not based on age, it is based on a frailty score where age is not a deciding factor. Q: What is the age limit for a geriatrician to see a patient in the Orpington Integrated Unit? A: Geriatrician s will see any patients who meet the eligibility criteria for the Orpington Integrated Unit. Frailty exists on a spectrum, and the use of a frailty score will enable health and care professionals to assess each patient considering an accumulation of deficits (ranging from symptoms e.g. loss of hearing or low mood, through signs such as tremor, through to various diseases such as dementia) which 11

12 can occur with ageing and which combine to increase the frailty index which in turn will increase the risk of an adverse outcome. Q: How will shared care records work? A: NHS organisations in Bromley have collaborated to develop the new secure electronic Local Care Record which allows GPs, hospital and community healthcare staff to see important information about their patients, to help inform decisions about their treatment. Patient records are already shared between local NHS organisations via traditional methods such as post, fax or . The new secure electronic record means that appropriate information can be accessed immediately by clinicians caring for their patients. This will include data such as test results, medication and previous treatments to help them make any treatment decisions. 9. TIMESCALE Q: What is the timetable for the roll out of the Proactive Care and Frailty Pathways? A: The first MDT in the Proactive Care Pathway took place in October 2016 and the mobilisation plan is looking for all three ICNs to be running MDTs at full capacity by the end of January The first ward in the Orpington Integrated Unit is expected to open during the month of January 2017, date to be confirmed. Q: The timetable seems very ambitious and I have heard that the building work is not due to complete until January and there will need to be snagging and commissioning to follow before patients can be admitted. A: There is a tight timescale for works completion. The building work is due to be completed in December and King s are confident the facility will be available and are working with their contractor to manage risks and issues. 12

13 10. COMMUNICATIONS Q: How will you communicate about these pathways to people who need to know? A: We are in the proposing of preparing patient information leaflets for patients who are on the Proactive Care and Frailty Pathways so that they know what to expect. We will share the draft content of these leaflets with members of the group for any feedback on content. : There is also a planned roll out of communication to relevant Bromley health and care professionals, including GPs. 13